The word that comes to mind on day three of the Telluride Experience is grateful.  I am grateful for the opportunity to be here with such amazing participants; grateful that there are people like Dave, Tim, Anne, Kim, Rosemary, Roger, John, and Gwen who are willing to share their wisdom with us and make us rethink what we do, how we do it, and how we can do it better; and grateful that Carole,  Helen, the Skolniks, and the hospitalist who re-enacted his debriefing interview, shared their painful stories and put a face on the human cost of medical error.

My hospital has done a great job of providing its employees with cutting edge tools and education, many of which we discussed here in Breckenridge. I have been trained to use Carolina Cares, TeamStepps, SBAR-Q, CUS words, 6 Sigma, and the list goes on, but in rolling out these initiatives, our leadership failed to effectively connected the dots for me and many of my colleagues as to why we need to commit to consistently employing all of these measures. The message was not personalized, instead we heard, “We have invested a lot of money in this.  Use it.”  As a result, our training often feel like one more thing to remember, one more task to add to the list, and one more item that needs to be addressed in the verbiage of the annual review.  I am so grateful for the passion, enthusiasm, candor and vulnerability I witnessed at Telluride because it connected the dots for me between these tools and and their ultimate purpose. I am leaving here with a clear understanding of the value of these initiatives and a true sense of purpose in implementing them. I am committed to sharing what I learned as a Telluride alum with others at my institution and to working with those dedicated to advancing patient safety in hopes that someday in the near future, like St. Michael’s, my hospital will fly.