Day One Reflection

::SIGH:: As a graduate student who does online blogging daily it is rare that I don’t know how to start a discussion, today is the exception. There are so may factors that I want to touch on;

  1. I appreciate hearing from the different professions on the many viewing and stories we heard today. I am not currently at a major teaching hospital and wasn’t aware of the mounting pressure and expectations that exist among medical students/residents.
  2. One of the quotes I took to heart today was “Develop mindful engagement to have situational awareness to help create a sustainable safety culture through a shared medical model.”
  3. Another quote that I feel will become almost my mantra is that “change comes through disruptive innovation”

After hearing Lewis’ story, the shock of Carol’s daughter, Alyssa, and then the movie ‘To Err is Human’ I am left very frustrated and almost helpless. It’s overwhelming on how prevalent errors occur and its disheartening to hear that there is still so much ground to cover in something that seems so necessary to patient care. One of the questions that I had asked tonight was regarding dissemination of information. I have worked in 4 separate hospital systems in Colorado and all have the same process, if an error occurs, you stabilize the patient, notify the physician and you report it. There is no manual on what to say to the patient, in fact, we don’t tell the patient. After the error is reported it is sent off to Risk Management who then handles the information. There is little to no follow up with the nurse who reported/committed the error. It seems to be that if you don’t talk about it, it didn’t happen. What I can more clearly see coming out of this camp for me is the awareness and empowerment to become a voice, be an advocate and to turn preventable errors into learning opportunities so we don’t allow history to repeat itself.