Why is Pushing the Wrong Button So Easy?

By Sarveshwari Singh

On the first day of the Telluride East Summer Camp, Kathy Pischke-Winn and Dr. Joe Halbach organized a game using dominoes.   It really showed how miscommunication in health care can happen so easily and how simple steps can prevent it.

We assembled in groups of three — one person role-played a doctor, another a nurse, and the other an administrator.  The physician sat with his/her back to the nurse and instructed the nurse how to arrange the dominos according to a prescribed pattern.  The nurse couldn’t ask any questions.  Not surprisingly, the nurse didn’t arrange them correctly.

This scenario brought home how communication disconnects among clinicians happens so often in health care, and it underscores why a leading cause of errors is failure in communication.  Also, informal rules can deter students and residents from asking questions, which can lead to a really bad outcome. That’s what happened to Lewis Blackman, as we saw in Tears to Transparency.

Next, the group got a different domino pattern and could have a briefing before the start of the game.  Also, I noticed that in our group, the person playing the physician gave more precise instructions and repeated them for more clarity.  So there was learning and improvement between the first and second rounds. This time, the person role-playing the nurse arranged the dominoes correctly.

I took away from this experience lessons on how I need to be precise in communicating, whether in the classroom, at work or at home.

Progressive Hospitals are also the Transparent Ones

I found this article today and thought it was worth sharing for two reasons:

1. It talks about the most progressive hospitals being the ones that are also the most transparent concerning costs and medical records.

2. It highlights my ice breaker partner Luis’s hospital (Montefiore Medical Center in Bronx, NY) for their work in the community on social issues.

http://www.beckershospitalreview.com/hospital-management-administration/10-things-the-most-progressive-hospitals-do.html

Telluride East Final Reflections: Never Stop Improving

When I began medical school, my academic mentor advised me to be cognizant of when the more experienced would drop pearls of wisdom.  Well during these past 4 days it’s been raining pearls.  After trying to absorb so much knowledge, my brain feels like an overfilled suitcase with a weak zipper; it’s about to burst.   And therein may actually lie a problem.  To those with less clinical and formal patient safety experience, Telluride covers too much information in too little time.  Many of the activities and discussions felt rushed.  Here I present an open, honest critique of the Telluride program and make suggestions for improvement.

I will focus on 3 observations: 1) The negotiations, listening and human factors lectures were some of the best received, 2) Group exercises/games are highly beneficial and are worth the time expense, 3) People felt that there was not enough time for discussion.

Telluride promotes discussion between those of vastly different disciplines and experience levels.  The benefit is the plethora of viewpoints from the resulting diversity.  However, the challenge is creating lectures that can be informative for such a diverse audience.  Many of the experienced nurses were already well-versed in tools and  concepts such as SBAR, TeamSTEPPS, Just Culture, etc.  Therefore, although I as a medical student was overwhelmed with information, this was just review for many others.  The lectures that garnered universal interest, due to their novelty to all parties, were the non-clinical lectures.  I heard both the inexperienced and the experienced alike wishing they could have heard more of or done more activities with the negotiations, listening and human factors lecture.  Going along with this, there was unanimous praise for the efficacy and utility of the exercises done in Telluride such as the dominoes and see-saw.  Although activities such as these are time expensive, they are fun, and more importantly, effectively get the message across.  There should be more of these exercises.  One suggestion for a listening and retention exercise would be to have one person explain a very abstract topic, such as computer algorithms, to another and see the amount of retention.  This would model the feelings of a health illiterate patient listening to medical jargon.  Finally, several felt that there was insufficient time given to discussion.  This may have been due to incorrect expectations of what is Telluride.  A couple students had voiced that they expected Telluride to be more of a think-tank and were excited to brainstorm and interact closely with such titans of patient safety.  Instead they felt that this was too focused on didactic lecture.

Based on these observations here are my suggestions for improvements.  First devote each morning to a single topic.  For example one morning for negotiations, the next for human factors and the next for listening.  With each didactic lecture include 2 – 3 activities/games for each topic (like a dominoes, see-saw, parker-gibson, etc.).  Then save the entire afternoon for small group (~7 people) discussions devoted to brainstorming solutions to a selected patient safety issue (informed consent, decreasing central line infections, patient call buttons, etc.). Ideally within each group would be at least one person not from healthcare that has suffered an adverse event.  Finally end the day with each group sharing their proposed solutions or progress with the rest of the groups and opening the floor to comments.  These problem specific discussions have several advantages: 1) Allows for close faculty, student interaction, 2) It gives something specific and concrete that people can take away from the conference and work on.  This is especially important for the students who need some guidance as to a specific area to focus on in the vast realm of patient safety.  3) Finally the research collaborations that stem from these discussion ensure continued communication between various Telluride scholars.

Telluride has been one of the best learning experiences I’ve ever had.  I just hope these comments will be able to further improve upon the awesomeness which is the Telluride experience.

“Some is not a number and soon is not a time”

By Fiona Campbell (Medical Student at the University of Calgary)

It was refreshing to hear all of the insightful closing comments from all of the Telluride East participants today, and exciting to hear what we all plan to work towards as we return to our schools. It’s easy to see why we would all come away with such momentum and inspiration. This week was full of eye-opening discussions and thought-provoking workshops. It’s easy to feel empowered by everyone with a shared passion, and to think that we really can make healthcare better around the world.

But it’s also easy to succumb to real life and let that momentum fizzle away. It’s easy to forget how important patient safety is when you’re once again surrounded by leaders who don’t value it. It’s easy to get caught up in all of the knowledge we are expected to learn at school and forget about pursuing initiatives that will improve the system.

I’m still in the newlywed zone and every day I am reminded of the vows that I spoke one short week ago. They weren’t ground breaking, but by speaking them out loud in front of so many loved ones, it helps me hold myself accountable to following them. Today, we all vowed to each other to take what we’ve learned here, bring it back to our institutions and create something from it. Let’s not let life get in the way of accomplishing what we promised to do, and let’s hold each other accountable for making change. But as Dr. Mayer pointed out, some is not a number and soon is not a time – we need to think in realistic milestones in order to hope to accomplish anything. So let’s create more specific goals for ourselves and share our successes and shortcomings along the way.

My first step will be to do a patient safety project with the Human Factors group at the University of Calgary. I will start by defining the scope of the project this month and come up with a manageable deliverable to be completed before I start Clerkship in March. I’ll come back to this blog at least twice along the way to share my progress and get inspiration. Thank you to all of the Telluride East participants and faculty for the knowledge, motivation, and support to work on making healthcare safer one project at a time.

Hope everyone has a safe drive home from the airport!

Being transparent…time for confessions

I found myself feeling upset today, especially as we were discussing the case study. I felt so frustrated as a nurse when we were trying to figure out the accountable person for the patient fall. I felt like I had a weight on my shoulders. As nurses, we do shoulder a large portion of the responsibility related to patient falls. We talked this afternoon about how it is EVERYONE’s responsibility to help WATCH the patients in an effort to prevent falls.

I also confessed to my group that a lot of times I do not feel comfortable going to lunch when I am staffing. Why, you might ask? I know part of it is that it is hard for me to hand over control of my patients to another nurse, even if only for 30 minutes. So, I am working on that. The other part is that I work with a young group of nurses (young in experience), and so sometimes I am nervous about leaving my unit. I know that I need to build better trust. It will be one of my goals.

Telluride Day 3 Reflection

The morning was spent in the trip to Arlington Cemetery. Going on trip with colleagues is a very different feeling from going on trip with families or usual friends. The trip actually provided a chance for us to talk over things that we would not cover in the conference room, such as a bit more personal life about ourselves. I appreciate that the conference has brought together people with so much diverse background, which could be inspirational to the others.

The afternoon started in the discussion of SBAR style communication. I had no experience watching professionals in my university hospital exactly using this, neither was this mentioned frequently in our courses, at least not in our pharmacy courses. From people’s discussion I realized that this “technique” has been much more emphasized than what I thought. This can be a good point to note and observe when I get back to school.

The highlight of today was root cause analysis workshop. I was designated by our facilitator Dr. Roger to play the role of risk manager to lead the discussion. Oh my god… I totally lacked the experience to play the role. I even had not comb my thinking flow well within such short time after reading the case, let alone to lead the conversation for others… There were teammates demonstrating much more experience than me, from which I learned that there is a long way to go before I can really play a good leadership role in this area. This is critical to know. Before the Telluride meeting, I thought everyone would be at the similar level, at least I would not imagine myself that far behind since I was on our school’s Enhanced Medical Training Track on Patient Safety and Clinical Quality. The first time I realized the reality is not like this was in the first day’s ice-breaker—-some people has already got years of practice experience to back up their knowledge in safety and quality issue while I am still kind of green…… now the impression strikes me the second time, reminding and stimulating myself to keep moving forward.

The most thought-provoking part of the day was Dr. Mayer’s lecture on transparency. What the elements of transparency are, what the barriers and benefits are, what actual outcomes of those stories are. I am particularly interested in and admired their story on this issue at early stage, when transparency was quite not yet advocated as a trend, when culture change was more difficult. It takes vision, belief and courage to be a pioneer, it also takes strategy, patience, and supports from friends. How “rich” the person should be before he/she deserves the reputation of “pioneer”! Facing these pioneers these days, one more thing I have learned is humility.

#TPSER9 Reflections: Day Three

By Mary Blackwell, Nursing Student, UPenn

By the end of day three my mind is saturated and I feel so lucky to have the opportunity to be here at the Telluride East Conference. Aside from the twins in utero, as a rising senior in UPenn’s undergraduate nursing program I am certainly the youngest conference attendee. As a student, and a nursing student at that, in the hospital I often feel like the lowest on the food chain. But in this environment of open communication the medical hierarchy collapses and it amazes me to see various healthcare professionals come together for the betterment of patient outcomes. Never before have I had personal connections or meaningful conversations with interdisciplinary healthcare students surrounding issues in healthcare. Because it is so clearly valuable to have these types of conversations, I wonder why academic programs don’t put a larger effort into connecting various healthcare students during their training. Having positive experiences with one another while we’re all still humbled by the title of student could change the culture of staff dynamics in our future clinical settings.

Over the course of the past two days we have heard several stories of near miss or sentinel events in hospitals across the country. As individuals focused on honing our clinical knowledge and skill, it is inevitable to put ourselves in the shoes of the providers in these cases. I shared the shame that several students expressed during these presentations. It was difficult to watch mistake after critical mistake during the tears to transparency videos. It made me cringe in frustration and anticipation as I watched medical professionals continue cause harm to trusting patients. It’s hard to imagine missing the telling vitals signs in the story of Lewis Blackman or passively allowing the sedated Michael Skolnik to sign a consent form. However the focus of our discussions have been that many of these errors arise from faulty systems, not faulty health professionals.

During Terry Fairbank’s discussion of human factors engineering I was able to understand how systems can keep professionals from practicing to their full potential. One of the great examples of systematic hazard was the nurse who accidentally hit the wrong button on the defibrillator in an emergency situation. Instead of delivering the necessary shock to the patient in cardiac arrest, the defibrillator turned off. This delay the life saving care for the patient decreased the patient’s chance of survival. I could imagine myself making this mistake as easily as I do when quickly pressing the wrong button on my cell phone or car. A normal error such as this could happen to anyone in a high stress environment. The instrument was poorly designed; the off button was green while the correct button in this situation was red and flashing. In our society, green means go and red flashing means stop so this design is counter-intuitive.

For the first time I appreciated my constant second-guessing as a student. It’s when patient care becomes routine, second nature that mistakes are easier to make without systematic support. It’s going to be great for us to all go back to our institutions hyper-aware of these systematic barriers.

Why are we afraid to admit we are human?

By Betsy Mramor, M2 MUSC

It seems like common sense for us to realize that we will all make mistakes at some point in our careers. So why are we so afraid of admitting this when it happens? Are our own egos so big that we can’t admit we are human? Why is it that this same humanity that our patients and society expect of us disappears in a mistake. By not talking about these mistakes we continue to allow society to form these unrealistic perceptions that the healthcare field is perfect. I believe that in order for the culture to change; this perception needs to be broken.  There is no other way for this perception to change unless mistakes are brought to the table, discussed, and proactive measures are taken to correct them. Sweeping them under the carpet will only end up reinforcing this perception of the perfect healthcare system. Not only will this perception be reinforced, but also the unacceptable behavior of hiding or covering up mistakes.

I was so happy to hear confirmation of my thoughts from Cliff. Earlier in the week, Cliff had told us a story about how he lost his first heart transplant patient. He told us how shaken he was afterward. So shaken that he came home and told his wife that he had a 100% mortality rate. The next day he was asked what he told his next heart transplant patient. He told us how he was completely honest. He told the patient it was his second time doing the surgery and he lost the first patient. I keep trying to place myself in this patient’s shoes. Would I let this physician do my own heart transplant? Even with odds not in his favor;  I would have let him. For myself, there is a feeling of comfort and safety that comes from someone willing to admit that he is just as human (imperfect) as me.

Bad person or bad system? by Aubrey Samost M3, UMass

I am a system engineering graduate student, and I firmly believe that the vast majority of bad outcomes in health care are due to good people working in bad systems. However, today when watching the story of Michael Skolnik’s death after three years of complications from neurosurgery I felt like I had just seen one of the rare cases of a truly bad person in the health care system.

For those unfamiliar with the case here is the two-minute synopsis. A previously healthy 20 something year old male presented to the emergency room after having a syncopal episode. A head CT shows what may be a colloid cyst with no evidence of increased intracranial pressure. An MRI is done and may show the same colloid cyst. Michael and his parents go to see a neurosurgeon who immediately admits him to the neuro ICU. He gets the family to sign a consent form that they barely understand and places a bedside VP shunt to drain the possible excess CSF.  Next the neurosurgeon told the family that Michael needed to have the cyst removed. He said the  procedure was small and glossed over any possible complications.  The parents felt they needed more time before signing the consent form for the procedure, especially after feeling like they had been deceived with the last procedure. Later that day the surgeon returned, and, finding Michael alone, had Michael sign the consent form despite the heavy doses of opioids that he was on. The next day the surgery goes ahead with terrible results. Michael suffered severe brain damage and had nearly every possible complication, none of which the family was prepared for because of the terrible informed consent process. After three years, Michael finally died of these complications from a surgery that it turns out he may never have needed.

As the story unfolded it felt like the neurosurgeon constantly placed his own needs ahead of that of the patient. I was so angry that he seemed to force the procedure on the family and patient never mentioning alternatives. Maybe his motivations were financial or maybe he just felt he needed the practice with this procedure, but it always seemed to me that he prioritized doing this procedure despite it not being in the best interests of the patient. On the other hand, perhaps he wasn’t truly evil in intention but just had terrible clinical judgement and truly believed that he was helping the patient by performing this unnecessary procedure. Regardless of which of the above might have been the truth – evil intentions or incompetent medicine – my blood pressure was surely elevated by the end of this film because I was so angry.

As we discussed this, I realized I wasn’t alone in my anger. One of my colleagues pointed out that it practically felt like murder what had happened to poor Michael. As I was listening to these comments and reflecting on my own, my blood pressure slowly lowered and the systems engineer in my started to speak up. The documentary we watched was meant to highlight the importance of the informed consent process and show that it was poorly done in this case. However, none of us ever asked why the neurosurgeon performed such a poor informed consent. What other factors may have led him to mess up this process so badly? As with any complex system, the answer is multifactorial and more complicated than it initially seems. The following are some of the ideas that I considered. I haven’t got the facts in the case to support these; they are really just my own theories and possible explanations, but it forced me to think beyond my initial gut reaction of blaming the surgeon.

-Financial incentives are misaligned: insurance pays you to do a procedure, not to advise the family and patient to not undergo said procedure. The need to get paid could certainly have biased this surgeon into pushing strongly for the procedure.

-Time constraints: The surgeon was most likely in clinic or the OR during normal business hours when Michael’s family was visiting. After the surgeon was done in the OR he could come up to see Michael and get the consent form signed but that did not align with family visiting hours. Therefore, the system could have acted against him being able to give the family the opportunity to go through the informed consent process and instead forced him to get Michael to sign it alone.

-Culture: Many of my colleagues remarked after seeing this documentary that they rarely or never saw an informed consent properly done. What the neurosurgeon did here was just another example of normalized deviance. If everyone else in the hospital was signing consent forms this way, is it any surprise that he did?

-Administrative pressures: Perhaps this was the only full-time neurosurgeon in this hospital and he was under a lot of pressure from administration to not shunt business to their local competitors. This pressure could make him feel unable to turn away a case even if he did not feel totally comfortable doing the operation.

Overall, I have no idea if any of those above system ideas are correct or played any role in this accident. However, by the time I finished thinking through these theories, I felt that we as a class had been missing the most important question. If we want to prevent informed consent failures in the future, we need to ask why he failed to obtain a true informed consent. And when we answer this question, we need to consider the possibility that any neurosurgeon in the same position might have reacted that way because of the pressures the system exerted on him or her. Only then can we change the system to prevent a well-intentioned young surgeon from falling into the same trap and hurting a vulnerable patient and family.

I attached a picture of a basic diagram of this system as it impacts the neurosurgeon’s decision to operate in my fictional system.

Trust and Safety in Medicine: Part 2 by Matthew Waitner M2 Georgetown

Perhaps, as Terry Fairbanks said yesterday, we should look not to our individual pursuits but the healthcare system that is in place.  Individually, we are each committed to the reason we put on the white coat – to cure, heal, and do our best to care for each of our patients.  And yet collectively as a system we are failing to provide that very goal.  How is it possible that such dedicated individuals are systemically failing – it would appear to be impossible, and the numbers certainly show that its more than just a few bad apples.  Perhaps our system needs to be overhauled.

I was struck at the insight that Dr. Fairbanks shared.  As a human factor engineer he explained that every other system in the world accounts for the natural errors in humanity.  There are fail-safes embedded in most systems to catch the errors before they cause undue harm.  Such fail-safes are not present in the culture of healthcare.  While every hospital is claiming to be patient-centered, we often fail to see the humanity within ourselves.  I am firmly convinced at this point that a systemic culture change is the only solution to our never-ending problem of patient safety.  Dr. Fairbanks made it clear that skill-based errors (or better put, automated errors) are the key to controlling our out of control safety issues.  In fact, as a first year medical student we learned in our neuroscience course about types of memory: short-term, declarative (semantic and episodic), procedural, priming, associative, and non-associative.  The last of these (non-associative learning) is when someone is habitually exposed to the same event over and over again that the event is done by rote.  This should sound familiar, as it’s the same as skill-based tasks that require automation or limited cognitive input in order to be achieved.

From my class example, this is when you live over a flight path (which I actually do), and you tune out the sound of the overhead planes because you hear them every few minutes.  Every once in a while a plane will fly lower causing a louder that normal event that triggers you to notice them again, and again with habituation it disappears from your thoughts.  So it is clear that our mind can become habituated by automated responses that require little cognition, and it is only when there is a difference that your routine is noted.  Hence is the case discussed today of the NICU heparin incident – habituation caused major medical errors.  I am fascinated by the idea that this system error could have been avoided if there had been a slight difference (a different shaped vial, a different drawer, any change from the expected norm).  Dr. Fairbanks would argue that this is how well-meaning, caring professionals make simple mistakes that cost lives – and it is not the individual practitioner, it is the system involved regardless of how mindful we may be.  That same error was noted in the book “Why hospitals should fly” when the flaps were not engaged yet 3 people confirmed a 15,15 green (indicating the flaps were extended) – it was the expected result and therefore it was what was seen.  These sorts of systemic errors are where the most margin for improvement can occur – because like any job, medicine becomes routine and we become habituated, and our brains are physiologically wired to become habituated.

To say this conference has been insightful would fall short of its true meaning in my eyes as a future medical professional.  These past two days have shown me that our profession is far from perfect (even though each of us strives for such), and requires some major safety overhaul before the public catches wind of our missteps.  In fact, I’m not sure how much longer we can pull the wool over their eyes before they catch us red-handed, and I’m not exactly sure how we have been fooling them for as long as we have.  The numbers are out there, the mistakes make headlines, and yet we are still more trustworthy than a stranger on the street, and we deserve no such pride.  As medical professionals, its time to put egos aside and start doing what we swore an oath to do: do no harm.