This week we repeatedly discussed how hospital safety culture must learn from high reliability organizations (HRO’s) such as the airline industry, nuclear power plants, and aircraft carriers. Just before my 90 minute shuttle from Telluride arrived at Montrose airport, I received an email communication from United Airlines notifying me that my flight had been cancelled due to “aircraft maintenance.” Unfortunately, the next flight out of Montrose would not be until ~6am the following morning. In the past, I would have been rather disgruntled with the airline and likely would have projected my anger and frustration onto the check-in staff over the cancellation much like the two gentlemen at the counter next to me. However, after our discussions of HRO’s and reading John Nance’s Why Hospitals Should Fly, I was disheartened at first knowing it would be one more day until I got to see my fiance and dog… Continue reading
On Wednesday 6/11 we discussed the case of “Sally,” a 9 year old girl who died because of medical errors. Regardless of how you look at it, this is a tragedy. In our discussion, the presenter described why this resident was “set up to fail.” The resident had undergone numerous emotional battles in the prior months on the wards and in the ICU, had struggles outside of the hospital, and unlimately quit the residency program as a result of Sally’s death, but there was not one discussion on Wednesday about how we should care for our residents. Unfortunately, this resident’s story is all too common. Many of our Telluride attendees sympethized with the resident outlining how similar their experiences have been to Sally’s resident. I too can look back and see myself in that position.
It is well documented in the literature that residents, regardless of profession, develop higher rates… Continue reading
I have only just begun my journey here at Telluride, but one thing is clear: I am not alone. As the first day unfolded, I have been given the opportunity to meet an amazing cast of future leaders. All of whom have patient safety as a main priority. Some of us are on the front end of our patient safety journey while others are more accomplished. Some beginning residency while others are soon to graduate and take their Telluride experiences with them into their future careers. As the first and sole participant from my residency program, where our patient safety revolution is still in its infancy, it gives me great pride and pleasure to know that I am not alone. Each one of us here at Telluride Patient Safety Resident Summer Camp is not alone. When we leave Telluride and head back to our home institutions, we will have… Continue reading