The first full day at Telluride was full of complex and honest discussions, as well as personal stories to help provide context and reminders that patients with adverse outcomes aren’t merely a statistic. In particular, we were honored to have Helen share a tragedy involving her son Lewis, and she was able to provide her perspective as a mother, as a patient, and as a patient safety advocate. Something that really struck me was when Helen mentioned that if Lewis had been anywhere else but the hospital (such as at home) then he may have had a different outcome due to a new set of eyes and an open mind about his deteriorating clinical status and acute abdomen. While our culture is changing and hopefully becoming more multidisciplinary and team focused there are still so many more steps we need to take to get to a place where all members of the team regardless of their position or training (RNs, RTs, food service, pharmacy, etc.) feel empowered to speak up when they are concerned about a patient’s safety. A wonderful point that I will take home with me and share with my institution is helping to foster that culture by thanking all team members and families when notifying us about patient status changes (ie. pages), and I think this could be a consistent way to provide positive feedback and allow all patient care team members to feel valued. I appreciate all of the wonderful conversations and look forward to more great discussions!
