Writing this on my return train ride back home from the Telluride Patient Safety Experience in Turf Valley. Reflecting on the entirety of the conference I think the story that impacted me the most was the Lewis Blackman story. As an emergency physician, missed diagnosis is what we as a profession fear above all in our daily work. The failure of a timely diagnosis like that in Lewis’ case could just as easily happen on one of my shifts so I am making a personal commitment to use the lessons learned to improve my practice and to teach them to my colleagues around me.
After learning about all the patient safety errors that occur on a regular basis, it can seem daunting to try fix the problem. However I am reassured by all the Telluride graduates and others who will be alongside me to confront the issue and be the leaders and first followers in the wave of change to come.