The view of the Napa Valley was breathtaking. Surrounded by great company and beautiful weather, I sipped on my wine glass taking in the magnitude of the evening at the Doctor’s Company reception, yet something didn’t feel right. Something was lacking. Something was making me feel unsettled and unnerved. I couldn’t get her picture out of my head, her enormous smile and bright eyes—sweet Alyssa. I nearly felt selfish about socializing and enjoying myself when I physically could not stop thinking about the bomb Carol dropped on the group during closing remarks as we wrapped up our first day. I couldn’t help but think about how we failed Alyssa. We failed Carol. We failed the entire family.
It has been an emotional day. The beginning of the session set the tone for the entire week. This is why we’re here. These are the situations, as pain staking to sit through, that are grave reminders of the reason each and every one of us took this opportunity to participate in this symposium. There is a better way. As a whole, we have to be willing to sit through the grit of these tragedies and work together relentlessly to always pursue patient safety in every situation.
As I listened to these stories today, I couldn’t help but try and navigate my feelings—anger, disappointment, confusion, and sadness. I cannot fathom the emotional rollercoaster these families have been encountered. At the end of the day, I truly feel it a privilege to have the ability to hear these stories, such as Carol sharing about sweet Alyssa. It is nothing shy of miraculous of those who are so incredibly brave in the aftermath of their immeasurable losses to share these tragedies with each and every one of us. They open their hearts and souls and have the courage to relive the most terrible day of their lives on repeat, so that we, as a whole healthcare profession, can not only learn from, but do everything in our power to promote positive change and cultivate an ethos of patient safety to ensure it is not repeated. I feel it is a privilege to be able to be extended the grace from these individuals who have experienced the failure of a very system that is supposed to be constructed to protect people. No one decides to practice nursing or medicine to harm any one, yet it is still occurring 250,000 instances a year. These types of opportunities, such as this remarkable Telluride Experience, are key in providing a safe environment to promote interdisciplinary communication and ultimately positively impact patient outcomes.
Our work may be cut out for us, but it is our mission and responsibility to constantly chase after zero–one Alyssa at a time.