Today was the first official day of 11th Telluride Patient Safety Camp and it far exceeded any expectations I might have had. From the moment I sat around the fire outside of our beautiful lodge nestled in the jaw dropping landscape that makes up Telluride, I was sold. The enthusiasm of everyone around me, the great conversations and the energy radiating off of this group of people all excited to be here learning from some of the best in patient safety as well as from each other tipped me off that this is going an unforgettable experience in my medical career.
After hopping on the gondola and experiencing one of the best morning commutes I could imagine, we settled in for a day filled with thoughtful discussion, heart wrenching stories and collaborative learning. Unlike many of my colleagues here, I have a very limited background in quality improvement and patient safety. I am here because of a personal experience where a family member of mine was subject to a medical error that rocked our family and forever changed it. I came to seek out knowledge that I feel is one of the most important topics I should be learning in my medical school curriculum but has been largely absent, at least so far. I also just completed my first year of medical school so I also have a very limited exposure to working in the hospital and seeing these errors occur from the physician and nurse’s side. For this reason I am so grateful to be put together with this group of people who are able to contribute so many different perspectives and experiences that I can feed off of and discuss these difficult topics with.
Early in our day we had the opportunity to do just that. We were shown “The Faces of Medical Errors…From Tears to Transparency: The Story of Lewis Blackman.” This video brought up so many different emotions and thoughts as it played through. I expected that it was going to be sad and that the preventable mistakes made would anger me but a lot of things shocked me as well. One quote that really stood out to me was when Lewis’s mother Helen said “We were just hoping that by morning somebody who knew what they were doing and could help us could come.” The first thought that went through my head was what?! This sounds like a person involved in a search and rescue not in a hospital where you would expect to be safe.
In reality, the hospital seemed like the most unsafe place Lewis could have been. No one was searching further into Lewis’s problems and no one was goal-oriented and mindful enough to rescue him either. So many small errors and assumptions were made in a system where there was no net to catch them and a culture that seemed to further perpetuate the arising problems rather than empowering the medical team to even acknowledge them. It quickly became apparent that most people here at Telluride have encountered similar problems and frustrations because everyone immediately jumped to offering solutions to Lewis’s case. However, when Paul Levy asked us to think about how this could happen to any hospital, I began thinking and we began discussing the systematic and cultural issues that are widespread across the entire health care system. I latched onto the fact that in medicine, for physicians especially, we have perpetuated this culture that doesn’t allow uncertainty. As a first year medical student, I spent most of my time in the clinical setting uncertain. Formulating a differential diagnosis is a skill I am far from mastering and although I know I will become much better at this as I continue on my education, I can’t imagine being completely certain with only a small snapshot of my patient and a few pieces to their puzzle.
In Lewis’s case it seemed like that is what the medical team was doing. How could they fully understand their patient Lewis and his post-operative course without including his mother in the conversation who has been in the room with him the whole time and has the best understanding of who her son is as a human being? How could they be so certain that Lewis was doing “well” and his pain was just due to constipation when there was no cross-communication and no one was asking the most important question: “What is the worst it could be?” As we all learned from watching the video, they couldn’t, but the culture they worked in and were trained in taught them they must. As our discussion continued and our diverse group of students shared their experiences with the challenging and sometimes dangerous culture we practice medicine in, it became easy to see how this could happen to any hospital and to any family, and it does.
I learned so much in one day at Telluride and I cannot wait to see what the next few days bring. Being a part of this experience so early in my education is empowering. I feel very lucky that there is such an incredible group of people passionate enough about patient safety to bring all of us out here and share with us lessons and tools that will help us be better health care providers and begin changing the culture in which we care for our fellow human beings.