Pre-Arrival Reflection

“Anyone have any experiences they wanted to share with the group?” It was my first meeting working for the Accountable Care Organization and I was tasked with leading the meeting of the nurse care coordinators from the fifteen rural family medicine clinics that made up our ACO. I surveilled the room looking for a volunteer to speak, worried that no one had any updates on how hospital discharge phone calls were going.

“You will not believe it,” Marie, one of the care coordinators in a town of 25,000 in northeast Nebraska piped up. “I called a patient who was admitted for a heart failure exacerbation. We spent ten minutes reconciling his medication, and I found out he had been taking a quadruple dose of his beta-blocker. He couldn’t figure out why he was feeling so lightheaded and tired after he got out of the hospital and nearly fell. We were able to get him on the right dose of medication.”

One by one, nearly all of the nurses around the table shared similar experiences of medication reconciliations that revealed potentially life-threatening errors post-hospitalization. I was shocked how frequently this was occurring in unique communities throughout the state.

Eight years later and with six years of medical education and training behind me, I have seen how the health care system, with all of its innovations and technology, has myriad opportunities for things to “fall through the cracks.” With continually increasing diagnostic and treatment capacity comes increased complexity and an increased number of opportunities for errors to happen along the way. As a primary care physician, I feel a deep personal responsibility to help my patients navigate the complexity of the system and to be their ally in illness and wellness.

I wanted to attend the Academy for Emerging Leaders in Patient Safety because I believe that it is the whole health care team’s responsibility to do everything we can to promote patient safety and I want to be a leader in making sure that teams are living this out every day. The health care system can be a scary and convoluted place for patients and health care workers alike; for all of our sakes, it is our responsibility to do everything we can to build safety into the system. The US health care system continues to grow in expanse and expense, and data consistently shows that more expensive care is a marker of poorer care. By building the health care system to provide high quality, high value health care, we are not only protecting our neighbors’ health and wellbeing, but are also promoting prosperity and sustainability. I hope that the information learned and relationships built this week will shape my career as I seek out opportunities to make the health care system stronger and safer for all patients.