Reflecting on Telluride

I’ve thoroughly enjoyed my time at the Telluride Patient Safety Roundtable. It seems that the peaceful, picturesque landscape of Telluride is a perfect location to discuss the critical and complex topic of patient safety and quality. I enjoyed and learned from each discussion, but below are a memorable moments from the weekend.

First, I was very impressed by the quality improvement projects headed by the seven residents.  Each resident should be very proud about what they have accomplished at their institutions and have inspired me to go back to my hospital and initiate change.  Important take- home points from the discussion include performing quality improvement projects in a large, multidisciplinary team, and getting leadership on board in order to make more efficient change. Medical errors and hospital acquired infections are unacceptable and patient safety is our primary responsibility as providers.

Other take away points that I wrote down in my notebook from the other great discussions:

-The inherent fallibility of human beings: “Any system built on expectation of continuous perfect human performance has hard-wired failure in it’s structure” – Don Berwick

-The scope of the problem is HUGE: estimated 440,000 inpatient deaths/year  secondary to patient safety errors

– In a moment of crisis, people behave different and do not always act logically. Patient safety mistakes/errors are plane crashes in patients lives. It is important to understand this when delivering news, undergoing shared decision making and speaking with patients and their families.

-The concept of anchoring when making patient diagnoses and in negotiation. People tend to overweight the first diagnosis or number they see.

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