Chapter 25: Patient Safety Training For Resident Physicians: The Telluride Success Story

INTRODUCTION

• Residents will understand the reasons why open, honest and effective communication between caregivers and patients is critical to the patient safety movement.

• Residents learn to utilize tools and strategies to drive positive change towards reducing patient harm.

• Residents will implement, lead and successfully complete a quality improvement project at their institution within 12 months of taking the Telluride patient safety training course

BACKGROUND

In 2013, a study was published in the Journal of Patient Safety estimating deaths due to medical error were not improving, but in fact, were now thought to be 4 times the number revealed in the Institute of Medicine (IOM) report of 2000.¹ To date, a formal systematic patient safety and quality care curriculum remains a gap within healthcare education across the country. Innovative healthcare educators, however, are creating ways to protect and empower learners as well as keep patients safe, through novel patient safety education opportunities. The Academy for Emerging Leaders in Patient Safety, formerly the Telluride Roundtable and Patient Safety Summer Camp, is one such entity.

THE ACADEMY FOR EMERGING LEADERS IN PATIENT SAFETY: THE TELLURIDE EXPERIENCE

In 2000, the IOM shocked the medical world when it declared that medical errors accounted for 98,000 deaths annually in the United States.² This made medical errors the eighth leading cause of death in the United States; more prevalent than deaths from breast cancer, AIDS, or motor vehicle accidents. Medical errors were also costing the nation approximately $37.6 billion annually, with between $17 billion and $29 billion of those costs associated with preventable errors. The United States had clearly entered an era in medical care where understanding the physiology and treatment of disease was not enough.

Quality health care and patient safety were, and still are, central public concerns in the United States. Secondary to the IOM report, modification of health sciences education dominated discussion in both the public and private sectors. Systematic safety and quality education for healthcare professionals was lacking, the available literature was scarce and inconclusive, and interprofessional training was just beginning to attract attention. Dr. Jordan Cohen, then president of the Association of American Medical Colleges, back in 1999, stated there needed to be a “collaborative effort to ensure that the next generation of physicians is adequately prepared to recognize the sources of error in medical practice, to acknowledge their own vulnerability to error, and to engage fully in the process of continuous quality improvement.”³

Reforming medical education to adequately address safety and quality issues, however, presents a major challenge to educators because the shortcomings that must be addressed are deeply entrenched in the tradition and culture of the institutions and organizations that compose the medical education system. While patient safety is now undoubtedly recognized as a key dimension of quality care, systematic safety education remains lacking in all healthcare disciplines. ...