The Day Before Telluride

As I approach my departure to Colorado, I can only think of the events that have brought me to this point in my life. Tomorrow, I will travel to a completely unknown place, however, I will also meet very similar minded individuals. I am both excited and nervous at the same time, most of all, however, I reflect on the patient incident that made me first interested in patient safety and quality improvement. I was an undergraduate student volunteering in a large urban hospital that served many underserved populations in the city. I met this patient early in my shift one morning and noticed that he had been labeled as a Fall Risk. This meant he had on his yellow socks and a yellow sunflower on his door. I was impressed by the double identification and the attention to detail. However, I soon realized the flaws of this system and the lack of a unified protocol for fall risk patients at this institution. I left my shift just as a nurse, a central nursing assistant, and another volunteer had begun to bathe this patient who seemed delirious at the time. I only found out a couple days later, on that same night the patient had been allowed to get out of his bed to use the restroom, suffering a bad fall that put him into a coma with a broken hip. I asked myself how this could have happened. I was shocked when I found out the truth. He had not been given his yellow socks back after being bathed by the medical team, and for this reason, someone had also removed the yellow sunflower believing that the patient was no longer a fall risk.

I first heard about Telluride from my fried who is now an M3. He knew about my interest for patient safety and told me about this wonderful opportunity to meet like-minded individuals. I decided to go to Telluride because I want to see change in the way that institutions handle patient safety as well as learn from experts on the topic. I want to bring my insight to this conference as well as learn from my peers about how they believe that patient safety can be improved. I am coming into Breckinridge with an open mind and a lot of enthusiasm.

Writing this today, I am ready to learn, meet everyone and most importantly bring back all the great ideas to my colleagues here at the University of Virginia.

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