Post-TTE reflection

Now that I have returned home from the week, I’ve had a chance to reflect on the lessons learned during our discussions.

The first two days of this week were powerful and were enhanced by the presence of the family members that had been their when lapses in medical care happened. The insight they provided us was invaluable, their interactions with different hospital systems was informative, and their lesson of disclosing early, apologizing, and keeping the patients and their families in the loop is one I’ll make sure to hold onto. Additionally, I learned much by having the faculty there providing examples from their careers as well as showing us how they learned to overcome barriers to arrive at a safer standard for patient care

I also found it helpful to learn about what steps should be taken before implementing certain tools in a hospital systems. I was already somewhat… Continue reading

Reflections from Wednesday and Thursday

Since the program has wrapped up, I wanted to reflect on my last two days in Breckenridge regarding what I’ve learned and taken with me as a medical student.  It has been a wonderful experience getting to know my cohort, fostering a passion for patient safety, and advocating for keeping our hospital environments humble and malignancy-free.

Day 3 (Wednesday):  The group hike in the morning was definitely a necessary activity on our agenda given the events from yesterday.  I really liked how low-key it was since I believe it helped foster mindfulness regarding the triggering and difficult topics we’ve discussed the day before.  The Domino Game afterwards was probably my favorite activity of the day since it taught me how essential communicating clearly and effectively is to doing any sort of task in a hospital setting.  It was at first difficult to access whether the… Continue reading

TTE Reflection

What a wild week. I am so thankful to have been a part of this group of healthcare professionals and advocates. This conference has been a truly eye-opening experience. Having just finished my second year of medical school, I have not had as much clinical experience as many of my fellow attendees, and as a result, I believe I am still rather naive to the issues that exist in our healthcare system. I, much like our patients, would walk into a hospital and expect things to run smoothly; obviously, those with more experience must have perfected their craft… right? Hearing a general statement such as, ‘the system is broken’ only gives so much information. However, the stories from staff and my fellow attendees pulled back the curtain on the realities of medicine I will soon encounter.

My goal when entering this conference was to be a sponge; I wanted to… Continue reading

TTE Reflection (Day #2)

It’s quite difficult to write this reflection one day removed from yesterday’s events. What was shared yesterday requires a much longer time – contextualized by more introspectiveness and observation – to truly digest and process. So, I write this knowing that it likely only reflects one aspect of yesterday’s personal impact.

I would be remiss to not centralize the panel of patient-advocates. When the panel shared their stories, all I could think of was how courageous they are. From what they experienced to how they have impacted meaningful change because of those events – hard to find descriptive words that would do them true justice. I am inspired by their courage. Navigating the healthcare system as a student, a woman, a person of color, an immigrant, etc. while holding the principles of advocacy, justice, and equity that have been taught to me by the educational (including medical) system has been… Continue reading

Day 2

Day 2 very thought provoking and emotional for everyone. Those who shared their experiences with medical mistakes and how it affected their family was very moving. In talking to Mr. Burrows after the movie, he mentioned that he initially wanted to cut the emotional scene in his living room when they were having a family meeting. I’m glad he didn’t,  I believe this is good for people to see. As a physician it is easy to lose sight about what people go through once they are out of the hospital, an out of sight out of mind mentality. But this is important for us to realize and help us to remain humble and provide the best care we can.

As an Anesthesiologist, yesterday was really thought provoking. In the end, bad things can happen even when you do everything 100% correctly. Training in Jackson, MS we have one of… Continue reading

Reflections from Monday and Tuesday

Despite my hectic journey to make it to Breckenridge (which I elaborate on in Day 1), I can safely say that my first two days here were emotionally exhausting but very informative and inspiring.  I wanted to use the time I have now to reflect and post a couple of takeaways I’ve gotten so far.

Day 1 (Monday):  I found the Story of Lewis Blackman to be eye-opening and shocking for a particularly unique reason.  On my trip from Dallas to Denver, my flight actually got diverted to Colorado Springs because of a tornado in Denver and the plane I was in not having enough fuel to make it there safely.  When the plane arrived to Colorado Springs, the engine died and so did the AC later on.  After 2 hours of waiting on the tarmac of the airport, with no fuel, AC, ways to… Continue reading

Reflection: It takes one…

If I’m going to be completely honest, the biggest reason that I applied to The Telluride Experience is because I didn’t have much experience with Patient Safety nor know anything about it. Someone just told me about it and said “this sounds so you…” and I just went with it. So I came to this conference thinking that it would be a really good opportunity to hear about everybody else’s experience and learn from them.


What I did not realize was that a medical error has recently unfolded right in front of me. What’s worse is that I have been directly involved in the care of that patient and was not aware that I have been unconsciously blocking it out and just not thinking about it. I walked into this conference genuinely thinking that I have never seen or been part of a medical error…however, as each layer of… Continue reading

TTE Reflection (Day #1)

Both the film we watched and the Teeter Totter exercise strongly impacted me today. In the film, I was particularly shaken by the massive number of opportunities each person had to notice a failure in the system and still did not. Over the course of the weekend, there were multiple educated professionals who were meant to have the skills and knowledge to identify and intervene accordingly. And they all went in and out of that room. We learn about anchoring and confirmation bias in medical school, but it was a difficult-to-put-into-words experience to watch those concepts lead to a fatal outcome. In a way, the exercise with the Teeter Totter better informed how I felt. When we debriefed after the exercise, right after our group failed to protect one of our egg-cellent patients with the last two people hopping off, the point was made that most “failures” occur when people… Continue reading

Reflection day #1

Today started emotionally with the Lewis Blackman film. So many errors were seen within the medical system but I have sadly seen many similar cases. From a nursing prospective I have seen incredible changes over my 10 year career. Today hospitals empower bedside nurses to speak up and even start the early detection of a patient’s decline. When I first started nursing I was never taught to speak up when doctors rounded or even challenge patient care/ orders. Today I see major changes in hospital culture. Medstudents start their day finding the nurse on my unit and asking how the previous shift went and what problems we anticipate or encounter. We preform daily rounding with a multi disciplinary team including the nurse and charge nurse for input. Specifically for the Lewis Blackman case, his vitals today would have prompted a SIRs or SEPIS alert and a nurse would then draw… Continue reading

Day 1 Reflection

In Gwen’s presentation this morning about experience as a learning platform, I was particularly struck by her use of the word “sensemaking”; it’s a word that has come back to me multiple times throughout today’s discussions and learning activities. Before today, I’ve sometimes paused to consider the challenge of how we make sense of or reconcile stories among the different individuals within healthcare encounters (including but not limited to doctors, nurses, patients, family, and patient advocates). I think understanding the viewpoints of others is part of what we’re getting at with some of our discussions today. However, there is another element I had not previously considered and it connects back to Gwen’s presentation – the importance of what language or words we use when sense-making. I wonder what happens if we first reflectively write our story, and then analyze the words and language we’ve chosen in trying to understand our… Continue reading

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