I chose to attend the Telluride Experience because I would like to learn more about tools and strategies that hospitals and physicians can use to deliver reliable, safe, and high-quality patient care. Patient safety is integral to good patient care because it is a fundamental element of the social contract between physician and patient and it prevents the unnecessary suffering caused by medical errors. A person visits a doctor with two basic expectations. First, there is the hope that the physician will diagnose and heal whatever ailment the patient is experiencing. Second, the patient trusts that the care they receive will be proper, regardless of the success or failure of the effort to diagnose and cure.
Proper care does not always mean that it never leaves the patient worse off – at least, depending on what exactly one means by “worse off.” For example, proper care may sometimes include dangerous operations with great risk to the patient because of possibility for success and the implications it would have – especially when patients request this type of aggressive treatment. These operations can lead to miraculous recoveries, but they can also lead to tragic complications even when the procedure is carried out with the greatest skill and care. In other cases, a patient’s condition may continue to deteriorate despite the physician’s best efforts to stem the advance of a disease. Even so, there is an important difference between this suffering, these unfortunate outcomes, and the suffering and harm caused improper care.
Errors, mistakes, slips, lapses – these are indicative of improper care, when processes are performed incorrectly in a way that causes harm to a patient in any phase of the interaction with the health care system. Care like this can lead to tragedy, shattering trust in medicine as devastating consequences underscore the betrayal – often unintentional – of the social contract between patient and physician. This is different from the previously mentioned case of a dangerous operation that fails despite the surgical team’s excellence, even though the result of a failed procedure may be even more detrimental to a patient’s health than, for example, a wrong-side surgery. Unfortunate outcomes can occur for any number of reasons in a field as complex as medicine, but those outcomes that are the result of an error are particularly troublesome because they constitute a violation of trust and can lead to unnecessary suffering. Patient safety efforts seek to prevent the delivery of improper care and avoid the horrible consequences that even the most innocent mistakes can produce. Good patient care is multidimensional, and patient safety is one of the most fundamental elements.