Some thoughts before Turf Valley

Having recently finished reading ‘Why Hospitals Should Fly?,’ I cannot help but feel a lot of the initial skepticism that Will had when visiting the fictional St. Michael’s. It seems intuitive that a top-down approach to massive cultural change cannot be as strong as one that emerges from the frontlines. However, one of the concepts that I empathize with as a GI fellow and former Medicine resident is the amount of cultural inertia there can be in a hospital or a hospital system. That inertia is often either met with jadedness/frustration vs resign/burn-out by house staff who may feel that they have little influence or say in the matter.

Furthermore, as someone still in training, I have already witnessed or have been a part of medical errors, some small and some big. I have mistakenly written for the wrong medications or doses in the past, I have lost patients due in part to decisions made while being up for 30 hours, I have seen adverse events from endoscopies, such as perforation, that are unfortunately complications that inevitably happen. I have been able to participate in patient safety event reporting, which I think is a great thing. What is less great has been my experience of M&M, or Patient safety and qualify conference, which is still a thinly veiled M&M that focuses more on liability and legal ramifications versus finding solutions to systemic issues.

As a novice in patient safety, one of the reasons I’m participating this week is to learn more about how I can implement change to this mindset even as a fellow. I believe that patient safety and QI can sometimes carry negative connotations in fields such as GI, where there still can be a culture of infallibility. My short time as a physician has taught me that that mindset will only be detrimental to my career. I hope that my experience at Telluride will provide me the initial tools and ideas to really take part in patient safety in my career.

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