What is Preventable?

The word preventable can be misleading. It may imply that preventive perfection (zero harm) is possible. It does imply that some things are not preventable; sometimes these harms are distinguished by the label “complications”.

I like to take the view that all harm is at least to some extent preventable, and that there exist ways to minimize the risk of any given harm associated with any given procedure. It is a continuum. Sometimes, as in with central line infections, we have highly effective methods to minimize the risk, and then we label and declare all central line infections preventable. Other times we honestly don’t have methods to reliably minimize risk for a particular harm, and we do not consider it preventable. In these cases we declare the harm to be an unpreventable complication, i.e. “these things happen”. An example of this would be central line infections…15 years ago. I would… Continue reading

By Aaron Cantor, MS1 Pennsylvania State College of Medicine

In just the first day, I feel refreshed to listen to, and take part in, the unique conversations that develop spontaneously after activities and during breaks.  I hope we can discuss results of increased patient safety as a group with regard to medical student training at free-of-charge clinics.  These venues often provide care to vulnerable populations, who medical students may “help” by performing common procedures or assisting an overworked volunteer physician.  Many procedures have an inherent learning curve in which mistakes are common during the learning stages, and these mistakes may cause undue harm to the patient.  There is certainly a fine line between a medical student providing helpful care and learning versus harmful mistakes and discouraging patients from visiting again.  Medical students may also overestimate their skills and find themselves in uncomfortable situations without readily available assistance.  For example, I am aware of… Continue reading

Reflections from Telluride, Week 2

By Jan Boller, Western University of Health Sciences

Yesterday was my first day at the inter-professional Patient Safety Summer School for medical, nursing, and pharmacy students. I echo the conclusion (by Kim Oates) that the future is brighter. As I listened to the students reflect on what they were learning, it was inspirational. They will reshape healthcare to be safer, more effective, and more affordable. I felt a renewed sense of urgency to spread and sustain this exemplary model for preparing future health professionals. Thank you to David, Tim, Kathy, Gwen and the entire faculty team for creating this exemplary program, and to The Doctors Company Foundation for providing the student scholarships. Brilliant idea!

The best advocate

By John Joseph, MS2 Wayne State School of Medicine

We completed the first day of the Telluride Patient Safety Summer Camp and I can say already that I am so glad I took the time to make the trip out. Telluride is a beautiful place and the enthusiasm and passion of the participants and leaders has reignited my interest. The lesson that stood out the most to me today was the video put together by Drs. Mayer and McDonald on the heartbreaking case of Lewis Blackman. His mother, Helen Haskell, fought tremendously for Lewis while he was in the hospital (and she continues to fight the system that killed him to this day) after a routine surgery. She trusted her instincts that something was wrong and repeatedly pushed for more senior physicians to examine Lewis, over and over and over. I was shocked that despite her insistence, that her requests… Continue reading

20 Lessons Learned in Telluride by Heidi Charvet MD

I just returned from an amazing week in Telluride where I not only learned a lot but was also inspired and reinvigorated by the group of colleagues and faculty I met.  One of the most surprising things about the week was that despite our varied backgrounds and geography, we all came together with a common set of interests and experiences (sometimes bad ones) determined to make changes moving forward in our practice.  Thank you to everyone I met this week.

Here are the main lessons I learned during the week as well as some fantastic quotes from the group…

1.) Start every meeting with a story (it’s all about the patient!)

2.) The way we treat nurses when they bring a concern to us that ends up being wrong, is often more important than when they bring a concern that ends up being right (respect and appreciation are… Continue reading

I have looked into the future and it looks good

By Kim Oates MD DSc, Director, Undergraduate patient Safety Education, Clinical Excellence Commission, Emeritus Professor, University of Sydney

I am traveling back to Australia after once again being on the Faculty at the Telluride Resident Summer Camp, organised by David Mayer and Tim McDonald. Although I came to teach, I learned far more than I taught.

The course participants were 28 residents selected from across the USA for their passion and commitment to make a difference to health care by embracing patient safety. They ranged from Interns through Chief Residents and Fellows. They came from diverse specialties, united in their desire, not just to make a difference in their own work but to help develop safer systems in their work places. They were an inspiring group, a group representing some of the future leadership in this area.

When you look at many of the current leaders in patient safety, right… Continue reading

Day 2 – BHAG

Day Two At Telluride Patient Safety Summer Camp

Today’s final discussions revolved around what three tangible things we as residents can do when we return to our respective programs to improve shared decision-making and improve our ability to communicate in the case of patient harm. I was very encouraged that there was actually very little variation from each of the breakout small groups. We all seemed polarized to some very clearly defined, and what seemed like obvious, solutions to improved patient safety in our respective corners of the world.

The opportunity that I see after completing this exercise is that although we can all make small incremental changes in our respective practices, how can we reshape the practice of medicine to make our small individual changes part of a bigger and more permanent cultural change? If all 28 of the scholars would communicate with 10 colleagues about the importance of… Continue reading

The needs of the patient come first.

Take a look at Shabs recent post, How Can We Teach, regarding her QI project standardizing an appropriate informed consent discussion. She says several times that we need to put “patients first.” It warms me from within to hear this; I was already going to put up a little post about that very idea. I had the great fortune to go to medical school at the Mayo Clinic in Minnesota, and the most important thing I learned there was this philosophy: the needs of the patient come first. When we believe this and act upon it, we have the courage to address problem behaviors among our peers (and even our attendings and consultants!). We find the moment to sit down instead of hovering near the exam room door and we don’t accept the status quo. Consider it as a mantra for yourself and something you teach others!

How can we teach?…

My Fellow Telluride Patient Safety Gurus,

What an incredible week! I have been so fortunate to be surrounded by such a brilliant group of people leading change all over the country. You have all inspired me and energized me to go back and promote the mission that we have all set out for ourselves- create a system that is patient first.

Inspired by Rick’s proverbs reminding us all that we are teachers and it is our responsibility to share the knowledge that we have gained to improve our systems, I’ve come up with an idea on how to approach teaching informed consent to our fellow residents.

But how do we teach?…How do we teach hundred of grown adults, physicians, those set in their ways with their own ideologies and beliefs that may or may not contradict yours. How do you teach change?…

Here’s my attempt:
Create an “Informed Consent Checklist.”… Continue reading

Additional Day 3 reflections from faculty and residents follow:


By Patrick Smith MD

Day two of this conference was another amazing experience. I continue to be constantly surprised and impressed by all of the participants at this conference. It is very humbling to be in the presence of people of such outstanding quality with firm convictions to make the health care they give the best and safest it can be. I commend everyone on their character, heart and innovation. These people are inspiring in every sense of the word.

By Ann Lambrecht, RN, JD, FASHRM

Today was again very enjoyable.  Each component served as a foundation and building block for the next session.  The team building exercise was a profound learning experience.  The films raise real issues and the residents were so responsive in developing solutions. I am thoroughly impressed with these future leaders and the faculty… Continue reading