Today’s post is from guest author Brennan Killeen, RN, BSN, Clinical Nurse at MedStar Georgetown University Hospital (MGUH) and Telluride Scholar June 2015. Brennan was asked to give a speech to this year’s MGUH Nurse Residency graduating class. Her focus was patient safety and her experience at the Telluride Patient Safety Summer Camps. We are so happy to see the premise “Educate the Young” continues to build momentum in a new generation of healthcare leaders.
Hello everyone and congratulations on your graduation. I’m Brennan Killeen. I graduated from the Nurse Residency Program here at Georgetown this past March. I work on C4-1, the Cardiovascular and Thoracic Intermediate Care Unit and I’m coming up on my 2-year mark as a nurse in February. I was a second-degree nursing student here at Georgetown before starting my career as a nurse on C4-1. I remember feeling all of the same emotions you all felt after graduation: the anxiety of finding a job, picking a city, finding the right hospital, the right manager, deciding whether or not being part of a residency program was the right fit… I want you to take a moment and reflect on all of your accomplishments thus far. Graduating from nursing school, passing your boards, landing a job at such a well-respected place like Georgetown and completing your first year as a nurse are big deals!
I’ve actually been to this ceremony 3 times now. The first time was when I was still a baby nurse and had barely gotten on the floor yet. I remember sitting here and feeling slightly panicked that I’d never be able to complete an NRP poster or that I’d make a make a med error, I wouldn’t know how to hang blood, or I’d never get over being intimidated by doctors and senior nurses – there were so many emotions that flooded my mind that first ceremony. I did feel very overwhelmed but I never felt alone. I felt calm knowing that if I didn’t feel confident about my poster presentation I had Kristine and Kim, or if I was scared about making a med error or performing a procedure incorrectly I had my coworkers and policies to turn to, or if I felt intimidated I had my manager, Elly, or educator, Alisa to ask for guidance. This is the beauty in a place like Georgetown. The support that is provided to you as a new nurse is incredible. There are systems in place so that it’s hard for us as new nurses to fail and there are people around you who truly care about your success. There’s a palpable sense of pride at Georgetown. We honor our spirit values, we support one another and we always put the patient first by practicing as safely as possible.
The second ceremony this past March was my graduation. It was a day when everything really came full circle. I felt proud of myself and my NRP partner for completing a project that we felt passionate about. I felt so excited my classmates and I had survived our first year as nurses. I remember walking around and observing the posters and feeling giddy. It was such a big moment for all of us. We’d become comfortable in our practice and it was hard to believe that we were no longer the new nurses. By this time, I’d become involved in Georgetown’s falls task force because of my interest in patient safety and I knew that my second year of nursing would give me the opportunity to take on more responsibility.
Today is my third ceremony and I felt so much confidence in Georgetown when I walked around the room earlier and looked at your presentations. You all should be so proud of yourselves! You’ve survived your first year. But with that comes a new set of challenges and goals. It’s time to push yourself to really dive into this wonderful community. You’re veterans now and it’s you who’s going to be guiding the new nurses. The opportunities that Georgetown provides for us are countless. During my second year as a nurse I felt a strong sense of obligation to get involved. Georgetown invests so much time and energy in creating a safe environment for us as new nurses and in turn a safe environment for the patient. I can’t tell you how many times I felt thankful over the last year and a half for all of the safety measures that were in place for me at Georgetown: policies, MC75s, double checks, bed alarms, daily rounding and the list goes. All of these measures promoted safe practice for me and influenced my passion for patient safety.
This summer I had the amazing opportunity to attend a safety camp in Telluride, Colorado sponsored by The Doctors Company Foundation and MedStar Health. It was the first year that Georgetown nurses were included in the camp in large part due to Eileen’s Ferrell’s efforts. Med students, nursing students, doctors and nurses from around the country were able to gather together in Telluride to expand our knowledge on patient safety. We spent the week discussing patient safety improvement, techniques, philosophy and approaches for reducing patient injury and adverse outcomes. Family members of victims devastated by medical errors also attended the camp to collaborate with us on ways to make system changes to avoid such errors. It was an eye-opening week for me and I learned so much. The sense of empowerment I felt after the conference was incredible. Knowing that we’re at a place like Georgetown where we can make a change after just a year and a half of being a nurse is an amazing feeling. One of the risk reduction strategies we discussed during the week was education. In our residency program Georgetown specifically carves out time during our classes to educate us on such strategies. This community encourages us to call for help and demands that this is a sign of excellence and not a sign of weakness. We belong to an organization with a just culture that applauds transparency and shared-decision making. As nurses we are encouraged to promote a culture of compassion, empathy and trust and in doing so we stand by our mission to provide safe, high quality care, excellent service and education to improve the health of our community.
Telluride truly has been the highlight of my nursing career thus far and I have Georgetown to thank for that. I didn’t think that back in March I’d be standing up here speaking to you all about my Telluride safety experience but Georgetown challenged me to be better, to do more and to get involved.
I want to leave you with a story from Telluride that really resonated with me and inspired me to prioritize patient safety during my nursing career. Lewis Blackman was a 15-year-old boy who died from a medical error following elective routine surgery in November of 2000. He suffered due to deficiencies in the system. He’d been prescribed Toradol post operatively. He was on an inadequate amount of IV fluids and it was a 2-day struggle to get the IV fluids increased but by then it seemed like the damage had been done. After 30 hours of alarming clinical decline, 24 hours of no urine output and 4 hours of an undetectable BP, Lewis died on post op day 4 from an NSAID induced duodenal ulcer. During the morning of Lewis’s death, doctors and nurses scoured the hospital to find a cuff or a machine that worked so that they could detect Lewis’s undetectable BP. They took his BP 12 times using 7 different machines and cuffs, dismissing the undetectable BP as an equipment error. Lewis eventually went into cardiac arrest. Could his death been averted by an assertive nurse? Could open and honest communication have prevented this error? If the doctors and nurses had practiced mindfulness and considered the family as part of the healthcare team would Lewis still be alive today?
This story speaks directly to safety. It’s an example of why nurse empowerment in reference to patient safety is so critical and why you all are so valuable to the lives of our patients. We belong to an institution that empowers us to speak up, to be accountable, to communicate and above all to practice as safely as possible. I ask you all to remember this every day and to teach our new nurses that it’s okay to speak up, it’s okay to say you’re unsure of something, it’s okay to ask questions. By doing so, you could save a Lewis Blackman or a family from tragedy like this.
Now that you are official graduates of your residency program, I challenge you to lead by example and continue to foster a safe environment here at Georgetown. You are now leaders and it’s your job to take our new nurses under your wing and show them the way. Dave Mayer, our VP for Quality and Safety here at MedStar told our Telluride group this: “leadership is like tennis, it’s a skill that you always have to work on.” I’m proud to have you all as leaders and I have confidence in each and every one of you that we will be a safer institution because of you. Congratulations!
Today’s post is by Guest Author, John Nance, Telluride Experience Faculty, Author and ABC Aviation Consultant
Having had the delightful experience of attending and working with all of the sessions of the Telluride Experience this summer, I’ve spent some time since returning from Napa thinking through the scope and the effectiveness of what we all came together to advance: The goal of never again losing a patient to a medical mistake or nosocomial infection.
It may well sound hackneyed, but in fact I think all of us as faculty mean it to the depth of our beings when we say that the medical students and residents and nurses – all of those who joined us – are truly the best hope of changing the course of a noble but tattered non-system that slaughters people at the rate of 50 per hour. That does not mean that existing healthcare professionals cannot or will not embrace the dramatic changes that are required to keep patients safe, because, indeed, thousands are passionately involved in just such efforts. It does mean, however that the opportunity for leadership from the newer members of this profession will be critical, from the small and subtle gestures, to the grand and sweeping reforms.
And the potential for meaningful leadership, of course, is why those who joined us were selected in the first place, and what we expect of them from here on: Courageous leadership steeled against the oppressive influence of the status quo.
Having participated in this battle for patient safety for nearly a quarter of a century, I can say with some degree of authority that no matter how many presentations, discussions, articles, consulting hours, or other efforts are thrown at the problem nationally, creating a major cultural change is perhaps an order of magnitude more difficult when you’re surrounded by the very environment you’re needing to alter. Coming together at a distance – especially in a resort atmosphere, or in the incredible beauty of Telluride itself – is an important element in achieving transference of ideas, concepts, goals, and determination as free of dogmatic and traditional thinking as possible. And, of course, catching people at the beginning of their careers before the insidious influence of cultural rigidity has been allowed to take root and oppose change, is an equally important key. I know of no better forum than this, and I’m truly honored to be a part of it.
And so we came together and told you horrifying stories that made us all cry, exposed young learners to the realities and predictability of professional human failure, and rubbed all our noses in the reality that a profession whose routine operations count as the third leading cause of death in America does not possess the ethical choice to resist meaningful change.
But at the end of the day – and our time together – it all comes down to taking those small sparks of understanding and recognition and fanning them into flames back home, never forgetting that every hospital room, scheduled surgery, ambulance arrival, admission, or diagnostic test involves a fellow human who is as entitled to the highest standard of care and caring as your own family.
From a very personal POV, I thoroughly enjoyed meeting each of our participants this season and pushing the quest forward, and I look forward not just to next year, but to hearing how the seeds we all helped sow will sprout and change the landscape of American healthcare.
As our final week of the 2015 Telluride Experience comes to a close, our Telluride blog has been nourished by a new year of talented healthcare trainee reflections. Many of these young physicians and physicians-in-training, along with their nursing colleagues, have submitted reflections that we will share more on moving forward, but they can be viewed here today.
Because our scholars and Alumni often return to the ETY blog as a reference tool, we wanted to share another opportunity for all to showcase their passion and commitment for keeping patients safe through writing. The Doctors Company Foundation, an organization that also sponsors a number of medical student attendees to participate in our Academy for Emerging Leaders in Patient Safety each year, is once again partnering with the Lucian Leape Institute at the National Patient Safety Foundation (NPSF) to offer The Doctors Company Foundation Young Physicians Patient Safety Award. The award will recognize young physicians for “their personal insight into the importance of applying the principles of patient safety to reduce the incidence of medical error.” Applicants are invited to submit essays of 500-1,000 words about a patient safety event they personally experienced during clinical rotations that resulted in a personal transformation.
More information can be found on The Doctors Company Foundation website. A short summary follows:
Applicants are invited to submit essays that will be judged by a panel identified by NPSF. Six winners of this prestigious award will be selected and receive a $5,000 award, which will be presented at the Association of American Medical College’s (AAMC) Integrating Quality meeting in Chicago, June 2016. Nominations must be submitted by 5:00pm ET, Monday Jan 25, 2016.
- As of July 1st, 2015, applicants must be either a 3rd or 4th year medical student at an American medical school
- Award is for the best essay explaining your most instructional patient safety event experienced during a clinical rotation and that resulted in a personal transformation
- Award will be presented by The Doctors Company Foundation at AAMC’s Annual Integrating Quality meeting in Chicago
- Registration, hotel and travel will be covered to the AAMC meeting for Award recipients
Examples of winning essays from 2014 can be viewed via a past ETY posts (click here), and a review of the 2015 Essay Winners will soon follow. For additional questions, visit The Doctors Company Foundation website, here. We know there are many Telluride Alumni deserving of an award like this so please enter, and share the patient-centered care you are working so hard to make standard of care. Good luck!
It is happening…and it is growing. A newer generation of caregivers – young physicians, nurses, pharmacists and other allied health professionals – are stepping up and starting to make a difference. Many of them understand and appreciate they will soon be the gatekeepers for high quality, low risk, high value patient care. They seem to be taking this responsibility seriously – more seriously than I and my older generation colleagues did at their age. They stay connected reading new information shared through social media outlets. They are doing regular literature searches for new articles on quality, safety and value. They want to learn and understand.
The reflective post shared below by Rajiv Sethi is just one of many similar posts that come from our Patient Safety Summer Camps. These young learners don’t just write reflections…they take their reflections and use them to research and learn best practices related to the topic in question. They want to learn, they yearn to learn.
There are days when many of us feel we are slogging uphill, going nowhere and will never live to see the changes so badly needed in healthcare. Working with these young caregivers revitalizes the faculty, just as much as the students are energized and educated around patient safety. Spending time to both educate and learn from the young is so important to the future of healthcare, but also our future and the future of every patients.
Published July 28, 2015 | By Rajiv Sethi
Having only been at Telluride Experience: #AELPS11 for a day, I hadn’t imagined I would have learned so much. We covered a variety of topics with important patient safety learning points. I am so grateful for the opportunity to be here and share the experience with so many motivated individuals keen to be change agents.
I wanted to focus on one of the key moments for me: The Story of Lewis Blackman (http://qsen.org/faculty-resources/videos/the-lewis-blackman-story/). We were very lucky to have Helen Haskell (Lewis Blackman’s Mother) with us and I am so grateful to her for sharing her story. So many issues were raised during the video and I was able to draw many parallels to health care in the UK. For example, the issue of reduced staffing levels on the weekend (see link). The consequences of this can be severe as was found in a study published in the BMJ, Day of week procedure and 30 day mortality for elective surgery… where patients undergoing planned surgery were more likely to die if they have their operation at the end of the week. The new plans proposed by Jeremy Hunt (Health Secretary) to increase staffing provision at the weekend in the UK are causing much controversy, recently culminating in the hashtag #IminworkJeremy (staff posting pictures of themselves at work at the weekend).
Another issue I wanted to focus on may seem rather obvious, but as a student I believe is one of the easiest things to incorporate in daily practice; the importance of health care professionals and students introducing themselves fully to patients. In the story of Lewis Blackman, there was a lack of communication and identification of the team involved in the care of Lewis. As a result his family were unaware of who best to raise issues with.
There is so much to learn from this story but I want to end reflecting on Dr Kate Granger’s hashtag #HelloMyNameIs campaign. On her blog she describes herself as a doctor and terminally ill cancer patient musing about life and death (Click here for story). She has done remarkable work in encouraging health care staff to introduce themselves to patients, with support from over 400,000 staff in over 90 health organizations including many NHS trusts. Only recently did I see a lot of the standard hospital name badges at Guy’s and St. Thomas’ NHS Foundation Trust (where I train as a medical student at King’s College London) being replaced with bright and colorful #HelloMyNameIs name badges. Although it may sound simple, the impact on the patient experience is phenomenal.
Our final session of the 2015 Telluride Experience kicks off in Napa, CA this week. Once again, the learning began by sharing the Lewis Blackman story, and we were fortunate to have Helen Haskell as part of the faculty to lead discussion after the film, along with Dave Mayer. Having been part of the team who created the film, and having viewed it more times than I can count, I am always in awe of the new ideas each viewing inspires. A large part of that inspiration arises from the conversations and stories that are shared by attendees after they hear the story.
Today, there were many excellent comments but it was something Natalie B, a nurse practitioner and educator, mentioned about the fear junior healthcare professionals hold of getting chewed out by healthcare leaders that often prevents them from speaking up when they are unsure. (See her post Transparency and Vulnerability=Scary! on the Telluride Blog). The second inspirational comment came from our newest faculty member, Kathleen Bartholomew, also a nurse, who pointed out the need for a greater sense of urgency around adopting a culture of safety above all else. She continued by pointing out that 900 similar case like Lewis’ occurred in the single day and a half since our group arrived at this meeting.
This begs the question that, shouldn’t delivery of care always be about putting the patient first versus the care provider’s ego or fear of jeopardizing a career? This phenomenon is far from limited to trainees too, which is of even greater interest. Perhaps an interesting model to consider would be to have medical and nursing schools recruit, train and accept only the most courageous students versus those with the best MCATs or test scores. It would be nice to weed out those who would/could put their own professional well-being before that of their patient at any level.
The reminder of the need for a greater sense of urgency was both valuable and validating. There have been times when it has been hard to watch Lewis’ story yet again, knowing errors related to healthcare hierarchy and culture continue to occur again and again. Helen shared that on November 6th, it will be 15 years since Lewis died–was killed–if we’re being honest. She pointed out that all too soon he will have been gone from her life longer than he was alive. This is a hard fact for all of us to hold.
One of the greatest values to the Telluride Experience is infusion of the mindfulness and ire into the minds of young healthcare trainees that comes from hearing these stories. It is both that will be needed for real change. We need providers at all levels of training who are more afraid of harming a patient than of being chewed out by a dysfunctional healthcare mentor. I would challenge those going into healthcare, as well as those already in healthcare, to be prepared to put the patient first, always. Those who are unsure this is something they can do might want to consider a different career path.
One of the highlights of our Telluride East Patient Safety Summer Camp each year is our trip to Arlington National Cemetery. The cemetery serves as a burial-place for “laying our Nation’s veterans and their family members to rest with dignity and honor.” Numerous daily honors remind visitors of the service, sacrifice and valor displayed by those in the military protecting our freedoms.
Again this year, our group hiked up the hill and to a spot just beneath Robert E. Lee’s House where Rosemary Gibson provided a touching “eulogy” on the history of the cemetery and lives lost due to preventable medical harm. She concluded by asking all of us to share the name of a patient or family member we knew who died from a medical error so we could all remember them…many names were shared and honored.
As we stood on the hill at the end of the ceremony reflecting on those lost to medical error along with those who gave their lives for our country, we looked out upon the white gravestones that could be seen in all directions. Gravestones that seemed to go on forever. The informational brochure says the cemetery is currently the final resting place for more than 400,000 people.
The irony of the 400,000 laid to rest in Arlington hits me each year, as this is the same number of patients who die every year due to preventable medical errors according to an article published in September 2013, A New Evidenced-based Estimate of Patient Harms Associated with Hospital Care in The Journal of Patient Safety. All the white tombstones that stretched to the end of the landscape and seemed to go on forever also represented the same number of patients who die each year from preventable medical harm. We fill an Arlington Cemetery every year.
After our collective remembrance of those we knew who gave their lives to medical errors, I broke from our group and walked over to the Tomb of the Unknown Soldier. As I walked up to the white marble sarcophagus, it was easy to see the words inscribed on the back:
Here rests in honored glory an American soldier known but to God.
Wanting to know more, I began reading additional information I found at the Tomb…
On Memorial Day, 1921, four unknowns were exhumed from four World War I American cemeteries in France. U.S. Army Sgt. Edward F. Younger, who was wounded in combat, highly decorated for valor and received the Distinguished Service Medal in “The Great War, the war to end all wars,” selected the Unknown Soldier of World War I from four identical caskets at the city hall in Chalons-sur-Marne, France, Oct. 24, 1921. Sgt. Younger selected the unknown by placing a spray of white roses on one of the caskets. He chose the third casket from the left. The chosen unknown soldier was transported to the United States aboard the USS Olympia. Those remaining were interred in the Meuse Argonne Cemetery, France.
The Tomb sarcophagus was placed above the grave of the Unknown Soldier of World War I. West of the World War I Unknown are the crypts of unknowns from World War II, Korea and Vietnam. Those three graves are marked with white marble slabs flush with the plaza.
Maybe it was because I had just seen David Classen at our Telluride Patient Safety Summer Camp in Colorado, but at the exact moment I finished reading the pamphlet my mind flashed to his global trigger paper that concluded adverse events and deaths from medical errors may be ten times greater than what is reported. [See‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured Health Aff (Millwood). 2011 Apr;30(4):581-9. doi: 10.1377/hlthaff.2011.0190. Classen DC et al]
Standing in front of that Tomb, I couldn’t help but think that each of those unreported adverse events and medical error deaths that Classen and colleagues are referring to are the unknown soldiers of healthcare. In our own Telluride East ceremony at Arlington the last three years, we have paid tribute to those we knew had been lost to medical harm, but we failed to remember our own unknown soldiers. They say that what is seen cannot be unseen. What is felt or experienced first hand, or even vicariously through the experience of others, also leaves a lasting impact. Knowledge of the magnitude of our losses due to harm through study, along with the sharing of their stories firsthand through family members at Telluride ensures that next year, we will make sure to also remember the unknown soldiers of our own.
I attended the Patient Experience, Empathy and Innovation Summit hosted by the Cleveland Clinic in May. Sessions covered a wide range of topics, including insight into how technology such as wearables, apps, and greater access to information about patients is influencing the delivery of care, and with it, the experience of care by patients. At the end of the day it was clear, engaging with patients honestly and with empathy, and inviting them to participate in the care they are to receive will never go out of style. It is encouraging to see the renewed focus and importance placed on the power of what have long been viewed as the “soft skills” of medicine. There are many of us, including an increasing body of research, who understand the healing properties of touch, a smile or a kind word to help reframe a healthcare encounter. What truly made the content shared in Cleveland come to life, however, was viewing it all through the lens of a conversation I had with a close friend who recently went through treatment for breast cancer.
I am most happy to report that my friend is now almost two years cancer free. With a family history that is all too weighted in favor of a recurrence, she is taking each day as a gift while at the same time remaining vigilant of every new ache or pain. When she was first “discharged” from treatment last year, she expressed dismay at how quickly and easily her “care team” said goodbye and good luck. With no more follow up visits to an oncologist or surgeon, and no more chemo or radiation appointments to attend, she also had no one regularly monitoring a disease that had taken the life of both her sister and mother. With no one holding some type of medical authority to give her a reassuring touch on the arm, or an all-clear from regular blood work, she has been left to wonder what the future holds alone. And I was left to wonder how post-cancer care can be so lacking in empathy for a patient, a person, who just experienced one of life’s most challenging events.
In the last six months, my friend moved from the often cold, unfriendly confines of the Chicago area for the warm, inviting sunshine she had left five years prior. When she arrived back in her adopted home town, she also needed a follow-up surgery as a result of infection from her implant resting on radiated breast tissue after the double mastectomy she had opted for in hopes of beating her odds of recurrence. This immediately put her in contact with a new breast cancer care team–one I can talk about without quotation marks because she is giving them high marks. She loves her new hospital, surgeon and everyone she has had to work with to get through this next health and life milestone. When I asked her why the care was so much better in her new environment, she shared the following:
They just seem to care so much more. It’s as simple as the gowns. Here the gowns are warm, soft and pink. When I would go to put a gown on at the old place, is was scratchy, cold and old, barely covered me and often tied in knots. I would sit there trying to untie knots in the gowns and get frustrated.
The image of my friend sitting alone, uncovered, frightened of what her future holds, and struggling to untie these knots brought tears to my eyes. Someone easily could have been mindful of making sure the gowns were easy to put on and take off; that they brought comfort instead of more anguish. Admittedly, it is a challenge to turn healthcare culture around on a dime, but can’t we at least hit the mark with the simple things? Couldn’t we try to make the entire experience of care feel like putting on a warm, soft, pink gown, even if we struggle to fix bigger system’s issues?
As her care continues at the new facility, she is also learning more about the way health systems work because people who work within this system are taking time to talk with her, explain things and put her mind at ease. She also feels more comfortable and welcome within in the new system, and is asking more questions. For example, she learned that her oncologist back home was not necessarily ignoring her by sending in a mid-level practitioner to talk with her. In fact, it was a signal that her recovery was going well because she did not need the oncologist’s time. Wouldn’t it have been nice to know this as a patient in their care, versus wondering about the quality of care being received as well as one’s prognosis?
At a recent surgical follow-up visit, my friend’s new surgeon took time to explain the procedure he had performed in detail, describing what he had done and how he thought she was healing. Not only did he take time to talk science, he asked her how she was feeling, and told her “it was his pleasure” to be of service to her. He used phrases that real customer service focused industries use, and my friend picked up on this because she works in the hospitality industry and notices things like this. And she notices when the simple niceties of customer service are lacking.
Do you know who your patients are? If you haven’t asked, it might be a good idea because they have skills and they are paying attention. Maybe just these few patient engagement/experience tips could be bullet-pointed and handed out at white coat ceremonies, or posted in hospital break rooms across the country. I’m hoping my friend will choose to become a patient advocate at her new location, as she has much to offer. Her first agenda item is to become well, and perhaps then she will share the wealth of knowledge she has acquired over the last two years about good and bad healthcare delivery. And while the new system is far better in her experience, she still has experienced bumps in the road. There is so much patients can teach us about what we do well, and where we need to improve, but they need to be invited into a conversation. Start today by asking a patient how he or she is feeling, if there is anything they need. or if you can be of greater service.