#TPSER9 Reflections: Day Three

By Mary Blackwell, Nursing Student, UPenn

By the end of day three my mind is saturated and I feel so lucky to have the opportunity to be here at the Telluride East Conference. Aside from the twins in utero, as a rising senior in UPenn’s undergraduate nursing program I am certainly the youngest conference attendee. As a student, and a nursing student at that, in the hospital I often feel like the lowest on the food chain. But in this environment of open communication the medical hierarchy collapses and it amazes me to see various healthcare professionals come together for the betterment of patient outcomes. Never before have I had personal connections or meaningful conversations with interdisciplinary healthcare students surrounding issues in healthcare. Because it is so clearly valuable to have these types of conversations, I wonder why academic programs don’t put a larger effort into connecting various healthcare students during their training. Having positive experiences with one another while we’re all still humbled by the title of student could change the culture of staff dynamics in our future clinical settings.

Over the course of the past two days we have heard several stories of near miss or sentinel events in hospitals across the country. As individuals focused on honing our clinical knowledge and skill, it is inevitable to put ourselves in the shoes of the providers in these cases. I shared the shame that several students expressed during these presentations. It was difficult to watch mistake after critical mistake during the tears to transparency videos. It made me cringe in frustration and anticipation as I watched medical professionals continue cause harm to trusting patients. It’s hard to imagine missing the telling vitals signs in the story of Lewis Blackman or passively allowing the sedated Michael Skolnik to sign a consent form. However the focus of our discussions have been that many of these errors arise from faulty systems, not faulty health professionals.

During Terry Fairbank’s discussion of human factors engineering I was able to understand how systems can keep professionals from practicing to their full potential. One of the great examples of systematic hazard was the nurse who accidentally hit the wrong button on the defibrillator in an emergency situation. Instead of delivering the necessary shock to the patient in cardiac arrest, the defibrillator turned off. This delay the life saving care for the patient decreased the patient’s chance of survival. I could imagine myself making this mistake as easily as I do when quickly pressing the wrong button on my cell phone or car. A normal error such as this could happen to anyone in a high stress environment. The instrument was poorly designed; the off button was green while the correct button in this situation was red and flashing. In our society, green means go and red flashing means stop so this design is counter-intuitive.

For the first time I appreciated my constant second-guessing as a student. It’s when patient care becomes routine, second nature that mistakes are easier to make without systematic support. It’s going to be great for us to all go back to our institutions hyper-aware of these systematic barriers.


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.

Changing Perspective

By Pat Bigaouette, Georgetown University School of Medicine

While riding in the plane from Dallas to Montrose I was reading the book “Collateral Damage”, which was suggested/required reading for Telluride. Immediately after the stewardess gave us our drinks, the man directly across the aisle from me leaned across and asked if I was going to Telluride. I looked and my book and then looked at him and replied “yes”. He introduced himself as Tim McDonald and I immediately recognized the name and remembered it being listed as of the four coordinators of the conference.

Knowing that the man I was speaking to would probably be giving several lectures, and that he was probably very important in the patient safety/quality community, I tried to keep a low profile while being polite as possible. I imagined 100s of people squished into a hotel conference room and I had a huge fear that Dr. McDonald would soon be singling me out to answer questions because I was the one person he recognized from the plane ride over. I figured keeping my mouth shut would give me the best shot at being unremarkable.

We briefly talked. He told me that I would learn a lot and to be ready for a unique experience. Unique would be an understatement. I’ve been to conferences where the majority of people would listen to lectures, go to poster presentations, and escape to the hotel rooms at the first possible opportunity. Telluride was a little different.

Dr. Mayer made a comment the very first day about going home and continuing conversations about patient safety over dinner and drinks. He stated that people are often so passionate that conversations would continue until midnight or later.  Inside I laughed. I thought there was no way people would sit through lectures all day and then go home and talk about patient safety all night. However, that is exactly what happened. And it happened every single night.

I could make blog posts for the next year about important topics that were discussed and stories that were shared. However, the most important thing that I learned while in Telluride was the importance of passion. I sat and listened as passionate after passionate lecturer shared their experience and expertise with me. I learned how they have all made a difference in their respective healthcare systems by being enthusiastic and passionate. I found myself going home and discussing patient safety for hours after the conference had ended. It happened over lunch, in the gondola, at the store, while rafting, while hiking, while walking to the school, and pretty much any time there were two people available to talk.

One night in town a few of us were headed toward the gondola to catch the sunset at the top of the mountain.  We walked by Kathy and Dr. Halbach eating. Several hours (and dessert—thank you Dr. Halbach) later, we pulled ourselves away from the restaurant. Not because we were done discussing and sharing stories, but because the restaurant was closed and the staff was waiting around hoping that we would leave.

I laughed at myself as I boarded the plane from Montrose to Dallas. The nearest person from the conference I could talk to about the conference was several rows ahead of me, I ran out of patient safety/quality books to read, and I had read all of the articles saved on my iPad from PubMed. It would have been fun to sit next to Dr. McDonald again to share the change in my perspective from five days earlier.

Knowing that the people in my immediate surrounding probably did not want to hear about patient safety or the Telluride conference, I decided to read the book I snagged from the free box in downtown Telluride.

See One, Do One…#TPSER8

There’s an old adage in medical education “see one, do one, teach one.” I don’t particularly subscribe to it in a literal sense because I think training requires a more intensive learning process than that.  But sometimes it does apply quite nicely.  A perfect example of this was on Wednesday when I helped run a session about shared decision making and informed consent at our new house staff orientation.  The session consisted of a viewing of the video of Michael Skolnik’s story followed by a moderated discussion with the house staff.  The idea came out of a casual conversation with my hospital’s Associate Vice President for Academic Affairs.  I thought it would be a helpful to new residents to think about these important issues before they really start on the wards and she let me run with it.   Just two weeks out of TPSER8, I just felt the itch to continue sharing what I’ve learned.  I had never led anything like this, but after seeing how David Mayer and Tim McDonald guided our discussion in Telluride I was inspired to try it myself.  I had some great help from a fellow Telluride alum, Hilary Kunizaki as well as several other CIR staff who came for the session.  Here are a few comments from the new house staff:

  • I asked, “What do you do when patients don’t understand a treatment or procedure?” and had some great responses: “draw a picture”, “have someone else ask” and “figure out if there is a language barrier”
  • In regards to the stereotype that general practitioners know less than specialists, the interns suggested that specialists should work with PMDs in a team-like manner, concentrate on common goals and the interests of patients, and verify information by referring back to the literature.
  • There was some hesitance among  house staff who might be doing a procedure for the first time about admitting their inexperience to patients so I pushed them to consider an appropriate response.  Interns said they would tell patients that “they were under supervision and working with attending X who has x number of years of experience.”
  • Important strategies to verify consent included the “teach-back” method, assessing capacity to make a decision, and involvement of family members.
  • One intern said that “no one patient is an island” and echoed the consensus that involving family members is important even if the patient is over the age of being legally able to sign an informed consent document.
  • Some difficulties that residents mentioned when performing informed consent include language barriers, time, and dealing with patients who are uncooperative.

Overall, the new house staff seemed to really enjoy having the opportunity to be engaged in a discussion rather than just hear a lecture about the importance of informed consent.  I think this further proved the importance of narratives in medicine.  I’m looking forward to holding more conversations like this in the future.

Day 3 Telluride Reflections–Denise Neal #TPSER8

The hike today was amazing.  We set our today at the bottom of the mountain with reservations of conquering the challenge ahead of us.  Some of us were unsure if we would make it to the top.  We already had moments of being short of breath just from the altitude.  The hike symbolized the challenges we will face as we move forward to implement change and increase patient safety.  At times we walked together; similar to when we are all in agreement with a change.  At times we also walked up hill alone, similar to when we do not have buy in for a change and we carry the burden to move it forward alone.  The journey seamed long at times and it was hard to know how far we had left to go, and felt unsure of how far we had come.  We took the climb one small step at a time and eventually we saw the end in sight.

We finished the day brainstorming ideas for change.  The group came up with many great ideas and solutions for change.  We discussed barriers that might get in the way and solutions to address these barriers.  We talked about identifying stakeholders in order to garner support for our patient safety solutions.  We also talked about measuring the outcome of the changes.  The group used creative ideas of how to share these solutions with other groups across the country.

Denise Neal

Telluride Reflections Day 3–Matt Starr at #TPSER8


In my return to Telluride 6 years later, not a lot has changed. The people here are still as friendly as ever and the best taco stand I have ever found is still making the same mouth-watering burritos (pictures to come). However, my journey here is far different than before. This week I have been exposed to a wide variety of people involved in the health care community all wanting to hone in on issues surrounding patient safety.

The discussions that are taking place will one day shape the future of healthcare as patient quality and safety continues to evolve. Ideas are being bounced around and discussed around the clock. I think so far the most profound stories for me were the videos of Lewis Blackman and Michael Skolnik. It is hard to see how easily the medical system can fail so easily, but these stories and those of many others will only help bring change to the medical community.


Today was the best day of the week so far. It started off with an awesome hike up the mountain to waterfall just outside the valley. Before we set off on the hike the camera crew asked me if I would wear a camera around my head that would capture my trek up the mountain. In addition the camera was pointed at my face and not away from it, which was also weird.

It was kind of intimidating knowing that they would be capturing my conversations with everyone as we all went up the mountain. At first nothing really came, but as we progressed through the hike we started conversations that we continually came back to throughout the day. We tended to focus on the notion of how can we make change at our institutions, something that this week was building up to. We couldn’t discuss this topic right away until we had the foundations that were built on the first few days.

The afternoon produced the most productive learning session the group had as a whole. Everyone was contributing their own ideas and thoughts that led to some really great changes that everyone wants to bring back to their institutions. Immediately we all began thinking of ways to stay in contact after the week so that we could successfully implement these changes across all of our schools and hospitals. It was just awesome to see that everyone in the room was genuinely excited about the changes we could make that began in a small room in Telluride. It is a powerful sign about what can be accomplished by medical students when you gather them together and show them that they can make a difference, which was illustrated by the article Wendy gave us about the IHI initiative on surgery checklist.

After a hard day of hiking and discussions a group of us had worked up quite an appetite and so we headed to the infamous taco shack. However, my cravings were not indulged as that stand had closed an hour earlier. But we found the cook and made sure that we would be there tomorrow while they were still open.

The taco stand being closed did not set a bad tone for the night, but in fact was just a minor speed bump in what was an awesome night. After dinner a group of us went into town with Tim. It was fun to hang out with everyone in a social setting just getting to know each other. Four of us stayed down in town until the last gondola ride and Tim stayed with us the whole way. What was even better was that when we got back the five of us didn’t go to bed but continued our conversation of how we can make changes at our institutions with Tim giving us some excellent insight. The leaders of been saying sometime this week we would have our “aha moment” and that moment for me was last night talking with Tim. I have always thought of how standardized protocols (aviation) and lean thinking would be the cure all for medicine. Throughout the week, Dr. Angood had mentioned that maybe that wasn’t always the case, but he had never gone into much detail. However, Tim gave me a great analogy that just shook my current way of thinking (I will post this in a later blog as it requires a little bit more writing).

I’m looking forward to this last day in Telluride, but it is also bittersweet to think everything is coming to an end already. Also looking forward to finally eating my burrito. More to come soon.

-Matt Starr

On “Informed” Consent and Walking the Line by Natalie Kress #TPSER8

As day two neared a close, a spontaneous conversation amongst roommates touched on two topics relevant to our discussions today.

1.  “Informed” Consent

The goal of informed consent is simple: to provide the necessary information that allows the patient to reach a decision regarding his or her health.  Today we discussed the pitfalls that have led me to view the word informed in a different light.  From obtaining consent in less-than-ideal situations to forms filled with complicated jargon, it seems to me that the current consent process requires the patient to be vigilant.  In many ways it seems that the burden of responsibility to understand the decision-at-hand has been placed on the patient.  Is a system where the burden of responsibility is placed on the patient safe?

2.  Value in Walking the Line?

In various activities yesterday and today, the theme of self-evaluation has been prevalent.  We have been asked to self-evaluate our leadership and listening skills, to name a few.  One interesting tangent from these introspective activities was discussed informally this evening:  what is the value, as a medical professional, in walking the line?  Despite being told to set our personal biases aside when interacting with patients (which is much easier said than done), would it be beneficial to walk the line/ride the fence on certain issues?  Would this approach allow you as a caregiver to be flexible in understanding your patients?  On how many issues do you truly have the ability to understand both sides of the argument?  And how valued is this trait in medicine?

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