Before coming out here to Napa for this conference on patient safety, I wasn’t sure what to expect or what I would get out of this experience. I had this preconceived notion that I already was practicing safe medicine and I didn’t think there was too much that could be taught that I hadn’t already learned in school and as a practicing nurse. So coming here I was interested in what we would be discussing, and to maybe feel more validated in myself that I am doing what I am supposed to. But after the first day starting out with discussions about actual medical errors that have happened that resulted in death and then meeting Helen, after watching about her son made me take a step back and think about a time where maybe I had messed up and thought “oh no big deal” because it was such a small thing. Having her actually walk in after viewing the horrible events that led to such a devastatingly preventable death made my heart drop. After that moment I felt open to everything I could possibly learn, to try and take back as much information I can to my colleagues. So over these last couple days trying to take notes and absorb what I can do to help fix this culture, my favorite thing I am wanting to bring back with me is having a voice and not being scared to use my voice, and to try and help the newer nurses coming into my hospital system feel that they can use theirs as well. There have been instances where I have seen people not stand up for themselves, or feel like they will get yelled at for bringing up their concern more than once about a patient, and ultimately the patient suffers.

Now that we have made it to the end of the week, the other thing I know I’ll be bringing back with me is the Bleed Out documentary. Watching those events and how they unfolded lit a fire inside. A fire I know will light up in any good health care professional who watches it. It’s something that laid out all of the facts so well from the beginning of the story all the way through the end. I was angry at first, and confused as to how that hospital could not take responsibility? And as a nurse, I was incredibly embarrassed by how the nurse in this setting acted, going in and modifying notes, thinking of all the things I would do differently. The hardest part was trying to take a step back and understand why they did what they did and feeling the need to lie and cover up how horrible the care was for this woman. But now I feel determined. Determined to really make a difference and fix what needs to be fixed at any hospital that I am or become involved in throughout my lifetime. I am excited to go back and try to open eyes about what is really happening and how unfortunately often this goes on without us even being aware at how often we are making medical errors. I only hope that I can make as big of a difference as I am wanting to.