Slowing down to Speed Up

Day one reflection–Telluride East

by Scott Emory Moore

“We don’t run in the ER.”  

Early in my career as a new graduate nurse in a Level 1 Trauma Center, I remember hearing these words.  I do not remember why the nurse said this to me at the time, may not quite be the same reason as it comes to mind now, but it is a valuable lesson none-the-less.  In reflecting on my first day at Telluride East, it is evident to me that one person’s hasty actions can have tremendous impacts on outcomes and patient experiences.

Often in the healthcare industry we are quick to focus on speed and time rather than diligent and deliberate precision in the execution of the interventions.  Getting caught up in the fervor of the emergent situation does no good for us, rather it is when we slow down and take a full account of the situation that we are able to serve our patient’s best interests.

Slow down in order to speed up…

The Lewis Blackman story is a great example of the need to really take our time to ensure strong work and safe outcomes for patients.  Intentional focus on safety must be at the center of our work as healthcare professionals.  The stories of patient loss like Lewis Blackman must pave the way for improved hindsight, insight, and foresight surrounding patient safety.

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Day One: Telluride East Reflections

By Linda Hunter, RN, PhD Student

I continue to learn from and be impressed with my health professional peers and feel like we are starting to get closer to the top of the patient safety mountain and picking up speed as we move “up and over”. I am thrilled to see the interaction and reflection amongst the multi-disciplinary group we have.
When Rose mentioned that Lewis was with us and watching – it reminded me of when my sister passed away due to a medical error involving morphine. She was 24 yo and legally blind due to juvenile diabetes but was vibrant, intelligent and fun! She died while I was working in Saudi Arabia and when I was coming home on the plane (crying the whole way) I looked out and saw her walking on the clouds and smiling at me. We can never forget the loved ones we have lost due to error – every “error” has a face and all have a story that continues. Let’s continue to work together and realize how vital it is that we all have and use this knowledge and then share and spread the patient safety knowledge with our peers back home.

By Lynne Karanfil RN

What makes a train? Not just the engine or cars but the coupling device that hooks it together….Professor Cliff Hughes indicated….we need to be a team to make change happen…brilliant!

And then Garrett, 2nd year medical student asked me why don’t all medical school curricula have a course on patient safety like Telluride East? Spot on Garrett! All healthcare providers should have this basic training! Day one at Telluride East was phenomenal! I always learn something new from listening to Lewis’s story and how to engage the healthcare community to become better change agents. Day two..bring it on!

By Rose Ngishu

From tears to transparency is a very powerful story that captures many of the barriers to patient safety in our hospitals. It is more than an irony of ironies. As Helen Haskell pointed out, it is sad that “if Louis had been anywhere other than the hospital, he would still be alive.” Until every patient is safe all the time in the hospital, we are challenged to keep speaking up. And when that goal is achieved, we have yet to keep speaking up on matters of safety.

The best advocate

By John Joseph, MS2 Wayne State School of Medicine

We completed the first day of the Telluride Patient Safety Summer Camp and I can say already that I am so glad I took the time to make the trip out. Telluride is a beautiful place and the enthusiasm and passion of the participants and leaders has reignited my interest. The lesson that stood out the most to me today was the video put together by Drs. Mayer and McDonald on the heartbreaking case of Lewis Blackman. His mother, Helen Haskell, fought tremendously for Lewis while he was in the hospital (and she continues to fight the system that killed him to this day) after a routine surgery. She trusted her instincts that something was wrong and repeatedly pushed for more senior physicians to examine Lewis, over and over and over. I was shocked that despite her insistence, that her requests were not honored. I was also horrified to think that if this type of cascade of errors can persist when the patient has a vocal advocate like Helen, what must happen to patients that are alone or do not have advocates that feel comfortable or able to question at all? How many children and adults have died because they did not have someone on their side? This hammered home the need for patient advocates and I look forward to learning more about their roles and implementation later in the week.

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