To Err Is Human - The Silent Epidemic Of Medical Mistakes.

Summary

Gravitas Documentaries presents a stirring exploration into the issue of medical errors in its film, "To Err Is Human - The Silent Epidemic Of Medical Mistakes." Through personal stories, particularly the heart-rending account of Sue Sheridan's family, the documentary sheds light on how diagnostic errors, communication failures, and systemic flaws contribute to sizable preventable harm within the healthcare system. It appeals for enhanced patient safety standards and accountability to mitigate these hidden yet profound impacts.

Highlights

• Sue Sheridan shares her family’s tragic experience with medical errors, spotlighting the urgent need for reform. 😢
• The documentary reveals staggering statistics, placing medical errors as a top killer in the US. 📊
• Experts discuss the systemic failures in healthcare communication and diagnostics. 🗣️
• Emphasis on the need for improved safety protocols, such as better data tracking and error reporting. 📋
• Inspiring stories of advocacy and change from families impacted by medical mistakes. 🌟
• Documentary calls for collective action in driving awareness and policy changes in healthcare. 📣

Key Takeaways

• Medical errors are the third leading cause of death in the US, highlighting the gravity of the issue. 🏥
• Communication failures and lack of follow-up are major contributors to medical mistakes. 📞
• Preventive measures and accountability are key to reducing medical errors and improving patient safety. ✅
• Real stories of affected families drive home the emotional toll of healthcare failures. 💔
• Standardization and innovation in hospitals can significantly lower incidents of preventable harm. 🚑

Overview

In Gravitas Documentaries’ poignant film, the severe implications of overlooked medical errors are unravelled through personal stories and confronting statistics. From the real-life sufferings of Sue Sheridan’s family to the looming epidemic of misdiagnoses and communication lapses, the documentary delves deep into the human cost of preventable medical mistakes.

The narrative highlights the systemic flaws within the US healthcare system, presenting alarming numbers that showcase medical errors as the third leading cause of death in the country. The film also delves into how these mistakes are not just isolated incidents, but part of a broader failing in patient safety cultures and protocols, urging for a shift in how such domains are approached and improved.

With emotional testimonies from affected families and insights from health professionals, viewers are called to action to push for transparency, communication, and innovative measures in medical institutions. The documentary underscores a pressing need for standardization and accountability in healthcare to prevent further tragedies.

Chapters

• 00:00 - 03:00: Introduction The introduction discusses a significant and shocking event that occurred in the United States, causing disbelief and emotional devastation among the people. The narrator expresses difficulty in comprehending how such an event could happen in a developed nation.
• 03:00 - 10:00: Personal Stories of Misdiagnosis The chapter titled 'Personal Stories of Misdiagnosis' discusses the experiences of a family where both the husband, Pat, and their son, Kale, faced diagnostic errors. Kale suffered brain damage from newborn jaundice due to being misdiagnosed, which led to significant cerebral palsy. At 16 hours old, a nurse noted his yellow color, but it was not considered serious, and they were discharged with a sick baby.
• 10:00 - 15:00: The Impact and Statistics of Medical Errors A new mother discusses her experience with her baby's jaundice, noting that medical staff downplayed the seriousness likely because she was a first-time mom. She was unaware at the time that her child was actually in critical condition, later discovering that her baby suffered brain damage while under medical care. The narrative highlights the serious implications of medical errors and the importance of not dismissing the concerns of new mothers.
• 15:00 - 20:00: Preventable Harm and Safety Measures In this chapter, the discussion is about preventable harm in medical settings with a focus on a poignant personal story. The recount shared introduces Pat, a man who lost his life at the age of 45 due to cancer, highlighting a critical failure in communication within the healthcare system. Despite the cancer being appropriately diagnosed, the pathology results were not communicated either to Pat himself or to his doctor. It was only after an MRI revealed a mass in Pat's neck, and subsequent surgery occurred six months later, that this oversight became painfully clear. This tragic example underscores the critical importance of safety measures and effective communication in preventing harm in healthcare environments.
• 20:00 - 25:00: Learning from Other Industries During a series of doctor visits concerning Pat's untreated condition, it was revealed that his initial pathology was miscommunicated. While he believed his initial surgery had a benign outcome, in reality, it was a high-grade malignant snowmeal cell sarcoma. The necessary document confirming this either never arrived or was overlooked, leading to a critical gap in his treatment history.
• 25:00 - 30:00: Patient Advocacy and Systemic Change The chapter discusses the significant impact of errors in the healthcare system by sharing a real-life example. It begins with a story about a mistake in a patient chart, evoking emotional reactions and tears from those involved. This incident illustrates the profound human cost of errors in healthcare, emphasizing that such mistakes are not just theoretical but have real, life-altering consequences. The story underscores the necessity for patient advocacy and systemic changes to prevent such detrimental occurrences.
• 30:00 - 35:00: Technology and Innovation in Safety The chapter discusses the personal impact of medical errors, emphasizing that they can affect anyone, including our families, and are issues that need addressing. It references the 1999 Institute of Medicine's report titled 'To Err is Human,' which estimated that 98,000 people die annually due to medical mistakes.
• 35:00 - 40:00: Cultural Shifts in Healthcare Safety The chapter titled 'Cultural Shifts in Healthcare Safety' highlights the alarming statistics of medical mistakes, which have become a significant cause of death. Over a period of 15 years, efforts to better understand the impact of medical errors were made, yet the numbers continued to rise. Recent studies suggest that as many as 440,000 deaths occur annually due to these errors, ranking medical mistakes as the third leading cause of death. This statistic is starkly illustrated by comparing it to more recognizable imagery, such as the number of graves in Arlington Cemetery or the equivalent of two to three jumbo jets crashing every single day.
• 40:00 - 45:00: Educational Initiatives and Training The chapter titled "Educational Initiatives and Training" discusses the alarming issue of preventable deaths caused by hospital errors, placing them just behind cancer and heart disease as leading causes of death. The author emphasizes the gravity of this situation, highlighting that it's not merely a theoretical concern but a pressing reality affecting local communities. The focus is on the potential to prevent numerous fatalities through concerted efforts and improved educational initiatives within the healthcare system. The chapter underscores the need for immediate action and collaboration to address and mitigate these critical challenges.
• 45:00 - 50:00: Family Experiences and Advocacy The chapter discusses the underestimation of a widespread epidemic affecting already ill individuals. It highlights that pre-existing health conditions do not make their deaths any less tragic. The analogy of a plane crash underscores the unpredictability and inevitability, emphasizing that the initial condition of being sick does not justify their fate. It concludes by challenging the problematic mindset that excuses the safety failures by considering the patients' pre-existing conditions.
• 50:00 - 55:00: Ongoing Challenges and Hope for Improvement The chapter "Ongoing Challenges and Hope for Improvement" discusses the broader implications and underestimated toll of preventable harm in healthcare. It highlights the challenges in measuring safety and injuries accurately, noting that the figures related to deaths may not fully capture the extent of the harm. The transcript underscores the variability in data depending on how safety is measured, suggesting that more thorough investigations tend to reveal more issues, which could sometimes accelerate death or diminish quality of life for affected individuals, such as those who end up in wheelchairs or nursing homes. This reflects ongoing challenges in healthcare safety but also a potential area of focus for improvement.
• 55:00 - 60:00: Conclusion In the conclusion chapter, the discussion centers around the alarming frequency of injuries related to medical errors. The debate about the exact number of deaths varies between 40,000 and 100,000, but regardless of the exact figure, the consensus is that the number is excessively high and needs urgent attention. Moreover, beyond fatalities, a significant number of patients experience non-fatal medical errors. Recent studies indicate that one-third of all patients may be affected, highlighting the importance of addressing this public health emergency effectively.

To Err Is Human - The Silent Epidemic Of Medical Mistakes. Transcription

• 00:00 - 00:30 [Music] it was devastating it was very hard it was hard for us to understand and believe that this could happen in a developed country like the united states
• 00:30 - 01:00 both my husband pat and my son kale experienced what would i would say classic diagnostic errors cal suffered brain damage from his newborn jaundice when it was misdiagnosed and it was never tested or treated appropriately and today he has significant cerebral palsy at about 16 hours the nurse charted that he was yellow you know it was no big deal we were basically discharged with a very sick baby but we were told
• 01:00 - 01:30 he was a well baby i was familiar with jaundice and it was true it was communicate to us it was no big deal not to worry about it and they asked me if i was a first-time mom i said i was and they reminded me that first-time moms are often overreactive and they didn't seem worried at all i didn't really know at the time but i learned later on the cow was in the process of dying we actually watched our son suffer brain damage in
• 01:30 - 02:00 the hospital before our eyes and quite honestly that will that will haunt me forever and pat my husband died when he was 45 from cancer a cancer that was appropriately diagnosed but the pathology failed to get communicated to the doctor or pat they did an mri and they discovered there was a mass in his neck at the base of the skull and so pat had surgery six months later the pain
• 02:00 - 02:30 returned in pat's neck a whole series of doctors came through asking pat why he never got treatment after his first surgery and i had all the documents and i said well because it was benign and then by the time the third doctor came through i said wait a second what was his pathology on the first surgery the final pathology was a high-grade malignant snowmeal cell sarcoma and that document either never arrived or was
• 02:30 - 03:00 placed in his chart without the doctor seeing and i remember showing it to pat and um i remember pat crying you know to think that another error had taken place in this time with him that was difficult for us to witness in our healthcare system stories like sue sheridan and what happened to her where a small mistake can really be a life-altering event that remind us the human cost of what we're talking about these are not theoretical events these
• 03:00 - 03:30 are not just things that happen to other people that happen to us they happen to our families and there are things that we need to work on [Music] in 1999 the first significant report on medical mistakes was released by the institute of medicine they called it to air is human this report claimed that as many as 98 000 people die every year as a result of medical mistakes
• 03:30 - 04:00 over the next 15 years efforts to better understand this number increased but so do the number itself recent studies have raised the projected number of deaths to as high as 440 000 to put this in perspective that's more than the number of graves in arlington cemetery it's the equivalent of two to three jumbo jets crashing every single day so where does that rank medical mistakes on the leading causes of death number three
• 04:00 - 04:30 right behind cancer and heart disease now suddenly whoa this isn't just some uh egg-headed study this is a big deal this could be you and they're right wait a second you mean those hostels my local hospital was killing people is that what you're really saying we could prevent many many many of these deaths immediately if we just put in the effort things are happening let's take a look at this i just think
• 04:30 - 05:00 this is like a massive epidemic that we have underestimated and the reason is because it's happening to people who were already sick but like they were sick that doesn't mean they were going to die and their death is no less of a tragedy because they already had a medical problem every time you get on a plane you don't expect that plane to crash and everybody who dies on a on a plane crash you say well those people are healthy they were going to do fine otherwise i think the problem with patient safety is you say oh these people were sick anyway and i think it's a very problematic way
• 05:00 - 05:30 to look at the world maybe they didn't die but they spend the rest of their life in a wheelchair or nursing home and that accelerates their death and obviously harms their quality of life so the the numbers about deaths are a big deal but in some ways they underestimate the overall toll of preventable harm we don't have a stable agreed way to measure safety or injuries actually the number you get depends on how you look one rule is the harder you look the more you find so when you really throw the book at it and you do
• 05:30 - 06:00 everything you can to look for injuries you're going to find a ton of them when people start debating you know is it is it 40 000 or 90 000 or 100 000 uh it's a lot it's a ton and our job is to is to make it zero this is urgent it's a public health emergency while the number of deaths related to medical error is staggering the number of patients who experience non-fatal errors is even bigger recent studies suggest one-third of all
• 06:00 - 06:30 hospital admissions experience a medical mistake and 1.7 million hospital-acquired infections occur every year 69 of those infections could have been prevented through methods that already exist like hand washing but healthcare workers wash their hands less than 50 percent of the time with some research suggesting it's as low as 30 percent there are even more dramatic examples in a five-year span surgeons operated on
• 06:30 - 07:00 the wrong body part over two thousand times left nearly five thousand tools inside patients and in 27 cases operated on the wrong patient entirely but diagnostic errors like the ones that left cal sheridan with cerebral palsy and delayed the detection of pat sheridan's cancer contribute to 1 in 10 patient deaths but whether it's a diagnostic error or any other preventable harm the only way to fix it is to first understand what
• 07:00 - 07:30 causes it when we study communication in in my lab we look at how people communicate and what are the reasons for miscommunication in very simple experiments when we ask people to communicate something to somebody else about 50 of the time when they thought the other person understood them they were wrong i don't know the extent of the miscommunication in in medicine but i am sure it's more than
• 07:30 - 08:00 uh physicians think part of the problem is that when you when when say a doctor miscommunicates he or she might not know that's that's the core of the problem right they might not get immediate feedback that they miscommunicated and if that happens then that error could amplify without anybody realizing that the source was just a minor miscommunication now i know how
• 08:00 - 08:30 what happened to my husband and now i understand how it happened that that there's been no systems-based intervention to ensure that lab tests are followed up on that pathologies and radiology reports are followed up on to know that this happens in our country that's unacceptable [Music]
• 08:30 - 09:00 most of us think of a hospital as a place where people go after they have an accident not as a place where people go to have accidents however like just about any place there are safety hazards in a hospital some are unique to the hospital environment and some are not generally the hospital staff is very aware of medical safety practices such as the proper handling of infectious cases
• 09:00 - 09:30 careful checking of patient id before administering any medication keeping things sanitary and disinfected yet all of us at times tend to overlook some potential hazards that we are around every day we must try to learn to think safety in everything we do but safety doesn't come just by learning a lot of rules it comes from an attitude for everyone who works in a hospital safety has to be a full-time job
• 09:30 - 10:00 this is a problem that's you know hiding in plain sight and i think that no one is really surprised when they think about it for a minute if we think the amount of harm that is currently existing is just fine then maybe it's not it's not a crisis it's not a problem if that's okay then we're done most of this in medicine just said well that's the way it is you know things go wrong people make mistakes there's nothing you can do about it it's
• 10:00 - 10:30 pretty obvious that safety is not number one priority in most hospitals when it is wonderful things happen what is the problem you're trying to solve and the answer is for most hospital administrators life is too short to get the doctors angry at you building a new cancer center your oncologists love you the other doctors love you it brings in revenue the community loves you if you reduce medical error you can't advertise it because the patients all think that
• 10:30 - 11:00 everything's safe anyway nobody knows the problem exists the doctors are angry because you started to talk about medical error so that's why you have an invisible problem every human being will make mistakes and will you know so the goal cannot be zero errors our goal needs to be zero harm because we know errors will occur so how do we make sure those errors don't actually lead to harm and are caught early 10 or 15 years ago we thought central line infections were not preventable we thought that was part of
• 11:00 - 11:30 kind of doing business and healthcare that okay people have central lines occasionally they'll get they'll get infections and that's just now we know infections can go down to zero preventing preventable harm is a skill and a commitment and a technology all of its own it's not glamorous but what keeps all of us safe if you believe first do no harm there is no excuse for not investing in
• 11:30 - 12:00 things which will prevent harm health care nowadays is incredibly complicated and a patient has literally hundreds of things done to them having blood drawn for a test or getting an x-ray or whatever and so there are many many many opportunities for things to go wrong so even when nurses and doctors and technicians and radiologists are functioning at a 99 level which is you know pretty good for human activity that still means a lot of opportunity for
• 12:00 - 12:30 things to go wrong i think this is a general problem that you have when you deal with people we are not built to not make mistakes we're not built to be perfect are you going to try and change the person or are you going to try and change the situation one way to do it is to design say the work environment in a way that would not necessarily
• 12:30 - 13:00 prevent the error but would assume the error we have to acknowledge that to error is human and then to figure out what do we do with that fact in terms of building a system that's safe for patients [Music] between cal's patient safety event and pat's patient safety event we had mackenzie in the middle there exactly at 16 hours just like hal she also had a very high
• 13:00 - 13:30 bilirubin which the hospital took action they tested it and they treated it i took a shower and it was the first shower after delivery and i remember i stayed in the shower for an hour and they sent a female chaplain in and i was crying and and the chaplain thought i was crying because my daughter was getting treated for her jaundice and i explained to them i was not crying with it i was crying because i witnessed what the only thing they had
• 13:30 - 14:00 to do with my son that it was so easy to prevent what happened to my son when i got into about first grade people started asking me what's wrong with your brother why like can he move like the rest of us and i didn't really get it because i was never told necessarily you know your brother has cerebral palsy your brother has kernicterus you know to me he was just my brother [Music]
• 14:00 - 14:30 [Music] yes
• 14:30 - 15:00 [Music] recently i became more interested in the case my brother's case because i knew before looking it up i knew that he wasn't given a bilirubin test and because of that he got cerebral palsy and kernicterus and i got frustrated and i got angry and confused
• 15:00 - 15:30 and my mom has taught me that i can do something positive with that kind of anger and further i can you know go out and make sure that those kind of things don't happen [Music] so i used to be a little scared hearing all of the things that could go wrong in the health system i just learned to be cautious and to ask questions and to you
• 15:30 - 16:00 know ask the doctors what are you doing have you washed your hands have you done this i look at doctors in a different sense than i think a lot of people do and as a child i looked at doctors differently as well i know why kids would think like the doctors don't make mistakes but i knew from a very young age that they do and that their mistakes can cost a life the first thing that we wanted was to tell somebody some kind of high authority that could tell all of the hospitals about what happened and so so all hospitals could implement change
• 16:00 - 16:30 and i thought somebody was in charge of patient safety in the united states and i learned that that simply does not exist [Music] when people think about science and health care they think about genes and cells and drugs and chemistry yeah that's science that's one science there's another science which is the science of organizing care which is how do you actually
• 16:30 - 17:00 get the help what are the flows like how do you do surgery how do you take care of a chronic illness there's science there too and luckily this country began investing in that really in the past few decades the agency for healthcare research and quality for example it's an american investment in developing the sciences for delivering better care in 2000 after speaking with leaders in health care president bill clinton made a bold statement regarding the country's new efforts in managing medical errors
• 17:00 - 17:30 just think about it we can cut preventable medical errors in half in five years the agency for health care research and quality took on this task today ahrq remains focused on improving the quality and safety of health care for americans it does so by funding research developing tools and training and collecting measures and data on the health care system as a whole in 2016 a report was released on the
• 17:30 - 18:00 recent progress in patient safety efforts the report showed that from 2010 to 2015 there were three million fewer hospital-acquired conditions showing a 21 production 125 000 deaths were prevented saving 28 billion dollars in health care costs all with a budget that annually hovered between 400 to 450 million dollars but it's part of a health care system that spends over three trillion dollars and has more than 5 000 hospitals with over
• 18:00 - 18:30 800 000 physicians 4 million nurses and 330 million patients that means the agency is working with one 100th of a percent of national health spending and is tasked with improving the other 99.99 it is such an under investment that you know a doubling of the amount for the agency would be a vast improvement but it still is not nearly enough we need this information for us to take care of
• 18:30 - 19:00 our patients properly for health plans for leaders of large clinics to say actually no i i need to better understand how what the choices i make how it impacts our ability to deliver safe care it has funded some of the seminal studies that have had massive improvements in patient safety so it funded the studies that led us to create the checklist for central line infections that alone has saved the american health care system hundreds of millions of dollars if not billions of dollars but more importantly has probably saved tens of thousands of lives there are tens of thousands of
• 19:00 - 19:30 americans walking around today who would be dead if it had not been for some of the work that ahrq has funded it's really about how we apply the best of science to your individual needs and preferences to some extent i do know some systems that are doing a terrific job and when i learn from them about how they're doing it a lot of them are using the tools and methods pioneered by arc
• 19:30 - 20:00 [Music] much of the work that we use to train around patient safety and how to make healthcare safer is actually derived from ahrq research and tools when they put out a tool kit or research tools i know that they've been vetted and they've been tried and investigated and shown to be of benefit so a big problem that we face in safety in hospitals is
• 20:00 - 20:30 really improving handoffs which is when a patient moves from one area to another or when their doctors or nurses change shifts handoffs are somewhat invisible to patients but they actually have a huge impact on them like if an average patient got hospitalized tomorrow they would face upwards of 15 handovers and we know from arc funded research it's got to be more than just a passive listening where you're like uh-huh okay i got it but really engage ask questions
• 20:30 - 21:00 because oftentimes you'll pick up things combining our team steps with a standardized tool to improve handoffs actually led to a 30 reduction in preventable adverse events we also develop our own homegrown patient safety teaching programs one of my personal favorites that we've actually developed here is called the room of horrors we take 10 patient safety hazards and we embed it into a hospital room into a simulation this is training where you're
• 21:00 - 21:30 walking into a room and you're actually seeing with your own eyes can you spot what's wrong pneumonia c diff positive so probably should be some kind of like precautions yeah you should be contact plus allergies latex and penicillin so that's fine um let's see here oh there's our gloves over there are these latex gloves uh oh got latex gloves so it looks like he's got some dosa hanging um and he's
• 21:30 - 22:00 allergic to penicillin so that's definitely not ideal yeah absolutely why does he have magnesium i don't know it's actually not for his name his name is washington right yeah michael johnson all right different michael i'm also going to put the stress holster okay good call they have 10 minutes to identify all of the hazards that they can and then right after when they come out i actually debrief with them so that we go over how they did not only
• 22:00 - 22:30 what they got right where do they miss things and perhaps why did they miss those things if you train people in this way this is the way their brain is running in the background every time they enter a room they can automatically spot it from the corner of their eye as an organization we cannot improve patient safety unless we have frontline personnel including our residents and nurses and everyone else that works in healthcare raising their hand to say hey i saw something wrong and so that's why it's really important to embed people into a clinical situation where they are able to recognize what types of events they
• 22:30 - 23:00 should report [Music] probably the most important foundational thinker in the field of patient safety is a gentleman named jim reason who's a now retired or a semi-retired psychologist in manchester england what reason was doing was as a psychologist studying or what he called organizational accidents how did terrible errors in accidents and harm happen in industries whether it was
• 23:00 - 23:30 nuclear power or space shuttles or intelligence failures in the cia so he studied a bunch of them and what he found was the same pattern over and over again what he found was if you look at it superficially you would see a human being who who screwed up that was the superficial understanding it was easy because it fit with a human model that i i need to blame somebody and if i can just point a finger i'm you know i've solved the problem what was really right was that in in unsafe organizations these organizational accidents happen
• 23:30 - 24:00 because of a long chain of events that allowed that human error sometimes several human errors to cause terrible harm so he came up with a model that to me i remember the first time i read this it's called the swiss cheese model a little light bulb went off and i said aha oh now i get it and now i look back on errors that i've seen through my entire career and now it makes sense organizations build in protections to block those simple human glitches from causing harm the problem is those layers of
• 24:00 - 24:30 protections he likened to pieces of swiss cheese they all have holes if i kind of blow something one day i forget something or write something in the wrong space most days if the that first layer swiss cheese blocks it but on a bad day the first layer misses it goes through the hole and it hits the second layer and the second layer blocks it when we kill someone in medicine because we gave them the wrong medicine or cut off the wrong leg or there's a space shuttle crash or three mile island and you look back you realize there were a lot of layers
• 24:30 - 25:00 each one of them had a lot of holes and also that particular day the karma was pretty terrible and it just happened to be that all of the holes aligned and that's how the error made it through all of these quote protections to cause terrible harm my instinct was no longer let me figure out who screwed up my instinct was now swiss cheese it became automatic here's a bad error what's the swiss cheese what are the layers of protection that we had that we that failed how do we shrink the size of the holes and how do we create enough
• 25:00 - 25:30 overlap in layers of cheese so that an error never makes it through all those layers to cause terrible harm [Music]
• 25:30 - 26:00 with pat i actually spoke to the pathologist about why he didn't pick up the phone and call the neurosurgeon when they learned it was cancer and it was a a rare kind of cancer and his answer was
• 26:00 - 26:30 it's not my job [Music] the doctor told our family you know your dad is fine he's benign the tumor is benign everything's great go on and live your life a few months later my dad got very sick and i got the documents from the neurosurgeon and it said that the pathology was an atypical spindle cell neoplasm which the doctor said was benign we expected the hospital to fully describe to us what happened to
• 26:30 - 27:00 you know take care of us and we were discharged without any explanation so we left there with all the documents in our hands with absolutely no explanation that this was an error i think our first reaction was fear we were scared it scared us that a hospital a well-known hospital with professionals would intentionally cover up that kind of information so the
• 27:00 - 27:30 first the first emotion was fear one day pat woke up paralyzed from his waist down and we were at home in boise idaho and we thought maybe it had a stroke we learned then that his cancer had returned explosively they estimated he had about 10 days to live and i remember my mom sitting cal and i down right before and she said you know your dad is sick and he is going to no longer be
• 27:30 - 28:00 with us i requested a meeting with the doctor and with the ceo and with the risk manager they agreed to it and i flew down there and nobody showed up except the chaplain i demanded that they implement a disclosure procedure that when there was an error at their hospital that they sit down with the family which you know which they did not with us
• 28:00 - 28:30 [Music] you've probably heard the term deny and defend that was the model that is still existent today unfortunately at many hospitals that if we cause a preventable medical harm the goal has always been to shut things down let the lawyers handle it don't talk to the patients and families and then it turns into a legal battle for four five six years where the hope is that the patient and family will just give up and go away and and that's been the model and now
• 28:30 - 29:00 we've moved to more open and honest communication we do a simulation on on how to tell someone that you've made an error and that's a skill that's very difficult to develop to do in a way that conveys that you care and that you are concerned about the person's safety and that you're going to do something about it when you may face a family member who's irate very upset by the news and you know as a new clinician you need to have the skills to be open and transparent and
• 29:00 - 29:30 talk honestly and authentically with people so i'm about to go in and see a standardized patient is what we call it it's an actor that i have no idea how he's going to react and we're going to break him some bad news about a test result that we missed three months ago they're told to react differently to each student so i don't know what i'm going to get when i break them the news you could be angry frustrated or he could go easy on me i just don't know one of the
• 29:30 - 30:00 things that was ordered a couple weeks ago was a ct scan which indicated um some results that could indicate colon cancer and i i gotta cut this um you don't want to say there was another test result that might indicate colon cancer at this short intro into it right then you went right to
• 30:00 - 30:30 that could be colon cancer okay his dad died of colon cancer you could have a patient falling apart in moments you want to look at those pearls on effective communication lay out the facts that you know them and say that three months go on to ct and then as he's like and i know your dad passed could be a cancer but we don't know that right you know all that gingerly careful stuff hey walt hey how's it going all right
• 30:30 - 31:00 it's good to see you again thank you how was the drive in yeah three months ago you remember you came in three months ago i did it showed that you had some thickening of your colonic wall and some enlarged mesenteric lymph nodes we need to do a colonoscopy immediately we want to make sure that i'm not saying it's colon cancer but we want to make sure that and that it's not colon cancer and why
• 31:00 - 31:30 did it take three months to uh that i know this that was my mistake we're looking for structural abnormalities on your kidneys and i overlooked that part of the report three months ago i mean i would have been upset hearing it first when the ct scan happened but now i'm really pissed off that it's been three months that it was delayed right and i mean i understand that you're
• 31:30 - 32:00 angry i can see that you're frustrated and i can't i can't do anything to fix that mistake three months ago but what i can do now is make this a priority as your primary care provider and i can't even imagine how you're feeling right now with the mistake but let's let's take it from here and we'll we'll figure this out together and make this a priority okay thanks all right you know just that they always kind of tell you like never apologize because you're getting guilt and then it sets you up for a lawsuit but like in this
• 32:00 - 32:30 this is like a clear category no this certainly you could have said and i'm i'm really sorry this happened yeah the med students and my fellow physician assistant students like we feel like we have the need to be perfect and we can't make mistakes but we will make mistakes and this is a real life scenario that unfortunately probably will happen at some point in my career and charlie you're going to go next okay okay and the beautiful part parts that we are learning from each other
• 32:30 - 33:00 amazingly good morning hi well nice to meet you i'm sorry i met you before yeah we've known each other for years closer you are to the error the more important it is that you have some accountability for it that you communicate with the people who might be harmed by it and so all of us need to learn the skills to be able to acknowledge what we've done wrong and what we're planning to do to fix it we built it completely wrong i mean you
• 33:00 - 33:30 know we were training i was trained to no you don't talk about your mistakes with a patient that's liability you know the lawyers will be all over us i mean this is a time for openness and honesty and so we can learn and grow together healthcare is not like a toaster where i make it and i sell it to you and you take it plug it in no it's a it's always a cooperative enterprise so that the patient the family and the doctor the nurse they're co-producing the care and now that we're more aware of that over time there's a lot of possibilities for much more participation by both
• 33:30 - 34:00 i recalled a woman whom i took care of we had had a pep test done to screen her for cervical cancer the result was suspicious but i never knew that because i never got the report back and i didn't realize that i hadn't gotten the report back until she called me and asked about the report i tracked it down i found out it was
• 34:00 - 34:30 suspicious we followed it up unfortunately it turned out not to be anything serious but that was a near-miss it was a near-miss that could have been a tragedy had she not called me senator when i spoke at three medical school graduations last spring i asked all of the students who were graduating and i asked all of the faculty to raise their hands if they had ever
• 34:30 - 35:00 made a mistake in taking care of a patient every single student raised his or her hand every faculty member raised his or her hand when i was a medical student on one of my very first rotations i inadvertently during a code gave a full syringe of morphine to a patient iv and they had a respiratory arrest fortunately the person was intubated and resuscitated and did just fine
• 35:00 - 35:30 that was a shocking experience and made me aware at a very early point in my medical career that we have the potential to do things wrong and to potentially harm patients no one ever heard about it besides me and that nurse so it's not clear to me that any changes were ever made as a result and i don't think the patient ever heard i've i've made medical errors i've i prescribed the wrong medication on a patient there were two patients of mine
• 35:30 - 36:00 with very similar names and i just prescribed it on the wrong patient i felt terrible i felt incompetent i felt a little ashamed and i my first instinct was not just to fix the problem but then not to tell anybody right that's just a normal human instinct it is completely understandable why people's first reaction is cover it up don't talk about it it's a very human response doesn't make it the right thing it's actually clearly not the right thing it's clearly bad to do
• 36:00 - 36:30 that but i think we have to begin by acknowledging that it's a very human response you can feel very self-righteous you can say well the patient got the wrong drug fire the nurse there's a complication of the surgery bad surgeon you're wrong you're almost always wrong it feels good to blame someone you got a culprit put them in jail fire many things caused it so who's responsible everybody's responsible everybody can contribute to the enterprise of closing the vulnerabilities of making the whole
• 36:30 - 37:00 thing less likely to go wrong the most recent survey i have seen is that nearly 50 percent of nurses in america still don't feel it is safe to talk about a mistake they've made that's an absolute disgrace if something's bad is going to happen to you when you speak up about something you've seen or done that could help if you're going to get punished for that why would you speak up you don't
• 37:00 - 37:30 you run and hide you lie that's normal human behavior we're not talking about bad people we're talking about normal people become frightened and so leaders you've got a choice you can scare your workforce and give up the hope for improvement or you can celebrate invite work with your workforce and have a chance of learning together to get to a better world what we have learned from other industries is that if you can change the culture and reward people for being open reward people for being honest reward
• 37:30 - 38:00 people for coming forth and talking about their errors then you begin to counter that kind of normal instinct that we all have and begin to create a culture of patient safety where people are much more open and the system gets better because it learns from mistakes and doesn't hide them and we found in the food industry they were years ahead of us they had programs for instance burger king had a program if the employees saw another one not washing their hands they went over and they tapped them and then said got you and then they got either two hours
• 38:00 - 38:30 compensation off or some other reward i mean they're on board safety reports like democracy democracy isn't about having a free and fair election we can do that democracy is about having a second free and fair election the same thing is true a safe reporting it's not about filing a safety report it's about filing a second and when you see an organization with a high rate of reported error what that tells you is it tells you that they must be doing something about those reports
• 38:30 - 39:00 because they're just sitting on them people will stop reporting because even if you tell people they have to in the end it's all voluntary you can't solve it if you can't see it we can see it and more and more people are aware of it that's the good news bad news is you're still at risk be really at risk i mean we haven't pervaded healthcare with the designs and approaches and cultures that actually make you super safe and that's the task ahead and it's amazing how quickly hospitals can
• 39:00 - 39:30 completely overhaul their safety when they know that it's important to their patients hospitals had to hear the message from their own patients that it matters that they wash their hands it matters that they keep a safe environment it matters that they put the safety and protection of their patients first every minute of every day the only way they're really going to get that message is when the american public gets involved and pushes
• 39:30 - 40:00 one way to improve the quality of hospitals in america is to put a microscope on the data they do actually provide leah binder and her team at the leapfrog group in washington dc worked with leaders in patient safety to create a new way to rate the quality of hospitals that patients can understand we worked with the foremost experts in patient safety and we ask them to look at all this data and decide which of the data is most reliable which gives us the
• 40:00 - 40:30 best information about the safety of a hospital and then help us figure out a reliable criteria to put it all together and then we did something else we decided to issue a letter grade the letter grade would apply to each hospital on how safe they are relative to other hospitals so were they in a b c d or f when we first did it we got calls from some hospital ceos who said to me memorably i've decided i don't want a letter grade from you and i said well i've decided
• 40:30 - 41:00 you're getting one anyway because you serve the public and the public you serve deserves to know how you're doing it's very important to do these kinds of ratings because who wants to work in a terrible organization and so if you can make it very obvious to all the doctors and nurses in that hospital this is a highly unsafe hospital i think there's going to be internal pressure to reform and internal pressure to get better but certainly i think it's true that like if you're in an isolated area there's one hospital in town or you could be in the middle of chicago but your insurance
• 41:00 - 41:30 company covers one hospital only it's going to be a challenge in groups of choices but that doesn't mean you couldn't go to your doctor who works in that hospital and say hey why are you guys at d hospital and i think if consumers started talking to doctors and nurses that way it would actually begin to change the conversation where doctors would say why do i work in a hospital that has such high infection rates virtually every other industry in this country has their products and services in a transparent market and people choose so if you're buying a car
• 41:30 - 42:00 you can look up auto reviews and you can compare among different cars and different features in new york which i know particularly well restaurants that had for many years been getting public ratings from the health department on how safe they were those were all public but no one paid any attention to them so the health department said from now on you're going to get a grade on how safe you are and you have to post it in your window so restaurants started posting it and within six months any restaurant that didn't have an a was either out of
• 42:00 - 42:30 business or they were very quickly getting to their a so we said well let's do the same thing with hospitals i mean in our dream hospitals would put their letter grade on you know their front door and everyone would know that this hospital is safe or not actually john eisenberg's tell a great story of the drunk who lost his keys and he's out in front of the bar on the
• 42:30 - 43:00 street looking for his keys and some guy comes over him what are you doing he says i'm looking for my keys i said well why only looking right here he said well that's where the lamplight is this is known as the streetlight effect many in the patient safety field have been looking outside healthcare for solutions to preventable errors industries like nuclear power aircraft carriers and commercial aviation have become known as high reliability organizations due to significant efforts
• 43:00 - 43:30 to improve safety high reliability is different in healthcare because it points directly at examples of very hazardous industries organizations that have solved the problem of getting to zero harm that health care has not solved tools and methods and lessons from that work are very directly applicable to healthcare and we're starting to see healthcare organizations use them to
• 43:30 - 44:00 make improvements at a level that we have never seen before so over here we have the complex system of the modern american hospital and over here we have other industries that have learned to simplify and deal with these complex systems in the last calendar year there's been no fatality worldwide in commercial aviation due to an accident compare that to our business where we have 20 wrong side surgeries every week
• 44:00 - 44:30 pilots make one air per hour in the cockpit every day they work and yet we wonder why planes aren't falling out of the sky if aviation has said well you know what to fly you 600 miles an hour it's going to come with some mishap and you got to expect a plane or two to fall out of the sky and thank god they didn't say that and they said no we could drive it to zero we could drive it down to virtually no mishap and they have the aviation
• 44:30 - 45:00 industry is the safest it's ever been since the invention of the jet engine what we're really doing when we go up together in an airliner is pushing a tube filled with people through the upper atmosphere seven or eight miles above the earth at eighty percent of the speed of sound in a hostile environment with outside air pressure one quarter that at the surface and we must return it safely to the surface every time and we do in this country alone 28 000 times a day 10.2 million times a year and a little
• 45:00 - 45:30 over 100 years you've gone from quite a dangerous industry to the first ultra safe mode of transport bar none one of the reasons is because it is studied so well and every single event is clearly understood and is made public so others can learn from them i'd been flying airplanes for 42 years i had 20 000 hours in the air and throughout that entire time i had
• 45:30 - 46:00 never been so challenged at an airplane i doubted the outcome i thought i never would be i was wrong in january of 2009 captain sullenberger's training and instincts saved the lives of all 155 passengers aboard u.s airways flight 1549 after it struck a flock of geese and lost all engine power the dramatic landing on the hudson river reminded americans of the importance of experience in the cockpit
• 46:00 - 46:30 in an industry in which we worked very hard to make everything easy and routine and safe 100 seconds after takeoff we were suddenly confronted with the ultimate challenge of a lifetime to do something we've never done before and get it right the first time never having practiced it in a similar fashion in medicine there are some things that just can't be practiced safely any other way than in a simulation for the first time and it gives you a chance to practice things over and over and over again so it's important that the simulations
• 46:30 - 47:00 be done not simply individually but also collectively as a whole team flight simulators have been used to train pilots for nearly 100 years and while medicine has used cadavers to train doctors for much longer only recently have institutions begin using robotics to simulate any kind of
• 47:00 - 47:30 situation a care provider may face simulation is a very big part of our educational program here and it involves anything from patients who come in as actors and and will work with a student all the way up to very high fidelity robots and environments that are that are tricked out to look exactly like a hospital operating room or an emergency department or a hospital ward the airline industry is the prototype of using simulation where you can practice
• 47:30 - 48:00 landing in you know san diego with a terrible storm or a tsunami or a very calm day and you can practice all different kinds of failures within the airplane it's newer in healthcare but it's really something that's catching on and you can really put people through the the steps of handling many important situations so we're going to be practicing our new simulated protocol for our actual sepsis patients sepsis care can be very very difficult we know the science behind it
• 48:00 - 48:30 we know what helps but we don't necessarily know how to do it in a way that's organized and consistent we'd rather practice on our friend the mannequin here who it's very hard to injure rather than on real patients that way we can standardize things within our hospital and give our nurses and doctors a chance to practice what it is they're doing before they have to do it on real patients hi robert my name's emily i'm going to be your nurse today i'm here to do your morning assessment and take your vital signs how are you feeling i'm not feeling very well
• 48:30 - 49:00 you're not what's going on i just can't catch my breath this morning and i feel like my cough is worse he's remaining stable based on the alert um and the lactic acid i think i'm gonna start some oxygen okay are there signs or symptoms of an infection he has that white count of 16. okay sounds good i'll be right over okay thank you bye hi mr robert
• 49:00 - 49:30 how are you feeling i've had better days are you short of breath yeah okay and then when does this start there you go john culture's already correct yes this is robert though we can make the scenario more complex and we do on occasion we could have the patient enter state of shock or not respond properly to the fluids or the antibiotics so much of what we've done is related to the the need to kind of
• 49:30 - 50:00 fulfill the recommendations that have been given in addition to wanting to do what's right for the patient and following through on the best available scientific evidence when i graduated as a nurse the first time i ever had a chance to shock a person whose heart had stopped was in the middle of the night in a rural hospital and it was my first time i'd ever turned on the paddles in my life and someone's life depended on that that's not acceptable we want our students to practice and practice and practice how to shock people in a
• 50:00 - 50:30 simulated situation so that when someone's really depending on them they do it right the first time i shudder to remember how i was trained at a doc as a doctor to learn how to do stuff lumbar punctures you know spinal taps or put ivs in or even chest tubes you practiced on the patients i mean that was the only option some patient sometime was the first patient i ever put a chest tube in and that person paid the price they were paying to it might for my tuition you know we
• 50:30 - 51:00 don't do that with pilots we put them in a simulator and they fly something that isn't really a plane for a while first with high fidelity now we know how to do that in healthcare the growth of simulation so that the first chest tube doesn't go into a human being it goes in a mannequin that is looks like a human being that's great and i think that it's one of the emerging ways to help build skills uh in a workforce without the patients paying the payment tuition many aspects of the aviation industry have been applied to medicine from
• 51:00 - 51:30 checklists before an operation to monitoring physicians for fatigue but there are still elements of safety in aviation that have not been explored one of the most well-known improvements in airline safety is the black box a surgeon in toronto has been working with a group of designers to create a similar tool for the operating room i want my patients to feel the same way when they enter the operating room as i feel when i enter in modern aircraft unless we create a system where we understand that we tolerate and we learn
• 51:30 - 52:00 from our errors we will never be able to improve we've tried for many years to create something like the black box finally in 2012 we're able to create a technology that allows us to capture video and audio and data from everything that's happening in operating room we've been developing and implemented a number of sensors so we know how many times the door opens and closes we know how we wash our hands prior to a surgical procedure and all these data feeds are
• 52:00 - 52:30 combined and they're perfectly synchronized on the same platform when we talk with our patients about the black box and what we're doing here the first reaction the most common reaction in ninety percent of the patient is i can't believe that this hasn't been done before from the point we started recording our surgeries we had a we had tremendous amount of media attention [Music] everybody believed in the transparency doctor that's what he was nicknamed he doesn't have anything to hide i'm definitely going to go to him patients need to know that when they
• 52:30 - 53:00 walk into a hospital everything's being done to learn from mistakes and possible risks that take place this has to be common standard practice we've heard for too long that health care is complex that our patients are not aircraft and surgeons are not pilots i just want us to start doing something and changing it we're trying to create a system that identifies performance deficiencies and improves safety a new gadget comes out from a health from a industry provider all the time usually
• 53:00 - 53:30 it's a very emotional attachment like oh this looks sexy or i like how this handle feels when i'm using it during surgery you need something deeper beyond that so this is what we call a full surgical timeline and you can see the entire procedure broken down from beginning to end as you scroll down this timeline you'll start to see little beats here and that's where our surgical expert analysts have coded where they solve errors this screenshot establishes what one of the errors is so in this case this error is took place during the
• 53:30 - 54:00 suturing task and it was inadequate visualizations as the surgeon was suturing with the needle and driver he might have gone off frame which is incorrect because now you have no idea where that needle is you even see issues in say leadership or communication and we have a whole tool set determining exactly that this points a really interesting storyline because the blue bar establishes that the surgical resident the trainee under the main surgeon was doing the actual case and then when a cluster of errors take place you can see the
• 54:00 - 54:30 switch over to the main surgeon to dr van sure of this entire timeline is the data quantified we're breaking down the entire set of errors into tangible areas to provide further education on to essentially improve it analytics is at the heart of what the black box does but we're jumping into different areas our engineers are working on tools to improve hand washing to essentially create a detector that lets you know yes you've spent the right amount of time and the right technique to wash your hands so
• 54:30 - 55:00 over here one of our engineers kevin has been working on just that it's a motion sensing tool that will look at how you wash your hands and you look at the surface plane you're working with the amount of time you've spent on washing your hands and give you real-time feedback the key here is the data so i can go and tell any surgeon you have to wash your hands as many number of times and in this in this fashion but if i have a hard data showing because of doing it this particular way we've reduced side infections by this much it's irrefutable
• 55:00 - 55:30 [Music] so [Music] so [Music]
• 55:30 - 56:00 hi um [Music]
• 56:00 - 56:30 i'm gonna do to the best of my disability [Music] this is my living room well this is [Music]
• 56:30 - 57:00 my father [Music] feather them [Music]
• 57:00 - 57:30 dude
• 57:30 - 58:00 [Music] ladies and gentlemen please welcome your hosts for hello hello
• 58:00 - 58:30 welcome to the suit [Applause] all right holy crap white men can't jump
• 58:30 - 59:00 so maybe i don't even have a disability [Music] [Applause] and that's what a dad joke is it turns out it's just way too [Music] eye much so anyway [Music]
• 59:00 - 59:30 cal has gone on to become part of a comedy community he's producing he's produced two comedy shows cal uses his comedy in really novel ways that helps him deal with losing a dad i haven't been close with my dad at the recent
• 59:30 - 60:00 um so i'm getting us something to communicate better [Music] everybody develops their own way to deal with death or loss or grief and i think that that comedy is cal's uh his outlet mike only brought new life
• 60:00 - 60:30 he feels like he doesn't suffer but he sometimes struggles to be understood because his speech is impaired he struggles when he rides on airplanes because sometimes his scooters or walkers are broken [Music] he struggles in environments where it's not easy to get around the first year or year and a half we had 183
• 60:30 - 61:00 separate medical visits for physical therapy and ent and eyes and ears and teeth and neurology and and during that time in my heart i knew something was wrong with cal and our local doctors were really not willing to offer a diagnosis and then we took i took cal out of state to uh to a leading university where a team of specialists reviewed cal charts that i had never looked at i didn't think there was any reason for me to look at my birthing charts and back then charts weren't that available to patients and they
• 61:00 - 61:30 showed to me a report from an mri that they did on cal when he was five days old that clearly shared abnormalities in his brain from his jaundice [Music] and our healthcare system really didn't well they covered up they covered up gail's injury and i was not empowered with information and knowledge to challenge some of it or ask the appropriate questions you know in
• 61:30 - 62:00 healthcare they say the patients we need to ask more questions but sometimes we simply don't know what to ask understand before you go in for any particular procedure what are the questions you need to ask to keep yourself safe and if we all start asking those questions then pretty soon it'll become clear to any hospital that's not doing those things that there's pressure on them to do it if you're in a hospital
• 62:00 - 62:30 by definition today you're seeing a lot of different doctors there's a lot of caregivers coming in and out of the room most of whom work to communicate with each other but sometimes they miss so if you see something that doesn't look right or sound right you say whoa wait a minute that's not what they told me patient safety is a team sport and one of the ways to really make a difference is you've got to get patients engaged so if patients begin walking into hospitals with an expectation that they're not going to get an infection and they start saying hey have you washed your hands before you come over
• 62:30 - 63:00 to see me that's how it happens if they've done it outside the room or they've done it at the nurse's station on the way into the room they're touching the door they're touching things and then they're coming in so that doesn't count it has to be before and after patient contact here's what i look for in a hospital that's really outstanding on safety the sink is placed in a way that it is easy to walk into a room and immediately wash your hands you'll see charts on patient floors right there for
• 63:00 - 63:30 anyone to see that will show how they're doing on patient falls for instance or how they're doing on infections people have an attitude about safety you just can feel it there's an apocryphal story of president kennedy visiting cape canaveral during his presidency and he takes aside a custodian says what's your job the custodian says mr president my job is to help get a man to the moon and return him to earth safely everybody has a job to do to protect
• 63:30 - 64:00 patients not just doctors every nurse pharmacist physician custodian has a role in safety i think it's deeply unfair to expect patients who are sick in the middle of an illness to try to sort this out on their own now it may be unfair but the reality is that's where we are the best thing they can do is have a family member or a friend around because again when in the middle of an illness it's very hard for you to pay attention to know what's going on but your friend can your family member if somebody says you're going to get
• 64:00 - 64:30 medication x is that the medication that that actually showed up and asking in a very friendly and respectful way when a nurse comes by to hang a medication or give you a pill you know what is this what am i getting it's a totally reasonable question patients should feel comfortable doing it and if you have a provider that responds badly to that you should try to figure out if you can switch providers my father was a doctor in a small town in connecticut for a lot of time he was the only doctor there and he was
• 64:30 - 65:00 he was revered and you didn't question him it wasn't my father's fault in any way he was he was a proud and successful professional honored by his community that's not actually adaptive if we really want care to be what it can be i think i understand the hesitation people may feel to be to ask the doctor what's going on here but that's healthy that's good and we need to train doctors to not just to accept that but to absolutely welcome it it's better
• 65:00 - 65:30 medicine [Music] if as reports indicate there are as many as 440 000 preventable medical deaths in this country alone every year that is the equivalent of seven or eight airliners crashing every day with no survivors before the first day of that kind of carnage was complete airplanes would be grounded airlines would stop
• 65:30 - 66:00 operating airports would close no one would fly until some of the fundamental issues had been resolved but because aviation accidents are dramatic they receive the kind of attention that they do and the public awareness medical deaths occur singly and often behind the scenes but in aggregate the harm is huge we need to change the way we think about these medical deaths we need to think about them not as
• 66:00 - 66:30 unavoidable but as unthinkable we've got to be better at making sure that whatever hospital you go into in the u.s you're getting the same quality care and we are not there i mean you're asking people to do things differently asking doctors to think differently and work differently you're asking architects to build different spaces nurses to work differently in teams patients to have a different role to change patient safety exchange everything if you look at preventable harm across american
• 66:30 - 67:00 hospitals it has gone down considerably you know saving hundreds of thousands of lives and billions of dollars it doesn't mean we fixed it it is quietly slowly but definitely becoming the professional norm to take certain precautions to do things in a certain way so that patients are safe because you can be satisfied if you have very low expectations and the reality is that all of our expectations should be raised that we all get very high quality safe healthcare we all want
• 67:00 - 67:30 to do well we all want to get better nobody comes to work to harm a patient or wanting to harm a patient or to give bad care we haven't made this a public health issue where the public is really thinking about this and yet when you talk to any person who's had a family member or themselves in healthcare they all have a story i've also talked to doctors and nurses who've committed a terrible error and they say i know i can't take that back but what will really give that meaning is if i do something that makes the
• 67:30 - 68:00 system safer for the next person i think in part the job of people like me and leadership roles is to harness that passion harness that energy all the rest of these guys are much more serious about medical reduction they ever were is it going as fast as it could no of course not it is not stuff happens anymore that's where we're going and that's the good future that we're moving towards feels like we should be further along than we are but actually i think we've made tremendous progress in 15 years it is on the map we have these examples in the u.s and
• 68:00 - 68:30 around the world it's not any longer a question of possibility it's a question of will [Music] many of us go kind of through a self blame although we know it wasn't our fault we feel like we didn't protect our son and so there was really really significant grieving so the anger at
• 68:30 - 69:00 first was immeasurable when we discovered pat's air we both felt tremendous fear i think at that point it was just plain disbelief he said whatever you do he said do not give up on patient safety so that led me on the a journey to i wanted to make sure our healthcare system our government knew what happened to pat and kale so it took us eight years but we really did make some changes in our healthcare system where
• 69:00 - 69:30 babies being discharged would have a bilirubin test before they were discharged thanks to sue and the work that she's done there are now processes in place in every hospital to screen for that condition and the odds that that's going to happen again are now approaching zero and that's what we'd like to see happen throughout medicine and the work that sue has done is our model for how to do that she turned what she had gone through into empowerment and positivity and
• 69:30 - 70:00 if she can do it so can i and so can a lot of people i obviously always idolize my mom and i understood her job very well and when people would ask me what does your mom do i'd say well she saves lives having witnessed these tragic outcomes in our health care system the one place that we should feel unquestionably safe and it kind of ignited a fire inside me that wanted to you know do what my mom does which is you know talk with hospitals and talk
• 70:00 - 70:30 with doctors and figure out how we can make those kind of things not happen again so i went to portland state university and i chose to do public health because i wanted to feel like i was making a difference and feel like i you know could help prevent things that happen in my family happening to other people [Music] i am unwilling to believe
• 70:30 - 71:00 that we have done all that we can do my experience with diagnostic heirs and the healthcare system has been without a doubt the most powerfully emotional experience in my life however my family's story is also a story of awakening of passion of change and hope for the future i cannot change what happened to cal and pat
• 71:00 - 71:30 but i've always felt that i could somehow be part of it and make a difference my teacher encourage in hope and determination in passion of course he's my teacher in sense of humor what she believes his mother has none of but he is the reason for what's in me how many doctors does it take to change
• 71:30 - 72:00 a lot no it doesn't matter they're probably gonna screw up ah yourself what's in you thank you [Applause] [Music]
• 72:00 - 72:30 you know when pat was dying he said never give up patient safety at that time i did not envision my whole family being engaged before we went on stage today i thought about pat my daughter in the front row my son on stage it was just surreal
• 72:30 - 73:00 [Music] on march 8th which is the day that my dad passed away we spread his ashes on table rock whenever we go there i always feel like a warm just like presence and it's because it's such a beautiful place and it's beautiful that he's there as
• 73:00 - 73:30 well pat will always be alive in our our hearts and in our memories and it was very hard for them to lose a dad when they were only four and six they will continue to honor and miss and wonder about their dad i've always had this hope i will not believe that our leadership in our country and our health care system will continue to think this is
• 73:30 - 74:00 okay because it's not [Music] [Music]
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• 75:30 - 76:00 so [Music] so
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