Pre-Telluride Reflections

I’m a resident physician in Ob/Gyn, and I’m very excited to meet you all in Colorado!

My patient safety interest started soon after my residency experience began in a jarring way. Within my first month as an intern, a missed diagnosis on our floor lead to a devastating maternal outcome. We spent days and months trying to peel back the layers of what happened and analyze every page, order, and decision that happened or didn’t happen during her hospital course. It was easy for each of us to blame each other – or even more so, ourselves – for what happened. But we tried to focus most on ways in which the system failed her, and how we could build better communication and protocols to prevent this from ever happening again. In the end, she had a devastating disease – perhaps we could not have saved her no matter what we did. However, in working through her case we were able to identify many ways in which we could have cared for her, and other patients in the future, better.

Since that time, my experiences with patient safety and medical mistakes have been varied. Much of the time, our interdisciplinary team feels like a well oiled machine – everyone knows their role and we work well together to take the best possible care of our patients. But as anyone who has been on a busy floor knows, sometimes it feels more like flying by the seat of our pants.

Going into this experience, I am so excited to learn more about making the system work best for our patients. I’m looking forward to learning strategies on how to communicate more effectively with team members from every discipline, and to make safety a priority daily.

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