I want to begin by saying THANK YOU for sending me to Telluride to learn from some of the nation’s pioneer leaders in patient safety and quality improvement. I have been so moved that I want this to be my “niche” in medicine as I continue on to become a pediatric hospitalist. I am hoping at some point to sit down with all of you to discuss the processes CMH has in place to reduce error and at the same time acknowledge human factors. I have not yet made it to error prevention training due to scheduling conflicts, but I am excited CMH is taking this step towards becoming a high reliability organization. Nick Clark (a previous Telluride Patient Safety Summer Camp alum) has done a great job of incorporating patient safety moments into many of the meetings he has led, and I hope to carry this forward in some way.
We watched a variety of videos and heard multiple stories of near-misses and unfortunately, preventable patient morbidity and death. Carol, one of the representatives from the patient perspective, shared the powerful story of the loss of her daughter who had been diagnosed with leukemia 9 days before she died from a hospital acquired (and too late recognized) C. diff. infection. A C. diff. infection! This year has been particularly hard for Carol and her family as her daughter would have gone to senior prom this previous April and then graduated from high school in May.
In order not to make this email too long, I want to just make 2 more points and then, hopefully, I can discuss my thoughts with all of you in person at some point.
1) John Nance, writer of “Why Hospitals Should Fly,” said during his talk: “You have been trained to be the center of your own universe.” I do feel as if I was trained in medical school to practice “independently.” On rounds as students and many times as residents, we are expected to diagnose a patient (even if we are completely wrong), come up with a firm plan…and then present it confidently. Our goal is for everyone around us to nod their heads in agreement with the plan we have made. We hope no additional input is needed. However, this erases the team-based approach to medicine we MUST have in place in order to create the most safe environment for our patients. Our plans may be acceptable plans, but others’ ideas should be elicited EVERY time and considered EVERY time, so that we can ensure we have considered all options.
2) I want to begin my own QI project, but I’ll need a mentor. I just don’t know yet what I want to focus on. Sometimes it’s better when I write or talk about my interests or concerns, and then a person outside of my head points out the obvious to me. I appreciate all thoughts any of you have to offer.
Joy Solano, MD PGY-1
Reflections by A Young Physician Inspired by Telluride ExperiencePosted: June 29, 2015
For the last six years, health science students and resident physicians have inspired our Academy for Emerging Leaders in Patient Safety faculty as much as they report we have inspired them to become patient safety leaders within their medical centers. Each year, our faculty receive numerous emails sharing the safety projects they have been leading to make care safer for their patients. We hear about how the Telluride Experience has re-focused their purpose within medicine, sometimes even keeping them engaged at a pivotal point in their own careers when the burden of the current culture of medicine seems too much to bear. Bringing close to two hundred passionate and committed learners and future healthcare leaders to Colorado, Maryland and California each summer to work with our faculty from around the world is what keeps me excited and wanting to come back each year.
This post was inspired by the following reflection, Email I sent to my program leaders, posted on our Telluride Blog by Joy Solano, MD-PGY1. Thank you Joy! And thanks to all our Telluride Patient Safety Summer Camp Alumni (close to 500 strong now) for working to make healthcare safer for our patients, families and our caregivers.
Email I sent to my program leaders. Published June 19, 2015 |