#TPSER8 Today was the first full day of the Telluride Patient Safety Resident Summer Camp program. The mist had barely cleared the local mountains when co-host David Mayer presented the assembled residents with the outline of the 3-day session and set forth the objectives. The Telluride program began after David and colleagues introduced the first-in-the-nation 4-year longitudinal curriculum for medical students in quality and safety at the University of Illinois medical school. Noticing a lack of literature in the quality and safety field, they thought of organizing a conference to remedy the deficiency and contacted the folks at the Telluride Science Research Center. They feared that their proposed conference would be outside the normal scope of the TSRC scientific mission, but the board quickly endorsed the patient safety curriculum design session, noting, "We are all patients!"
The mission of the sessions was set forth as follows and persists to this day:
David talked about the desire to teach open and honest professional communication skills to overcome obstacles to improved quality and safety. Also, to focus on mindful practice -- understanding our own mental processes and thereby the biases we bring to the practice of clinical care.
Things then got serious, though, with a viewing of the video The Faces of Medical Errors...From Tears to Transparency. This is the story of Lewis Blackman, a 15-year-old boy who died because of a series of medical errors. It was produced by the Telluride faculty and relies heavily on the testimony of Helen Haskell, Lewis' mother. This is a searing story, with Helen at one point saying, "This was a system that was operating for its own benefit." Even after the death, "When we got home, we thought the hospital would call us. But no, they constructed a theory that was totally wrong. I was the only person who knew the whole story, and I was never consulted. They sent a brochure about mourning."
A deep and honest discussion ensued among the residents, reflecting on their current clinical experiences. Here are some of the comments:
"In my place, people are still not telling the truth to patients and families."
"We have to look at our own frailty."
"I am finishing my residency now. For a few patients, I know that I made the error. Not always did the attending physician want to debrief the case with me."
"M&M's in my hospital have gotten lame. I know of many cases that did not come up on the M&M docket."
"I often feel I don't have the support to give this [full quality and safety case review] the time and energy that is required. I have to get others to cover me."
"Calling the attending is still viewed as a sign of weakness." They will say, 'You are not able to independently manage the patient effectively.'"
All in all, a powerful morning, setting the stage and providing motivation for positive change and for attentiveness to the following events in the summer camp.