The first day of Telluride was eye opening. The story of Lewis Blackman was eye opening. I felt so angry at all the safety measures that failed for this family and at the same time I felt so sad for Lewis Blackman’s family. I have read about other tragic stories like this one but never have I had such analysis of how the “medical system” failed to protect Lewis Blackman. So often as medical professionals, we play the blame game. I really enjoyed analyzing this story as if we were detectives. From a nursing perspective, I learned that documenting is great but being assertive and going up the hierarchy of command will save a life. The nurse in the case of Lewis Blackman documented a completely different narrative than the resident but didn’t take the appropriate action, which would be to follow the chain of command or call a rapid response. Communication between the intradisplinary team could have changed the outcome for Lewis Blackman. Futhermore, patients are entitled to understand the hierarchy amongst the medical team, which often times isn’t clear. I can’t imagine a mother watching her son die at the hands of the people who are in the business of preserving life. This brings me to my next moment of shock, the movement towards “transparency.” The mother of Lewis Blackman had so many obstacles to face from watching her son die to all the hospital staff omitting the truth in some fashion. Lewis Blackman’s mother says the nurse never looked concerned although she was documenting another narrative. The Resident never properly identified themselves, even though the mother asked to speak to the surgeon or the attending doctor. This poor mother discovered her son had died from a GI bleed, contrary to the diagnosis given to her upon her son’s death. Transparancy needs to be a part of the medical process as assessment is to medical process. From this tragedy so much can be learned but more importantly are we willing to be the change agent? This first day has really made me think about patient safety in a different light.