A great first full day in Telluride, full of thought-provoking discussion. Reviewing the case of Lewis Blackman highlighted a number of key themes for this week: the importance of effective communication between care providers and between providers and family; the danger posed by confirmation bias and premature closure in coming to a diagnosis; and the necessity of informing patients when we have done them harm and providing them with accurate information, a sincere apology, and meaningful follow-up. One quote in particular from the day’s presentations stuck with me: “Culture eats strategy for breakfast.” It gets to the heart of why effecting change in patient safety is so challenging, even when we know what tactics should work, and why even the best laid plans are doomed to fail if the organization’s culture is not dedicated to safety.
