I told a colleague I would be out for a week to attend a patient safety conference, and her first comment was, “Oh, is that a particular interest for you? Patient safety?” As a student training to work with patients as a career, I couldn’t understand how any topic with the word ‘patient’ in it had the option of being an interest. Whether I liked it or not, I needed to know it and figure out how to make it an interest because it would be the main focus of my career.
From the opening remarks of the Telluride Experience, it was clear that whatever level of interest I had in patient safety prior to the conference would be exceeded as it has now consumed my thinking. It was the perfect riddle. Everything seemed to contribute to it and lack of something reduced it. Everyone needed to be aware of it and tell others about it, even if there wasn’t a system in place to address it. How do you achieve it?
Day one opened with the story of Lewis Blackman and afforded the opportunity to ask his mother questions about her experience in the hospital. Spoiler alert. While communication was stressed as an important link that broke during this medical error, both among health care staff and between providers and the patient or patient’s family, it wasn’t just the words said that mattered. When Lewis mentioned with a frantic demeanor that the pain in his abdomen that started suddenly had disappeared just as suddenly, the health care staff celebrated the improvement in patient status. They failed to use their observation skills to note his general affect or the tone in his voice as he said those words. Isn’t that just as important as hearing the words themselves? What is happening in clinical care that our intuition and reasoning is becoming secondary or even possibly defunct? Dr. Abraham Verghese has some interesting thoughts on the subject that resonate.
I also wondered about that first point of intervention to improve patient safety. Was there a pre-operative conversation with the family where the expectations for the procedure were clearly outlined, including details on risks and benefits with all aspects of the surgery and post-operative care? Is this the point when we should inform patients and their families about how to participate in their care and clarify the rules of engagement with health care staff to ensure better outcomes? Exactly what will it take to prevent another slow-onset medical error from claiming the life of a patient? The riddle remains unanswered.
Even after just one day of this conference, I feel that I am better equipped to have that conversation with my colleague or anyone else who wants to know if patient safety is a particular interest of mine. I am interested in clear communication, efficiency, providing high quality care, not falling victim to premature closure in medical diagnosis, and strengthening systems to catch errors that I will inevitably make as a fallible human being. So, yes, patient safety is a particular interest of mine.