The Journey by Anne Gunderson PhD

In its 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) concluded that medical errors, particularly hospital-acquired conditions, may be responsible for as many as 98,000 deaths annually, at costs of up to $29 billion. Suddenly, quality healthcare and patient safety became central, public concerns in the United States. According to the Institute of Medicine (IOM; 2000), medical errors accounted for between 48,000 and 98,000 deaths annually in the U.S. At that time, medical errors were considered the eighth leading cause of death in the U.S.; more prevalent than deaths from breast cancer, AIDS, or motor vehicle accidents.

I started my practice in medical education in 2000 at Southern Illinois   University College of Medicine. At that time we were creating a new and robust, medical curriculum. Similarly to other medical schools, however, we had just a few lectures in this content area. By 2003, quality and safety had become central concerns in the U.S. Communication failures were identified as the root cause of the majority of both malpractice claims and major patient safety violations, including errors resulting in patient death. The Joint Commission found that communication breakdowns were the root cause of 60% of medical errors, 75% of which resulted in death. 2,034 errors, which means 915 people died as a result of a communication error in 2003. Clearly it was time to get serious.

It was 2005 when I joined the University of Illinois Chicago College of Medicine faculty in the medical education department. I had the opportunity to engage with faculty members seriously interested in training learners in patient safety. For two years, I worked with this team to create and deliver lectures and simulations, co-lead a patient safety elective, and was invited to attend the Telluride Experience.

In early 2007, we were in the middle of creating a patient safety institute to deliver a formal curriculum on the subject. One of my goals was to create an online, degree-granting patient safety leadership program. 6 months later, the Master of Science in Patient Safety Leadership (PSL) proposal was created. Once it had been approved by the various required entities, the curriculum was created by our team of patient safety experts. In fall 2008, the first cohort of learners began; however, this was only the beginning. The PSL program was very successful and applications were rolling in. The learners couldn’t get enough learning and we were getting rave reviews. Despite the program’s success, however, I found a letter from the Senior Dean for Medical Education that said they no longer needed my services.

So the journey continued… Thankfully, I had received opportunities from other medical schools. As the Associate Dean for Medical Education at the University of Cincinnati College of Medicine (UC), I had the opportunity to work with an amazing faculty and a very talented Senior Dean for Medical Education, Andrew Filak. Within 20 months, we created a new, contemporary, four-year medical school curriculum, which was awarded full accreditation from the Liaison Committee on Medical Education. . During these very busy years, we created an Institute for Healthcare Improvement (IHI) Open school and embedded safety, quality, and leadership into the curriculum. With other deans from nursing and pharmacy we implemented interprofessional sessions for medicine, nursing, and pharmacy learners. Each year, I also attended the Telluride Experience as a faculty member and continued to bring learners from UC to the events. One day, I picked up the phone and everything changed again.

It’s 2013 and the original PSL team is back together again; this time in Baltimore, MD and the District of Columbia. Despite 14 years of experience in medical education, I was amazed by how little quality and safety training was provided in medical and nursing schools nationwide. Basic training is required by accreditation bodies, but it does not adequately prepare the physicians and nurses for the complexity of medicine in today’s world. While some positive changes have occurred, we are still battling the same issues.

A little over a decade later, medical errors are now the third leading cause of death and account for more than 400,000 deaths per year. Recent studies have reported that as many as one-third of hospitalized patients may experience harm or an adverse event, often from preventable errors. Unfortunately, competencies for optimal patient care outcomes in the clinical environment include knowledge, skills, and attitudes in critical disciplines not traditionally trained in medical or other health science programs. Frankly, it’s hard to imagine that one can provide ‘care of the entire person’ if attention to quality care and patient safety is missing.

The absence of such training leads to medical errors – a serious problem that affects not just patients but also the health care workers involved.  Many good physicians, nurses, pharmacists and other health care professionals have left the field due to depression and lack of support from their colleagues. Even more unfortunate, a growing number of health care professionals take their own lives each year when involved in a preventable medical error.

It’s 2017 and we have created a solution to this pervasive crisis. I worked with Georgetown University and MedStar Health to create a new Executive Master’s Degree in Clinical Quality, Safety and Leadership (CQSL).

CQSL unleashes a systematic, evidence-based education that will achieve striking results in safety, quality, reliability, and healthcare value. With a learner-focused environment the CQSL program will equip learners to become leaders in the advancement of safety science and quality healthcare. The curriculum includes online asynchronous coursework, simulation, team training, and one onsite residency. The inaugural class begins in fall 2017.

Health-care practitioners and leaders need new skills and attitudes to meet the changing needs of patients in a medical environment that has complex multilayered systems, informatics, assessment, outcomes, and quality indicators. Secondary to these changes, health care has become a high-risk industry. As Yukl (2002) noted, “A vision is seldom created in a single moment of revelation, but instead it takes shape during a lengthy process of exploration, discussion, and refinement of ideas”.

And so the Journey continues…


Resident Physicians Share Their Stories at Telluride Experience 2016

Ah_Haa_School_Trees_on_CreekFollowing are leads from Resident Physician reflections after attending the first 2016 session of the Telluride Experience. Links are included back to the original posting on the Telluride Experience blog. Thanks to all who so courageously offered their stories from the front lines of care so that others can learn through them. It is by sharing our stories that we free another to tell theirs as well.

The Magic In Transparency

This phrase struck me as the perfect way to describe an experience I had my intern year. My first continuity ob patient had a fetal demise at 34 weeks.  She was the first patient I had followed from the beginning of her pregnancy.  I performed her dating ultrasound at 9 weeks.  Unlike many of my patients, she and her husband faithfully came to every prenatal visit.  She did not smoke, use drugs and followed the dietary guidelines.  Her husband was the chatter one of the duo, while she would calmly take everything in at our visits.  They both teared up when I told them they were having a girl at the 20 week ultrasound.  They told me her name was Emma. More…

Important Conversations

I was not going to share this but have been inspired by the courage of others around me. So thank you!

…In the first few days of Residency, we had a mandatory “Emotional Harm” meeting. I thought it was nice of them to do and always a good reminder. It focused on the empathy towards the patient and not losing our empathy when getting in the rhythm of dealing with similar situations and cases over and over again. I loved that they did this. This is something that is so important to remember and necessary to address.

Looking back however, I just wonder what about my emotional harm? Where are my resources? In this first 7 months of my residency experience two Senior Attendings committed suicide. I did not know the first, but I certainly knew the second. While there was heartfelt sadness and memorials to honor both, there was nothing else. No counseling offered to employees, no conversations, no checking in after some days, nothing at all. More…

Humility and Humanity

Humility and Humanity. This phrase stuck with me from Dan Ford’s talk. From medical school through residency it is drilled into us to be confident, un-phased, unemotional , these qualities are attributed to professionalism and success. Doctors are supposed to be infallible , so when we face an adverse outcome thats what we do instinctively. We become distant, listening to Helen, Sorrel and Dan thats the exact opposite of what patients need. Alienation only leads to prolongation of suffering for the patients family as well as the caregiver. Moving forward I hope to make these values a foundation of my practice.

Reading all the stories from my peers encouraged me to share as well, this was an amazing group of people and faculty. My first ICU night rotation as a PGY-2 I admitted a patient  in DKA and septic shock. More…


A Year of Hope for One Patient Advocate

The following is written by Guest Author and Patient Advocate, Carole Hemmelgarn

In the months of March and April I had the opportunity to take two amazing trips; one to Doha, Qatar and the other Sydney, Australia. Do I feel fortunate to have visited these incredible places? Absolutely! The irony is, however, I would not have been in either location if my daughter Alyssa’s life had followed its natural course.

I was invited to both places to be part of the faculty to teach patient safety and behavior change to the young emerging scholars in the fields of nursing, pharmacy, medicine and allied health. While these young individuals are regarded as our future patient safety leaders they represent something much more to me. They give me hope. Hope that we can start fixing a broken healthcare system by breaking down the hierarchy, improving processes and communication skills, creating resiliency, and learning to provide support and care to our very own healthcare providers. They are also the generation giving hope to patients and families; making sure we are at the center of care, and that our voices and stories are heard, listened to, and acted upon with dignity and respect.

Earlier this year I told my sister that 2016 was the ‘year of hope’ for me. People will tell me they want me to be happy, but I struggle to understand what happiness is or means. Hope, however, is something I can wrap my arms around. I can hope to see a beautiful sunrise while out running, to watch a smile spread across my son’s face, and to see a child exiting a hospital knowing they are leaving better than when they entered.

There is an incredible aftermath when you lose a child to medical errors. It is a topic rarely discussed and one no one can ever prepare you for. Grief is a journey; a journey without a beginning, middle or end. While those of us who have lost a loved one never want you to experience this overwhelming pain we would like you to understand why happiness may take time in returning, or hope may be the best we can ever do.

When I teach these young scholars, I share part of Alyssa’s story because it helps connect the head and heart, and we need to put this piece back into medicine and caring for patients. Every time I speak about Alyssa, I give a piece of myself and my hope is that you take this piece and use it to make change. The future of patient safety resides in hope because hope is not found looking down or back, it is only found looking up.

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Telluride Experience: Sydney Alum Anna Elias Continues to Dream Big

HarborBrushEach of our Telluride Scholars adds their own voice and passion to the patient safety movement that continues to need attention. The following are most likely words of unintentional inspiration from Anna Elias who shows what one individual can accomplish when they care deeply about a cause, and dare to dream they can make a difference. Anna is absolutely right — Watch this space! — her space, because she is on her way to great things!

You can also link to the Telluride Blog where Anna originally posted this piece.

Watch This Space

I think big and dream bigger but have been told many times in my life to stop doing so. My grade 10 careers advisor told me to aim lower when I expressed an interest in studying medicine, a male physician once told me that training a woman was like training half a doctor and I’ve even had a family member tell me that women joining the workforce are responsible for the downfall of modern society. Despite this, I’m now in medical school and will one day soon achieve my dream of becoming a doctor.

Over the last few days I’ve been given the skills and knowledge to undertake projects that improve outcomes for all patients; I’ve been empowered to make a change. Unfortunately these things take time, you need to carefully plan, analyse, monitor and assess. You need a specific problem to tailor your specific, well researched solutions and I am sure in the months and years to come I will use the things I’ve learned and the frameworks provided to make change happen. However, at this point in time, my goal is big and broad, it’s in no way specific and while I’m prepared to to do my due diligence and execute some high quality, quality improvement projects once I find my focus, right now I just need to do something. Improvements to patient safety education shouldn’t have to wait for me to specifically define the problem in a measurable way or wait to get ethics approval. It can’t wait, not while I know there are things I can be doing that will have some impact right now.

Don’t get me wrong, I know we need to improve patient safety, safely by following the right processes and procedures but today I am going rouge, I am not going to wait. Like a hungry Roundtable delegate on the hunt for a burrito I am going to take action. Tonight I will email my contacts and state my case to ensure that patient safety is on the agenda of every student-run educational conference in my state this year. Additionally, I will push to have a safety moment at the beginning of each event my medical society hosts. Lastly, because I can’t be everywhere at once, I will make a time to train others in my medical society so they too can be safety coaches and start getting the word out about this important issue.

One day soon (when step 1 is behind me), I will start the research and do it the right way but I won’t sit ideally by in the mean time. Watch this space.


Voices from The Telluride Experience: Sydney

As in Doha, SolidLine Media was along to capture the stories being told at The Telluride Experience: Sydney! Thanks to Greg, Michael, John, Ali and team for pulling this short video together utilizing movie magic across the continents in time for the Minister of Health herself to view it live in Sydney, at the Clinical Excellence Commission’s reception for students and faculty before we returned home last week.

Truly a great team effort by all to bring the reflections and voices of change to life.


Student Reflections from the Telluride Experience: Sydney

TESydney_GroupShotTaking the Telluride Experience global continues to equally educate our faculty on what both the delivery and culture of healthcare around the world is really like. While many cultural differences exist, it is the similarities in our human experience throughout that connects us all. The local challenges may create the obstacles, but returning to the patient, no matter the locale, grounds every care provider in “how to proceed”. Reflections from yet another impressive group of Academy for Emerging Leaders in Patient Safety alumni follow:

I work in emergency medicine. A buffer for the undifferentiated, where time-poor workers battle a “controlled” chaos. It’s also where patients come. Patients who have a stubbed toe, sprained ankle, a cough or a heart attack. By practicing the virtues of patient-centred care we can appreciate that these aren’t patients who have presented to be an inconvenience, but have come because there was nowhere else to go. Ask why. Why did they present. There are many reasons why they present including health literacy and healthcare infrastructure. The truth distills down to the fact that, in their mind, we are their only hope.

Viet Tran, Emergency Medicine, Registrar

It was very important today to see face to face the huge impact that medical errors can have in a person/family’s life; it has certainly touched me and I wish that every health professional I work with got to experience and see the testimonies I have been able to experience today. Seeing a mother with two children who suffer from chronic illness and how their lives have been shaped by this, and how a mother who lost a child in a way that could have been prevented has the courage and strength to re-live this painful experience in order to teach and change in some way how we practice and how we deliver care. This for me was the highlight of the day. Anyone can make mistakes, it can happen to any of us, but we never think that in reality we are going to be in that position. I have been touched by Susan’s and Carol’s talks, they have been just life changing.

Lina Belalcazar, Medical Student

We talk and even joke about aha moments but the past is marked by many such moments that go on to spark movements and eventually change the face of history. In years to come we will look back on the negligent attitudes towards patient safety the same way we look back on segregation and gender inequality, in disbelief. Doctors of the future simply wont believe that patient safety was not always highly valued, well taught and at the forefront of everybody’s mind during each patient encounter.

I am so pleased to have met the leaders in this field and feel privileged to be one of the first followers. Now let’s not stop till everyone is dancing with us.

Anna Elias, Medical Student

I will continue to strive for excellence in patient safety and I will utilise whatever means on hand to achieve our primary goal. A safe and highly satisfactory patient journey. We cannot perform without our patients and they should be central to what we do. This I feel we as a cohort of professions fail to achieve. I am a professional. I am an expert. These excuses create barriers which have become ingrained in our culture. I hope that as evidenced by this conference with the Australians bucking the trend we can continue to do so and continue to strive towards excellence and truly take place as advocates and global leaders in healthcare.

Ben Gross, Nursing

Today another lived experience was shared. It was that of a widowed husband, this time from the UK, who shared the experience of his wife, undergoing what was a routine surgery but ended up not making it to surgery and having a fatal consequence as a net result of an adverse event and subsequent accrual of system failures, particularly those of a human factor nature. This brings to the light the many human factors that we continually witness in practice, which may be harmful especially when aligned in particular contexts, notably in situations that are unfamiliar or deviate from the norm. One of the things I particularly reflected on is how we as humans are fallible to task focus and makes us become situationally unaware. It is something we need to keep in mind when retrospectively analysing incidents. Even I have to admit that I have been unaware on occasion. It is important to be conscious that we can become like that. This emphasises the importance of teamwork, communication and dynamics, which are able to overcome authority gradients and their pertinence to allow goals to be met.

Kym Huynh, Pharmacy


Leading with Love at Telluride Experience: Sydney

DaveLeads_Sydney_CropIt was only a matter of time before the Telluride Experience, which began as a labor of love by healthcare leader, Dave Mayer MD, almost twelve years ago came to Sydney, Australia. Kim Oates, MD, a local healthcare leader, Telluride faculty member and another who leads with love in the healthcare workplace, championed the experience for young healthcare professionals on the third continent this year.

Kim_Teaching_DayOne-2Dave and Kim are two healthcare leaders who know what it means to put the patient first, what patient centered care really means, and they put that knowledge to the test in real life practice. Another gift both leaders possess is the ability to gently teach and guide, without sacrificing principles. They understand how hard it is for healthcare learners to rise above the medical culture because they have lived it. Today, Kim shared that the three hardest words in medicine are, “I don’t know,” and “Please help me.” Dave openly shares his own experience of being on the wrong side of medical harm when he was a resident physician. They both care deeply about patients. They also care deeply about educating young healthcare professionals to not only protect patients, but to also ensure these well-meaning nurses and doctors stay safe as well.

Healthcare needs more leaders like Kim and Dave, who lead with love. They never have to question the right and the wrong of a situation. Their hearts are their true north.

For more information on how to learn alongside healthcare leaders like Dave and Kim, as well as take home the lessons of the Telluride Experience, go to www.telluridesummercamp.com.