Pre-Telluride Post: Why Wouldn’t Someone Follow Proper Procedures?

During nursing school, I received extensive training on preventing adverse events. Despite sitting through countless lectures about infection control and fall prevention, something never clicked for me in the classroom. I reasoned that most – if not all – of the things I should or shouldn’t be doing were common sense. Why wouldn’t someone wash their hands before each patient encounter? Why wouldn’t someone follow proper procedures each and every time? Why wouldn’t someone contact the attending physician if they were concerned about their patient, regardless of the time of day? I imagined patient safety and health care quality occurring in a vacuum of my actions; I assumed that if I was diligent, attentive, and careful enough, adverse events would never happen to my patients. I didn’t realize it at the time, but I also assumed I would be making these rational decisions as a fully rested, engaged, and supported nurse.

Once I started working in a hospital, I quickly realized there were complex factors influencing patient care that I had never considered and that were, more jarring, outside the control of my vacuum. There were cultures, processes, and communications that were unique to each department and even time of day, depending on which shift was working. Burdened by stress, burnout, and sleep deprivation, health care professionals were asked to do more with less resources. Soon, I began to understand why problems and mistakes occurred. A provider missed prescribing a medication when discharging a patient, because there was pressure to free the bed for another patient who had been waiting in the emergency department for ten hours. A patient fell, because he was confused and forgot that he was connected to multiple machines, and his nurse was caring for a newly transferred patient. A patient received substandard care, because a newly trained nurse received incorrect information and didn’t feel comfortable asking questions of the leadership. I saw how factors such as accountability, fear, training, staffing, and leadership could create a culture that fostered or stifled quality health care delivery.

As a graduate student, I chose to attend the Telluride Experience, because it will challenge my paradigm and fill in gaps in my training. I desire a deeper understanding of how to effect cultural and systemic change to impact health and health care and to equip others. Through this week, I anticipate developing ideas, connections, and resources toward that goal.

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