Day 2 in Telluride by Peter Ureste

Today is Day 2 of my Telluride patient safety and quality improvement experience. Overall it’s been a very informative and, more importantly, inspirational.

I expressed to colleagues today my struggles with applying these broad concepts, which often are discussed in the context of surgical and medication errors, to psychiatry. The most obvious application is engaging the patient in a conversation when proposing to start psychotropic medications. Shared decision making based on their personal values and goals makes complete sense when a patient has capacity as our psychotropic medications directly effect the brain along with other systems. Some of these effects include GI distress, sexual disfunction (SSRIs), weight gain (i.e. valproic acid), dermatologic reactions ranging from psoriasis (i.e lithium) to severe Steven’s Johnson Syndrome (i.e. lamotrigine), prolonged electroconductivity of the heart leading to ventricular tachycardia, (i.e. supposedly ziprasidone), oversedation (benzodiazepine), metabolic and extra pyramidal side effects (antipsychotic medications), some of which are irreversible like tardive dyskinesia, or blood dyscrasias (i.e. clozapine or mirtazapine). At my institution we do our best to have a conversation with patients regarding the benefits of starting a medication, the risks, the alternatives, and then obtain written consent (they sign our consent form).

However, what are other ways psychiatry can promote patient safety? Prior to this conference, I logged onto and was inspired by another project idea for improving hand-off of high risk psychiatric patients from one outgoing resident who is advancing in their training to an incoming one. A colleague suggested today looking at ways to reduce harm from them being placed in hard restraints. At my own institution we’re in the early stages of assessing the effectiveness of mock code greys so the violent patient can be best managed with reduced patient and staff assaults. I think psychiatry needs our own seminar, conference, or journal where residents can share our QI thoughts. QIgateways definitely can serve this purpose.

Lastly, today inspires me to bring the concept of patient safety to county hospitals that serve predominately low socioeconomic and racial/ethnic patients who may be unaccustomed to requesting a second opinion, asking that a hospital investigation be done, or asserting their patients rights. I’m grateful to the Committee of Interns and Residents for seeing the value of recruiting a diverse group of residents to attend this conference so that we return to our institutions and improve safety and quality for underserved patients.