Day 2 Reflections

At the end of my second day in beautiful Telluride, I am just as enthusiastic as I was on day one!  Every speaker was fascinating!  After years of having patients sign informed consents, I now actually know that this is a process and not simply a task that needs to be checked off.  Watching Michael Skolnik’s parents discuss the loss of their son with such regret and sadness will be a memory that I bring to every conversation I have with patients regarding decisions about procedures.  The Shared Decision Making concept was novel to me, and seemed very awkward to our group during the first round.  However, with the second two rounds, the language started seeming more comfortable making this process seem not only possible, but ideal for ensuring our patients understand their options and are truly receiving the care they need and desire instead of what we want and impose upon them.  I loved the teeter totter game!!!!  I can not wait to take this back to my hospital!  The teamwork, communication, leadership, fun, and laughter that was practiced here was incredible!  While I knew EMR’s are far from perfect, and that I get frustrated with the issues I encounter, I did not know that the issues are leading to deadly mistakes.  What was even more impressive is that the problem is known and not being addressed in an urgent way because of financial investments.  What I will take from this is a heightened awareness of the need to check behind the EMR in order to catch the mistakes I now know are inherent in the flawed products.  Mr. Nance’s discussion was absolutely fascinating!  I love hearing the way he discusses expecting mistakes in order to remain vigilant to catch them early as opposed to the traditional method of expecting perfection and feeling a need to cover mistakes when they occur.  The story of the near plane crash prevented by an 18 year old proved to me everything we have been taught in this program so far.  First, that effective communication and the freedom to question authority is key to preventing mistakes.  Second, that even the most experienced and accomplished professionals can make a mistake and even the most inexperienced can save lives if given permission to do so.  I had no idea there was so much in my profession that I did not know!  I can not wait to see what else blows me away tomorrow!

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