Day 2: Written in Blood

Today we heard from John Nance, who spoke with such a depth and breadth of knowledge that it would be impossible to succinctly cover my response in one post. However, he said one thing that stuck out above everything else. He described the experience of flying his own plane, and consciously going through the pre-flight checklist faithfully. Nance said that he follows the checklist to a T because every item on that list is “written in blood.” Each item on that list is an error that killed someone, or many someones. More than those deaths, each item represents a shockwave of tragedy: orphaned children, grieving widows, and parents who will not see their son or daughter grow up. The phrase stuck with me, but the implication didn’t hit until I went for a walk after the town of Telluride went to bed.

A few years ago, my unit both doubled in capacity and started seeing a spike in emergency admissions which were too unstable or complex for a general ward to handle. We used the buzzword “inappropriate admission,” meaning inappropriate for general care, and we frequently activated rapid response calls and transferred patients to the ICU. However, we didn’t fix the system that sent unstable patients to the stable medical oncology unit. Eventually we admitted patients who very clearly died because we weren’t able to give them the level of care they needed. We weren’t prepared for emergent dialysis, or massive transfusions, or impending respiratory failure. These situations describe people who died to give us the impetus to change, to communicate across disciplines and breakdown hierarchies that prevented our hospital from giving the right care the first time. But, eventually we did change and create a list and a common language for different professions and units to speak to each other that made patients safer on admission. Reflecting on this arduous process, I wish I had the kind of training that this experience provides when I was working to make admissions safer. I wish I had learned about these culture and systems issues, and the high reliability organization techniques that Dave and John talked about today. And I hope that these skills are soon spread throughout medical and nursing curricula and that we can use them to prevent deaths in advance rather than react to them. Despite being less than 20 days from my Master’s degree in leadership, I still had not really learned about many of these techniques until recently, some just today,

On a positive note, I have had some very productive and encouraging conversations with these medical students, and am amazed at their drive to serve people and to be as prepared as they possibly can be for the realities of patient care. They give me a great hope that their leadership and attitudes can echo through their practice.