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Patient Safety on the Rocks: Reflections from the 2012 Telluride Patient Safety Roundtable

Rugged yet breathtakingly subtle, the backdrop of Telluride, Colorado was a boon for our group of medical students to dissect the obstacles we encounter to safely care for our patients. The setting was the 2012 Telluride Patient Safety Roundtable.

I, along with nearly 20 other medical students and leaders from prominent patient safety and health care quality organizations, convened to become better advocates for patient safety. This innovative roundtable, in its eighth iteration, sought to immerse upcoming medical professionals in discussions that further promoted the culture of patient safety.

We assembled in 2012 under the rubric of transparency in medical care. Our mission was to share insights on the events, good and bad, that have tested our leadership in recognizing and redressing challenges to the safe delivery of health care.

The testimony we shared touched on the many facets of medical errors. These revelations were striking.

A fellow participant vividly recollected her involvement in a wrong-sided surgery. We heard from a medical student whose team missed a critical medication check with the consequence of further plunging a dying patient into a confused and decompensated state.

The stories were many. Death and disability were repeated outcomes. But importantly, those tragedies unearthed opportunities to recognize and retract harmful practices. For us, progress took hold in our revamped commitment to pursue patient safety as an organizing curriculum, not only as formal scholarship but also as a paradigm for patient-first health care.

We repeatedly asked ourselves why patient care is not safer under many circumstances when seemingly simple and effective behaviors could positively steer the course of care. The health care narrative casts a formidable shadow of unwashed hands, unasked and unanswered questions, overridden checklists or disregarded timeouts.

In theory, supplanting these dangerous practices with safer decisions is an accessible, low-technology endeavor. As we were reminded, however, persistent cultural investments in longstanding physician behaviors can pose barriers to accommodating breakthrough practice models.

Grooming physicians to be patient safety champions requires that physicians embrace swift and continual interventions from all members of the health care team, most notably from patients themselves. This means that communication and transparency are crucial.

In other words, patients and other stakeholders must have credible information relative to health care to meaningfully prompt patient safety initiatives. Enhancing such patient participation requires that health care institutions and providers alike prioritize openness. The health care setting should embrace an encounter where those delivering health care ask questions and are willing to be asked questions that further the patient’s literacy in safer and more effective medical care.

Medical students are particularly well positioned for leadership on patient safety and quality improvement initiatives. For one, current medical students are maturing in a professional setting that is acutely shifting away from service and revenue models that often reward the quantity of procedures performed. Revamped health care models increasingly look towards the quality of outcomes to evaluate the success of care. Furthermore, the priority of optimizing reimbursement is also increasingly driven by quality-facing metrics.

In addition, medical students enjoy different kinds of luxuries with patients. As students, we often conduct initial interviews or take the initial history. This touchpoint offers a critical opportunity to educate patients and to frame the patient’s case narrative around terms that align with the quality agenda. But first, medical students must seek and have available a proper education on quality-driven health care decision making.

My time in Telluride was the beginning of my education in patient safety. Like all medical students, that education is lifelong and will continue with every patient experience. Leadership for constructing safer health care initiatives extends to both the big and small tasks. Policy and practice guidelines undeniably matter. But so do the arts of listening and investing in the commitment to admit and address mistakes.

Dacia Russell Dacia Russell (2 Posts)

Contributing Writer Emeritus

Ohio State University College of Medicine

Dacia Russell is a Class of 2015 medical student at The Ohio State University College of Medicine. She comes to medical school with a broad-based background in legal policy and community development. Dacia graduated magna cum laude from Harvard College with a degree in chemistry and a French language citation.

Since college, she has worked in economic development, health policy and law. Dacia earned a law degree at Stanford Law School and her legal training has included an externship at the United States Department of State in the Law Enforcement and Intelligence Division of the Office of the Legal Adviser. She is currently a member of the bar in New York.

Dacia intends to use her advocacy training to advance public policy aimed at improving patient safety and health care delivery. Dacia plans to pursue a career in emergency medicine and health administration.