I remember vividly the feelings of sorrow and outrage I felt when I first heard the story of Lewis Blackman as a second year student in my school’s patient safety course. Though I had dealt with adverse outcomes in my past clinical experiences, I was shocked and saddened by the series of errors and oversights which led to the death of a promising young boy after an elective surgical procedure.
Two years later as I re-watched the video at the Telluride Patient Safety Conference, I again felt an incredible sadness and frustration, though this time for a slightly different reason. As a recent graduate of medical school with two years of clinical rotations under my belt, I identified in Lewis Blackman’s story the slew of medical errors, communication breakdowns, patient safety events, adverse outcomes and near misses that I have personally witnessed (and occasionally participated in) as a student. While there are many wonderful and well intentioned health care practitioners, I have too often felt a sense of disappointment and futility at the lack of true commitment and adherence to safety standards and principles.
Luckily, my frustration at the system only fuels the fire. It reminds me to always be an advocate for my patients, to make my voice heard when it needs to be (regardless of who it annoys), to teach and empower my patients and their families to advocate for themselves, and to always keep searching for ways to improve. I feel excited and inspired today to be surrounded by a group of diverse, compassionate, interesting, and likeminded individuals who share these goals. It renews my sense of hope and excitement that things will improve and the culture of medicine will slowly change. I am amongst giants tonight in Telluride and I am humbled in their presence and so eager to learn the lessons and develop the tools to be an effective leader of change.