Patient Advocate and Telluride Faculty Dan Ford Describes TE: CO Class of 2016

Over the last five days in Telluride, I have gotten to know an awesome group of 26 medical and nursing students. You clearly will play key roles in changing patient safety in constructive ways. As Dr John Toussaint (ThedaCare Center for HealthCare Value, Appleton, WI) suggests: “How can we provide high quality care unless we provide a base of safe care.”

Various descriptors come to mind. Compassionate. Caring. Thoughtful. Very smart. Respectful. Self-reflective. Genuine listeners. Open to learning and sharing new ideas. Passionate. Willing to live your values in speaking up, decision making and problem solving. Mindful. Inclusive. Thirsting to know more about patient safety….and you did.

You became good friends, bonding, getting to know and care about each other as human beings without labels or titles or tribes. It is clear you are patient and team focused and became even more so during our indoor and outdoor classroom work, social times and the big hike.

Telluride and the mountains are beautiful. Y’all have an inner beauty that will continue to serve you very well in all you do.

I didn’t want our time together to end, especially when several commented that this experience has been life-changing. I am desirious of staying in touch as you take your individual learnings and feelings forward and to helping you in any way I can.

I continue to encourage you to always live and to role model your True North. You will be seriously tested.

I wish each of you many blessings! I am honored to call you friends….

12 Years and 1400 Patient Safety Leaders Later…

Twelve years…that is how long it has been since we first traveled to Telluride, CO to kick-off our inaugural Patient Safety Educational Roundtable and Summer Camp. As we headed west again this weekend to meet with the 36 graduate resident physicians and future health care leaders who were selected from a large group of applicants, it is hard not to think back about all that has happened in those twelve years and the many who have contributed to make it happen.

Twelve years ago, those who came to Telluride believing in our Educate the Young mission consisted of patient safety leaders Tim McDonald, Anne Gunderson, Kelly Smith, Deb Klamen, Julie Johnson, Paul Barash, Gwen Sherwood, Bob Galbraith, Ingrid Philibert, and Shelly Dierking to name just a few. However, the smartest thing we ever did was invite patient advocates to the Patient Safety Educational Roundtable. People like Helen Haskell, Carole Hemmelgarn, Patty and David Skolnik, and Rosemary Gibson were active partners in our work from that first year and made our discussions more productive and our outcomes better.

Over the years, many new faculty joined us in our Educate the Young journey. Some of these additional patient safety faculty included Lucian Leape, Richard Corder, John Nance, Paul Levy, David Classen, Kathy Pischke-Winn, Joan Lowery, Roger Leonard, and Tracy Granzyk. We were also fortunate to have international safety leaders join our faculty, including Kim Oates and Cliff Hughes from Australia, who became regular attendees and popular “mentors” to the future healthcare leaders even though they had to travel almost 10,000 miles to join us each year.

Through all these years, two things remained constant – our commitment to Educating the Young and our partnership with patients. Helen, Carole, Patty, David, and Rosemary continue to be active participants each year but additional patient advocates have joined us including national advocacy leaders Dan Ford and Lisa Freeman.

Through the vision and support of Carolyn Clancy and the AHRQ, what began as a small educational immersion for twenty health science students has now exploded. We continue to grow because of the generous support of The Doctor’s Company Foundation (who provides full scholarships to close to 100 medical and nursing students each year), the Committee of Interns and Residents, COPIC and MedStar Health. This year, over 700 residents, medical students and nursing students will go though one of the Telluride Experience Patient Safety Summer Camps. Out Telluride Scholars Alumni network continues to grow – our future health care leaders staying connected through the years, sharing quality and safety project successes and learning from each other.  And, for the first time, the Telluride Experience went International this past spring as we ran patient safety camps in Doha, Qatar and Sydney, Australia.

Thanks go out to the many passionate and committed faculty and others who have given so much to make our Educate the Young journey so very special. It has been an amazing twelve-year run…

Remembering Mr. Farrell and Other Fathers We Have Lost

As we reflect on our continued commitment to eliminating preventable medical harm, it is important to never forget the lost loved ones that help keep us focused on our important mission. On this Father’s Day, as a proud parent and even prouder grandparent, I can’t help but reflect back this morning to last year’s Telluride Patient Safety Summer Camp and the personal story Caitlin Farrell shared with all of us on Father’s Day last year. Her story is also featured this weekend on http://runningahospital.blogspot.com/  It is one story I will never forget…

Fear, Forgiveness, and Father’s Day

Published June 16, 2014 | By CFarrell

Yesterday was Father’s Day, 2014. I woke up before everyone else in my room. Rolling out of bed, I padded down the stairs and brewed a cup of much-needed coffee. Pouring my face over the steaming cup, I looked out my window to the inspiring landscape of endless white-capped mountains. This year marks the ninth Father’s Day that I have spent without my dad, but the mountains and my purpose this week made me feel as though he were standing there with me, sharing our cup of morning coffee, just as we used to.

After taking the gondola ride into Telluride, the students and faculty plunged into our work of expanding our knowledge in the field of patient safety. We watched a documentary outlining the tragic case of Lewis Blackman, a 15-year-old boy who died due to medication error, miscommunication, and assumptions made by his medical team. The film explored the errors in Lewis’s care that have become far too common in our medical system: the lack of communication between providers and families, the establishment of “tribes” within medicine who do not collaborate or communicate with one another, the lack of mindfulness of the providers, and the culture in which all of these errors were permitted to happen.

But what resonated with me the most were the feelings described by Lewis’s mother. She defined her experience as one of isolation and desperation. “We were like an island”, she said. There was no one there to listen to her concerns. Ironically, Lewis died as a result of being in the hospital, the one place where he could not get the medical care that he so desperately needed.

A pain hit my stomach as she said these words. My family also shared the feelings of isolation, uncertainty, and loss throughout my father’s stay in the hospital. After Lewis’s death, his mother was not contacted. Instead, she was sent materials about grieving and loss in the mail. After an egregious error occurred during my father’s medical care, a physician did not give us an apology, but a white rose by a nurse.

An interesting discussion arose after the film. Our faculty emphasized the need for physicians to partner with the families of the patients. This will create not only a team during the course of treatment, but will cultivate compassion, empathy, and trust in the case of a terrible event. I know that despite the growing number of “apology laws” that protect, and even mandate, physicians to apologize to families after catastrophic events, few physicians actually do apologize. This results in families feeling like the events were there fault. I can say from experience that this is a burden that you can carry with you for years to come.

As I got back to my room and put down my books, this conversation mulled in my mind. The death of my father has given me the fuel to pursue medicine and patient safety as my career. It has instilled in me passion, energy, and determination. Yet the one thing that I have not found in the nine years since my father’s death is forgiveness. Although I do not hold any one doctor or nurse responsible for the detrimental outcome in my father’s care, I have not been able to forgive the team for what happened. I have not been able to go back to that hospital. And as I sat on my beautiful bed in the mountains, I realized that I also harbored another feeling: fear. Fear of becoming a physician who does not practice mindfulness, who does not partner with my patients, who does not apologize for my mistakes. I am afraid that despite my best intentions, I will only continue the vicious cycle. A fear that I will allow my patients to feel as though they are “on an island”.

I put away my computer and got into bed. Lying awake, I took in the gravity of the day. I am so grateful to be here at Telluride among students and faculty who share my passion in patient safety. I could not have imagined a more perfect way to spend Father’s Day.

Happy Holidays and A Happy New Year!

To all our readers:

Thank you for sharing in our passion for education and a safer healthcare system for all–

See you in 2013!