This morning, waking up, looking at the beauty outside my window, I can’t help but think about Lewis Blackman, and Helen Haskell. I have seen the Lewis Blackman film before, and the second time around it has impacted me in new and different ways. It still gave me a sick feeling in the pit of my stomach, and it still brought me to tears. However, there were so many things that struck me differently. Initially watching the film, prior to attending Telluride, I made a big list of  all the “things people were doing wrong.” Kind of a crude version of my own root cause analysis so to speak. I was trying to find a person or an event to blame. Why did Lewis’ healthcare team continue to give him Keterolac when he had issues with urine output? Why was there no concurrent steroid administration? Why was Lewis placed on the HemOnc floor rather than a surgical one? Why wasn’t the intern or the resident taking Lewis and his mother’s concerns more seriously? Why would the nurse force Lewis to walk around the hall in so much pain?

Perhaps it is the beautiful mountain surroundings, or perhaps it was reading John Nance’s book prior to coming here, but this time around my view of the film was more global and more broad. I think all of us could go on for hours retrospectively analyzing each flaw in Lewis’ care, but what struck me the most, my “aha moment”, was when Ms. Haskell said, “no one was pursuing goal oriented behavior. They were completing tasks. They were in a system that benefited themselves and the patients were incidental.” I feel that this insightful statement really displays the larger issue at hand. Parents know their children far better than any health care provider who pops their head in to check on them every 2 hours. Why was there not a culture that allowed parents’ concerns to be taken seriously? Nurses know their patient’s far better than an intern who is just cross covering patients on a weekend shift. Why was the night nurse who had shared her concerns in the charting unable to voice her concerns in an impactful way to the team? Why was there such a lack in communication and handoffs?

Even though I have only completed one day here, I feel that I have already undergone a change in the way I think about safety, and the issues that endanger patient safety.  Telluride is truly transforming my mind. Lastly, at the end of the film, Helen writes that she instilled a desire for travel in her son from a young age, but ultimately he never even was able to travel on an airplane. Lewis plays such a large role in not only why many people travel all over the country and even as far as Australia to learn from the tragedy of his death, but also to ensure that other patients receive care in a safe manner and ultimately achieve their goals and desires.