by Nisha Patel

My time spent at the Telluride Patient Safety Summer Camp was enlightening and life-changing. It was life-changing for me and my future patients. In my application essay I spoke about how “I want to be part of the solution and enhance patient safety by figuring out how to prevent nosocomial infections, lower remittance rates, and develop better communication strategies between health professionals”. I learned this and much more.

The statistics presented to us were powerful. I cannot believe I was never informed about the infamous IOM report in my first year of medical school. The Hippocratic Oath says we must do no harm; it would be wise if we learned how to actively not do this in medical school. However, this patient safety conference has educated me and I plan to spread awareness to my class. Medical errors account for the third leading cause of death in the U.S.; 100,000 people are estimated to die every year from medical errors in the United States. 100,000 in an industrialized nation. I couldn’t believe this. I also know this is a low-balled figure because of the lack of transparency. Furthermore, this number represents those that died from the errors, not all affected.

The stories presented to us were EVEN more powerful. Michael Skolnik. Lewis Blackburn. Alyssa. I did not expect to tear up at this conference but the gut-wrenching stories about these people, especially Alyssa, made it happen. Medical errors are too commonly accepted within medical culture, just like getting bug bites in the summer. It is horrifying. Medical errors are preventable and they are not numeric; each number represent a human life taken too soon. When patients are ignored in the hospital and one has to resort to calling 911 for help, you know the system needs to change. I pledge to carry these stories with me and share them so that I can enforce cultural change and not be a physician that says this is the way we have always done it; this is the commitment I made before leaving Telluride. I vow to listen to patients and their families when they tell me something is wrong.

The assigned readings were hardly assignments. Both were easy to read and enjoyable. My favorite was “Why Hospitals Should Fly” by John Nance. Having John speak to our class was amazing. I had no idea he was going to be in Telluride and I was very excited for his lecture. His lecture nicely mirrored the main topics in his book. He talked about the importance of complete transparency, teamwork among health professionals, leaving ego at the door, and having the bravery to speak up when something is not right.

John Nance told us of a potential flight accident he was involved in. When telling his story, he said something that horrified me: “this could have been worse than Tenerife”. The Tenerife airport disaster was the hallmark of systemic aviation failure, and it loomed throughout his book. Tenerife was the result of an atmosphere that extolled hierarchy and terrified those beneath the leader to speak up when it came to decision making. If Nance didn’t create an open environment, his co-workers would not have spoken up…Can you believe that? I sometimes still can’t. Nance is an EXPERT pilot. Despite his knowledge and experience, he could have been the face of the world’s biggest plane accident. Regardless of the knowledge I continue to learn in medical school, a broken system could lead to my future patients dying. This thought is hard to swallow. It is even harder to swallow that something as simple as proper communication could prevent it.

Yesterday I told my friend about my experience at Telluride and she said misdiagnoses are just a part of human error and cannot always be considered a systemic medical error. I disagreed. They are medical errors because we perpetuate a culture that does not expect human error. I then proceeded to explain the Swiss Cheese Model of accident causation. While one slice of cheese may have a hole in it (e.g. misdiagnosis), the slice behind it should be able to cover that hole so that an entire rod or medical error could not get through the log of Swiss cheese. If a doctor misdiagnosed a slide of cells as cancerous, there needs to be a system in place to catch that mistake. Not having a system in place to catch it is the REAL medical error. We must EXPECT people to make errors because humans naturally err; we must not expect people to be perfect. Like Nance’s book states, “It’s not bad people, it’s bad systems”. Before this conference, I would have had the same stance as my friend.

The constant comparison between the healthcare “industry” and aviation was particularly poignant. If there were as many fatal errors in aviation as there were in medicine, people would not choose to fly. When it comes to one’s health, you don’t really have much say in the matter. You either risk dying from your illness or risk dying from a medical error in the hospital. If high risk industries like aviation and nuclear power can run fairly smoothly, why can’t healthcare? Yes, healthcare is less technical and more complex. However, this is not an excuse. We can try, and eventually we will succeed. CULTURAL CHANGE TAKES TIME. I like that this idea was enforced throughout the entire conference and faculty kept reminding us of this reality.

Why don’t we recognize that 100,000 deaths per year is preventable and not acceptable? I’m so frustrated with our complacency. Actually, I’m enraged. It is not better to cover up medical errors. We need to bring them in the light in order to get rid of them. When my peers told me that the hospitals they worked at were celebrating 100, 200, 300 days without an error, I gained some hope. Hearing about the great work at MedStar also made me hopeful.

I kept a page of noteworthy quotes throughout the conference and thought I would share some of them:

  • “Nothing about me without me”
  • “If we were anywhere else, he would have been saved”
  • “Stop the line for safety”
  • “Medicine used to be simple, ineffective and relatively unsafe. Now it is complex, effective, and potentially dangerous”.
  • “Any human system built on the expectation of continuous perfect human performance has hard-wired failure into its structure”
  • “If you see something, say something”
  • “We exchange the ability to reprimand for greater knowledge”

Thank you to all the faculty and facilitators who made it possible for me to attend Telluride. Thank you for plucking me out of the dark and showing me this truth. I cannot express how grateful I am for you all teaching me how to take steps to achieve patient safety. I was one of the few in our class that had never done any QI projects or really anything to improve patient safety prior to the conference. Thank you for taking a chance on me. Thank you for trusting that I will take to heart what I learned and apply it.

Sincerely,
Nisha

P.S.This conference revitalized my passion for medicine. My first year in medical school was rough and certainly not what I was expecting. I lost sight of the end goal: helping people. This camp reminded me of why I chose medicine. I did make the right choice.

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