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Randy Bass: I'm delighted to welcome you all to the event here tonight on behalf of Georgetown.
My name is Randy Bass. I'm the Vice-Provost for Education at Georgetown.
Students, faculty, alumni, parents, honored guests,
friends in the community, everybody welcome.
This event marks the inauguration of a new annual series
hosted by the Kennedy Institute of Ethics here at Georgetown
called Conversations in Bioethics.
The aim of the series is to bring together
student work as you saw downstairs, distinguished speakers,
and the broader Georgetown community to go deep on the topic, and
inspire leadership for change on critical issues in bioethics.
The topic this year is medical error.
A topic as we are about to hear that is both
shockingly common and richly complex.
It's most fitting to talk about this topic here
at Georgetown which helped to found the field of bioethics.
The Kennedy Institute of Ethics located on the
fourth floor, the top floor of Healy, one floor up
has been a world leader in bioethics for more than 40 years.
It has the world's most comprehensive collection of
bioethics resources located in a beautiful library on the first floor.
It has the number one ranked PhD in Philosophy and Bioethics in the world.
The bioethics undergraduates took first prize in the National Bioethics Bowl.
Any of them here tonight?
(Applause)
You're uncharacteristically humble.
And the KIE is producing the world's first MOEC,
that is massive on-line open course on bioethics launching April 15th.
In case you want to shift your mind onto other critical life issues.
And the KIE is now developing Ethics Lab on the
second floor of Healy Hall, an innovation in bioethics that
combines bio-ethical inquiry with the critical methods of design.
To me the Kennedy Institute is the meeting ground of past, present, and future.
It is the best of philosophy in its depth of inquiry.
It's the best of Georgetown in its commitment to
conversation for the common good.
And it is the very embodiment of an emergent forward looking
interdisciplinary field where theory, practice, policy,
and innovation all come together.
I have not only the deepest respect, but also
affection for the KIE finding myself homeless and officeless in the Fall.
The KIE gave me an office and my home is now up on the fourth floor.
And I would like to take this opportunity to publicly apologize
for whatever the presence of an English professor
amidst all those ethicists and philosophers
has done to your real estate values.
(laughter)
Nothing more embodies the spirit and achievement of the KIE than its
director Maggie Little whom I now have the honor to introduce, and
who will in turn introduce our panelists and convene the conversation.
I met Maggie many years ago when she first took over the KIE,
and I knew from our very first conversation that
we were kindred spirits and that she would be a
very dangerous person to know because every
conversation would produce 10 new ideas and
I am happy to say that that's exactly how it has turned out.
Maggie Little is an accomplished philosopher,
a brilliant teacher, and I know this first-hand because
we have taught together, and a visionary leader
who has utterly transformed the Kennedy Institute for Ethics.
So it's my pleasure to welcome you and to introduce Maggie Little.
(applause)
Maggie Little: Thank you Randy.
Let me add my own welcome to Randy's.
It is wonderful to see all of you here in beautiful
Gaston Hall to talk about a critical issue.
I do want to give special welcome to our special guests.
We are so honored to have our friends from Gallaudet University here.
We have members of Georgetown's Board of Regents
and Board of Director.
We have the Provost in the audience.
We also have 12 students who embarked on a
journey last semester to take a special course on
this topic diving deep and doing some amazing research,
so I welcome them in particular.
We're here this evening to talk about medical error.
In 2000 the prestigious Institute of Medicine
issued a report that sent shock waves throughout
the medical community estimating on review that
medical error, preventable medical error,
cost the lives every year of 100,000 people in the United States alone.
As one of the co-authors of the report said that is the equivalent of
three fully loaded jumbo jets crashing every other day.
If it happened in the aviation industry we would all take notice.
The FAA would be paying attention, but instead
it happens in some sense on behind closed doors
in silence in ways that don't come to the fore, but do damage patients,
their families and critically the providers themselves
who are trying to help and ended up harming.
It's an incredibly challenging issue as we're about to see.
It's also an issue that isn't just about the error itself,
but the aftermath of error for one of the worst
aspects of the problem given the way that our
medical system is structured and fears of liability,
providers, doctors and nurses, are often told they can't say
I'm sorry even after they committed an error that does terrible harm.
Something that does a further layer of damage to the
patients and the families and also can lead to
lasting trauma for those health care providers who
aren't allowed any of the means to sort of reach
a kind of reconciliation with their own souls on this.
So tonight we have three amazing nationally acclaimed leaders
in patient safety each with their own stories about medical error.
I'm delighted to introduce them.
Let me have them come out and join them and then I'll tell you who they are.
(applause)
Beth Daley Ullem, nationally recognized patient safety advocate,
and a Georgetown alumni SFS '95 after her own experience,
which she will be sharing with you about medical error.
She went on to take her training as a McKenzie analyst
to take analytic tools to leadership levels of hospitals.
She now sits on the board of directors of two hospital systems taking
cutting edge approaches to decreasing the rates of errors
and making possible truth and reconciliation in its aftermath.
Sitting next to her Brian Goldman, a physician, emergency room
from Toronto who has written an amazing book The Night Shift,
writes with brutal honesty about the realities of the
medical experience from the providers perspective,
what it's really like on the wards, why it's really
difficut not to commit errors, and why it's hard
to talk about them when they happen.
Next to him John James, PhD [unintelligible] psychologist just retired from NASA.
Also his own experience with medical error wrote a beautiful book called
A Sea of Broken Hearts. He, too, has become a national leader,
founded the Patient Safety of America, and
as we'll be hearing about published an updated
set of statistics that make it clear that the problem
is not decreasing, but increasing.
Let's start the conversation.
So, thank you Beth, Brian, and John for joining us.
You know we talked a bit about the statistics,
three jumbo jets every other day, that's a lot.
Lest we make it sound like it's about large numbers
I wanted to start by personalizing the issue, and ask
each of you how you came to this topic of medical error.
John, let's start with you.
John: I'll go ahead. In 2002 I lost my 19-year-old son to medical error,
in his college town. He was a runner and it turns out
he was severely potassium depleted, but somehow
his cardiologist didn't recognize that and put him
through a lot of testing and when they discharged
him from the hospital they didn't warn him not to
return to running and two weeks later he died while running.
And as I got his medical records and looked at them
and then I looked at medical literature and what ought
to have been done in his case I realized that they
had made a number of serious errors and also in my
reading at that time I also began to realize that he was not alone.
In those days the Institute of Medicine estimate of
up to 98,000 was just coming out and so it was making
a lot of headlines, but other estimates were even higher
than that at the time, so I kind of took it on as a crusade.
I can tell you it's not easy to overcome the grief
associated with loss of a child, but once
you can get that under control you can begin
to say this has got to not happen to other people,
as best I can make it not happen, and so that's why I'm here.
Maggie: Beth.
Beth: Ten years ago I went to have my second child
at a major hospital and I had what's called a
uterine rupture where a scar splits open and
it was kind of the perfect storm of things that could go wrong.
It was a busy Saturday night.
The doctor was not there so really relying on residents
who were not well trained enough to detect what was going on.
The fetal monitors were turned off, and then
when we finally realized that there was a very big problem
because you wouldn't realize it from the fetal monitors
of the alarms going off since they were off,
and I started bleeding all over the room.
There was no [redundant] paging system to allow
the doctor who should have been answering the page
to come and help me so they paged that doctor
not one, two, three, four, five times.
And then finally my husband carried me down to the
operating room until they could find someone to operate on me.
So I would say our event was, you know, I was 9 months
pregnant with a perfectly healthy 9 pound 12 ounce child.
And because of this perfect storm of errors any one
of those things could have changed the course
of me delivering my beautiful son and not having
a son who was born severely brain damaged.
So when we talk about these numbers it feels
like jumbo jets, Maggie, and to me I just see his face,
and I see taking him off life support, and just
the agony that I lived in for a very long time,
and part of starting to heal from some of that agony
is, you know, the same for me is trying to figure out
how to make this not happen or not happen as much,
and how to get to a better place as a system
where this isn't happening and when it does happen
we feel comfortable so that we can learn from it,
and not have it happen again.
Maggie: Brian, you're the physician here and
especially being in the Emergency Room I can
just imagine the chaos you at times experience.
Tell us a bit about what it's like from the
medical providers side, the idea of medical error,
and what got you into this issue.
Brian: I'm both a practising physician and I'm a writer.
Early on one of the reasons why I did emergency medicine
was so that I could do it in shifts and be able to write in between.
One of my first articles in a newspaper was on medical errors,
and it was probably because of something that
happened to me as a second-year resident, and it involved
something that happened in the emergency department.
I saw a woman during my cardiology rotation,
so it was my job as the cardiology resident to
go down to the emergency department and see patients
who had been referred by the emergency staff
to cardiology and I saw this elderly woman with
all the symptoms of heart failure and I made
the diagnosis fairly readily, easily,
started to treat her, and she felt better.
At the time I didn't want to be a high maintenance
resident and I imagined that a high maintenance
resident asked for a lot of help and asked for
what should I do, what should I do here,
what should I do there, and I made a couple of grave mistakes.
The first one was to send the patient home. She was feeling better.
I sent her home without consulting with the attending
cardiologist who knew her and probably could
have provided a lot of background information,
might have said "I should see her myself."
That was the first mistake.
The second one was ignoring the small voice
which I've come to respect, the still small voice
that says "Goldman don't do that, bad move."
And I ignored it and I sent her home and
I felt so uneasy about it that I went back to my
work on the wards and on the way home I did
something I don't usually do I walked through
the emergency department and that was the first time
that I heard the three words that I talk about
in my TED talk and talk about in my book.
The worse words that a physician can hear,
but in particular an emergency physician because
we do episodic care and there's a good chance
that we don't remember every patient we've seen.
I've probably seen 80,000 patients, and the three words are
"Do you remember?" And the nurse said,
"Do you remember that patient you sent home? Well, she's back."
And she was back near death.
She had collapsed an hour after the paramedics
sent her home and the staff internal medicine, etcetera,
the cardiac arrest team tried valiantly to
bring her back to her previous level of health.
She was admitted to the Intensive Care Unit,
also suffered from brain damage, and
was allowed to pass away 10 days later, and
there's never a good time to experience this, but
my heart goes out to anybody who has an experience
early on and is scarred by it because there's
just something about that experience without
a culture that helps you understand what happened,
but I was resilient enough to resolve, to learn
what I could from it, to pay it forward, and
that's the way that I get through the day, and
my surprise was discovering that, you know,
until the next time it happens and the next time.
There's a saying in emergency medicine that
something bad will happen every few years.
Some of it's luck. Some of it's just, you know, you can't be
perfect all the time and I've come to accept that we're
humans and that's one of the reasons why I'm here.
Maggie: You know, this is reminding me when
I was teaching the class last semester and we were
talking about the incidents of the magnitude of this
problem and what it must feel like from the
providers perspective that one thing medical
students probably are not told is that there is
a near 100 percent probability that in the
course of treating thousands of patients you
will make a mistake because you're human, and
when you make a mistake it may have tragic results.
And so let's talk about that now and do some
training now about all of that.
How to handle it, how to sleep at night afterwards,
how to support, give care to the caretakers, and
very little of that happens.
John, I wanted to ask you about that question of magnitude.
You know, I still keep picturing the
three jumbo jets every other day.
That was Institute of Medicine's estimate which
many people at the time said was actually incredibly
conservative and then you just published a
paper where you introduced a new methodology.
John: Well I didn't so much introduce a new
methodology as I took some studies that had been using
a new methodology called the Global Trigger Tool.
And it's a method by which certain triggers are
looked for in medical records by people that
have been trained to find them, things like stop order
for a certain drug or certain kind of measurements
that come from a clinical lab that are clearly abnormal
and suddenly appear, something drove those.
And so the way the Trigger Tool works is these
trained usually nurses or maybe pharmacists
look at the records and they suggest that
maybe there is a trigger here and then they hand
it off to a physician or two physicians that
look at it and decide, yes there was an adverse
event here and then the physician decides
whether it was preventable or not, which is a
very subjective measure, but that's the way it typically
is done, and that's very different than what the IOM did.
They had two physicians I understand look at
medical records from New York State in 1984
before a lot of you were born, that's how old
the material really was and the Institute of Medicine
estimate came out in about 2000 or 1999, but
it was really old data from New York State,
and as Maggie said it's up to 98,000 was their estimate.
They had looked at some data from Utah,
and they said 44,000 there, so that's why they
did up to 98,000, but one of the key things about
their search approach is that it finds primarily
errors of commission, that is somebody did
something wrong and it's evident in the record.
Now there's several other kinds of medical errors,
and I think you'll hear about those as we go
through some things tonight, I think.
There's errors of omission.
Was there something that should have been done that wasn't done.
A lot of that these days is defined by guidelines.
In 1984 guidelines were just starting to be born
to guide physicians on how to care for their patients.
So that wasn't even a benchmark in those days when that could happen.
There's other errors.
Errors of context.
When the patient was released did the people
releasing them from the hospital, and this goes
a little bit to what you said, did they understand
the context of where this patient was going.
Did this patient have the right support and that kind of stuff.
Another kind of error is diagnostic error, and
those can dovetail some of the other kinds of errors,
but those have been estimated to be about 40 to 80
thousand in the general population by MD's,
and the final error is one of communication,
and in a hospital setting or in other settings
that can occur a lot of different ways.
It can occur between nurse to nurse, intern to intern,
resident to resident, doctor to patient.
There's a lot of opportunities for miscommunication
and hospitals are busy places, shifts change,
and the message does not always get to the next shift,
or the next people that those happen.
So when I looked at the recent studies and I looked at
four that used the Global Trigger Tool I combined them into one.
I don't think any one of the four studies was robust
enough to represent the nation, but combined
together I think they really were representative of
a picture, at least, of the national way things are
in hospitals and using that I came up with about 210,000
based on what the Global Trigger Tool could find, and then
I asked myself what is it the Global Trigger Tool cannot find that matters.
That would be primarily errors of omission.
Errors of communication may not be evident at all.
Diagnostic errors are not found, and if there's
not evidence in the medical record that an
error actually occurred than obviously the
Global Trigger Tool can't find it.
And there are some scientific studies showing
that medical records often do not exhibit the right
parameter so that one can deduce that a medical error has actually occurred.
So when you factor those in that's how I got the 440,000 per year in hospitals
lose their lives in association with an adverse event.
Often these are very sick people and they're
complex and hard to treat, but the seminal event that
ushered in death was a medical error or a preventable adverse event.
Maggie: Four times with the IOM originally.
John: A little more than four times and they
said that was their upper limit, and I am pleased
to say some of the grand daddy's, if you will, in the
Patient Safety Movement backed me up, and that
obviously made me feel credible.
Brian: Well, John, there's so many reasons why what
you're saying makes a lot of sense that much of the
error that goes on that can cause harm is undiscovered.
The first evidence to me is retrospective.
We keep hearing about ... I'm in Canada.
I practice in Canada where we have provinces
instead of states and it's publicly funded health care,
but it's not uncommon to have, to find out in
retrospect that there's been a
callback to thousands of patients because
it's discovered 10 or 15 years after the fact
that they've been using an improper method to
sterilize a colonoscope or some other invasive
type of instrument that's used, and so now there's
a callback because there's a risk that a large
number of patients have been infected.
We have had inquiries because of CT scan reports
that have been incorrect attributable to one or two
physicians over a five or ten year period of time.
Pathology reports where there is incorrect method
used to determine whether a breast cancer,
a breast biopsy showing breast cancer is
estrogen receptor, positive or negative.
That's very important because it determines
whether that woman should be on Tamoxifen or not.
And we have lots of these that are clearly not
catching errors in real-time.
They're not catching them as they occur, so that's one thing.
The second thing is in the culture of medicine,
I'm going to keep talking about that, we aren't
curious enough about mistakes.
Whatever mistakes you've uncovered in your
methodology I guarantee you nobody knows what
the expected anticipated average median mean error rate
of a surgeon performing an appendectomy is.
Or a surgeon performing a laparoscopic, using a keyhole
surgery, a laproscope to take a gallbladder out.
Because nobody's ever looked for it, and that's a big problem in medicine.
Maggie: Yeah so, you know, when we talk about
magnitude and we talk about "error mistakes" I know
that in the class that I co-taught that the
imagination can first go, I think, to the idea
of the providers not being careful enough,
not caring enough, not being competent enough.
So the first sort of target in these conversations
often ends up being well the individual who made the mistake,
but one of the most important things we ended up
talking about was that the lion's share of
responsibility for medical error may actually be
responsibility of a broken system.
The analogy we used in class was if you construct
a highway with very bad convoluted on and off ramps
right next to each other and terrible signage
the structure is making sure is making highly
predictable that even the most careful of drivers
are going to rear-end each other.
So there is something about the system of medicine
that many have said an important piece of why
we're seeing so much error.
Beth, I wonder if we could start with you about what
are some of the factors here that make errors so common?
Beth: You know, I think we talked about the
different types of errors, but structurally if
you just think about how hospital systems have
evolved from being sort of mom-and-pop community
hospitals 50 years ago, to being such complex
institutions with just exponentially more acute
patients today than they had 50 years ago the
number of people that touch any one patient.
The number of times any provider logs into a
system to order something, to deliver something,
to change something, you know, there are just so
many different touch points that to deliver care
within that system for that patient is inherently
so much more complicated than sort of the
Leave it to Beaver days of, you know, your
physician guides you and holds your hand through
the whole process, so just delivering that care
is more complicated and delivering it to
exponentially sicker patients is the other big piece
that I see structurally is a big challenge.
So I think we should still talk about the culture,
but just the structure of the system is more complex
than ever and it's only getting more complex as
we see hospitals continue to merge and moving
into different businesses than they have otherwise,
and pushing a lot more of the patient care outpatient, you know.
The hospital systems where I served 30 years ago
they didn't have so many of the businesses that we now have.
We have a quasi retirement facility in one of my hospital systems.
We have dental care in another hospital system.
We care for Medicaid foster care, you know,
we're in a lot of different businesses where we're
looking at so many more touch points for these patients
and I think the complexity of that adds to the challenge.
Maggie: And Brian I know you've talked about the
complexity, too, and this sort of technology being a
double-edged sword because it can help you treat
faster, but that means there are more patients that
now you can treat and that means the pressures
from productivity start to sky-rocket.
Brian: Yeah, the economists talk about productivity,
and productivity pressure and, you know, in
my own emergency department I remember when I
first started working there we would see 70 patients a day,
and now we see 220 patients a day, and the physical space,
you know, we've had one increase in physical size.
Our emergency department was rated for about
41 - 42,000 patients, and now we're at 56,000.
And just that fact alone means that if space is
at a premium we are constantly improvising with
workarounds for things that aren't optimal.
We don't have the right place to look after this
patient, and so we look after them in a makeshift way.
We're using the security triage room as a place to do a quick assessment.
You tend to drive patients into areas
of the department where it may not be safe to look after them.
Our emergency department is divided into the
major area where we see people with the chest pains, and
the gastrointestinal bleeds and the intensive care patients.
The RAZ area which is rapid assessment zone.
The idea behind it is that you see them and
assess them and treat them and send them home in one shot.
Well, all you have to do is have to order a CT scan and a
bunch of blood work and that's gone out of the window.
I've noticed that sometimes the nurses will note
that that patient's ... that it's very busy in two of those departments.
You have a third area the ambulatory care area
which is for people with ankle sprains and
nosebleeds and cuts that can be sewn up.
And every once in a while they will, not every
once in a while, not infrequently, they will bring somebody to that
department whose having the worse headache of their life,
which is now rule out subarachnoid hemorrhage.
Well, if you have moved as we do from the major to
the minor, you know, to the ambulatory care section
of the emergency department you are trying to wind down,
and the last patient you receive is somebody who
is having the worse headache of their life,
so now you're into CT scan and if it's normal
than you're going to do a lumbar puncture, and
now you're going to be there for three or four hours longer
than you expected, and there is a natural tendency to cut corners.
Not only that, my colleague Pat Croskerry, who has
written about cognitive errors in medicine has said,
"Geography is destiny in the emergency department."
If you put a patient with throat pain in the
ear, nose, and throat room, you will treat them as a sore throat.
You will advise them as if they have a sore throat when they
may have angina, heart pain, and you really
have to cognitively move them to another part of the department.
The reverse is true, too, if you bring that patient into the
resuscitation room you're going to be acting as if there's a life threat.
Sometimes I feel, you know, technology ... one
more thing I want to say about technology it
can be wonderful, but double-edged sword is right.
Let me give you one concrete example.
It can be hard to operate and there are IV infusion
pumps that have contributed to the deaths of people
when they become so complex to operate that,
and this is a real case of a nurse programming a
patient to receive four days worth of chemotherapy
in four hours and once the infusion was in, there
was nothing to do, but keep that patient
comfortable and watch them die.
John: I can reinforce what Brian said about technology.
My son was supposed to have had a cardiac MRI.
It was kind of a linchpin study.
It was the one that would take him from the
non-invasive test to the invasive test depending on what it showed.
We were told that they didn't see what they wanted to with the cardiac MRI.
Months after he died I was contacted by a
radiologist in the hospital and he said,
"I'll tell you what happened to your son."
"We didn't know how to use the MRI machine we had."
"It had just been upgraded and the technicians couldn't
use the software right, so that test was never done properly."
And he and I over the years had quite a bit of
dialogue about medical errors, and he had lost a son
to a medical error actually and so we shared a
lot of our grief and understanding between each other.
But that's about all I ever got in terms of back from
the hospital, but the technology.
Beth: I wanted to add on to that.
One thing that I want to make sure that comes out of
this discussion that the number of medical errors
is much greater than we ever thought, and we've
talked about the technology challenges, the
geography challenges, the complexity challenges.
I want to make sure that, you know, everyone recognizes
that, I think, we help more people in hospitals than we ever imagined.
We take sicker people than ever imagined, and
we do miraculous things for them.
You know, we have procedures that 40 years ago
that child would die and now they live a robust life.
My son has titrologie which is a heart defect, and
he has a vibrant life because of all these medical innovations.
Every day I'm really grateful for the people
that come to work in the hospitals.
The people that come to work in the research institutions
that develop these innovations that try their best to care.
I don't want this to be sort of a grim reaper discussion,
you know, but it's that balance of saying you know,
I think everybody is trying to do a good job,
but the system is complicated.
The geography is complicated.
The technology is complicated, so you know,
what's the right way to support people to reduce
the likelihood of those errors, and when they happen
what's the right way to support them in having a
good transparent discussion, but I really want it
to come out that I do think medicine is incredibly wonderful
in helping people, and the people who practice
it do extraordinary good every day.
Maggie: One of the things that keeps striking me as
we talk about this including what Beth just said
about the incredible good intentions and high training,
and miracles that are performed every day,
and yet upwards of 400,000 people dying of
preventable errors that a system is making all too
easy for good people to commit, okay, so it's
not about bad people in the usual case.
Of course, there are bad apples in any profession,
but that's not what's causing 400,000 errors,
but then the question that presses is
why do we allow a system to continue like this.
So go back to the analogy with the jumble jets, right.
So pilots are very caring and highly trained, and
really want to do the right thing, and if we
didn't have any oversight and system that said
you actually can't fly when you have not had any sleep.
We do not do the same with our physicians, our nurses.
In aviation we say, wow, the new technology on
that plane is really, really complicated, so we're going
to have to do layers and layers not only of training,
but of back-up, make sure we catch the redundancy plans.
We don't do that in medicine, so that's a huge dis-analogy.
Why do we treat medicine so differently?
John: We don't see it. I mean, I think most of
the people out there have a friend or a family member
that believes they've been a victim of a medical error,
but what do you do about it?
There's no ... you saw it on TV that night that a
jet crashed somewhere. It's so pervasive in a way
that we just look right through it, and I think
that's starting to change, but medicine is so complex.
I'm firmly convinced it's much more complex than flying any plane.
Because every individual is different.
A lot of the planes are the same and you're
trying to fly certain kinds of planes and you're
not supposed to fly others, but if you're in an ER
you don't know what you're going to see and
maybe a plane crashed in your town
you're going to see a lot of people awful fast, and you're
going to have to make decisions that are difficult to make.
One thing that came to mind is your story about
the woman with congestive heart failure and
then your story, your description of systems.
Two countries, as far as I know, France and Taiwan
have medical records that are on little cards
like credit cards and so if your lady with
congestive heart failure had come into the ER you could
have gotten her medical record and you would have known it.
Why don't we have that in this country?
You could look right over there to Capitol Hill.
Brian: It's the same issue in Canada.
In my province Ontario, unfortunately there was a
financial scandal, it's now known as eHealth,
but basically we spent a billion dollars.
We wasted a billion dollars on sole source contracts,
and a whole bunch of snafus that nobody can talk about,
nobody could raise the issue politically.
It's politically radioactive to talk about a
cradle-to-grave electronic health record.
The nurses have a standing joke in my emergency department
about who has the worse handwriting.
I'm proud to say that my first freelance article
in the Globe and Mail, you know, one of
Canada's newspapers, that I hand wrote it and
my mother typed it, which you know that was before.
Maggie: You are dating yourself my friend. (laughs)
Brian: I am. That was before my first Kaypro computer.
Now I'm really dating myself.
My point is that I would never write a radio script,
or write a book, hand write it, unless I were Charles Dickens I suppose,
you know, reborn, but the absurdity that this
critical information is handwritten.
Maggie: In scribbles that are a point of pride for
indication of how elite the doctor might be.
You know I'm thinking here of Atul Gawande,
some of you may know, Harvard doctor who's written
widely about trying to make solutions to medical error
including check-lists, so let's find evidence-based
ways of treating, for instance, somebody presenting with
cardiac symptoms in an ER and here's the check-list.
He wrote a great article. Beth was actually the
one that sent it to me and our class read
comparing the industry of medicine in the
United States of America in 2013 to the restaurant industry,
and the case study of the article was the cheesecake factory, my people.
So he visited a bunch of cheesecake factories,
and he found, lo and behold, they're very efficient with their costs.
The food is decent.
There's a lot of choice.
The quality is consistent.
You can go any time of day.
You can go to any cheesecake factory you will find consistency.
None of those four factors apply to medical care in the United States.
The stakes are a little higher.
So he wants to start asking why not the cheesecake factory.
Beth, I know you've done some work just looking at
sort of the organizational structure of regular hospitals
as opposed to health care systems like Kaiser, and such.
Beth: Yeah.
Maggie: Why it's harder not to be able to have
sort of oversight and say, look here's how to
have consistency in the [unintelligible] you're putting out.
Beth: Yeah, and I think that the sort of legacy in
medicine of how you're caring for the patient
being an art and not a science is kind of ironic to me
because all the doctors are scientists.
They've been taught in scientific training and
yet how you get cared for by any one doctor there's
enormous variation for each type of procedure,
and to me as a layperson, especially a lay
business person, you know, it just never quite
computed why there's that much variation, so as
I began to look into this a little bit more the
structure of hospital systems really kind of pierced
me as something that was driving a lot of this
that the hospitals for the most part the doctors are
private practising and they're not part of,
they have privileges, they're sort of "subcontractors"
to the hospital, but they're not owned by that hospital,
they're not employed by that hospital, so to
the extent that the hospital might want to reduce
variation on how the doctors practice the doctors don't
work for them and then the national organizations
like American College of Obstetrics and Gynecology
they offer guidelines and standards, you know,
but the hospital system that I was working with said
"Oh we don't quite agree. We're going to do that a little differently."
So, you know, structurally it's very difficult if the
doctors are private practising doctors who like
doing things in their own art way, artistic way,
and there might even be enormous variation among
how doctors within that one practice do things,
so how do we as a system for the things that
should not have that much variation create a
more consistent approach to how we do things,
that just consistency lowers cost, consistency
brings in the quality band where there's not as
many errors and when you see the errors you
can tell everybody how to do it to avoid it.
It improves a cycle of learning as well.
So that was one of the things that I saw as a
challenge not insurmountable, but certainly
trying to get culturally the doctors to be more open to
applying a more consistent way to do it, and
structurally having them not be employed is often
a challenge to pushing down that consistent approach.
John: In some ways consistency in medical care is
defined by evidence-based guidelines.
The trouble is there is about 2,500 of those,
and some are high quality because they're carefully
peer reviewed, they're prepared by unbiased experts.
Others are sort of pushed by people that probably were
biased and have an agenda as far as what they want in the guideline.
There are ways to sort out which are which.
To my knowledge that has not been done on a global scale.
If I were a physician I'd be sceptical of guidelines,
but I would have a very good reason before I
deviated from those guidelines and I think
what I would do if I were in your shoes perhaps
is to say, okay, you guys, you guys the doctors,
you follow these guidelines or write down why, why not.
Your personal experience or, you know, something
going on in Europe or something that says this
guideline is wrong, but otherwise follow it.
Brian: I believe that the Veterans Administration is
probably doing a better job than other organizations
in standardizing approaches to diagnostics and therapeutics.
Maggie: Ashby Sharp works for the
Veterans Administration came and talked to our class
about just that and how because it's a vertical
integrated health care system it's able to do
much more progressive things than some hospitals.
We're going to talk in a minute about things we can
do and that are being done to make a real difference,
but I want to turn our attention first to the
aftermath of error, so one of the very important
things is just figuring out how to decrease error,
but another is figuring out the best way to help
patients and families and the providers once an
error has taken place. I mentioned in my opening
remarks that this is another area what's been called
the second layer of trauma.
Unthinkable error happens and then patients are
often, sometimes, but too often met with maybe
denial, closing ranks, often silence and the
stories some people have shared. Sorrel King
is in the audience who's written a beautiful book
called Josie's Story about her own experience
and she talked to our class about her
experience of being in a critical care unit
with her young daughter and the team of health care
providers becoming her friends because she was
there 24/7 for many days and then a terrible
error happened and those people who had been
her friends would not meet her eyes when she
saw them in the hallway because they were told by the
hospitals risk administration you cannot talk to them.
So now something that they actually did do wrong,
and what do we tell our children, try not to do
anything wrong, but as important as trying not
to do what's wrong is what you do to take
responsibility for what you have done wrong,
and all the things we teach our children.
The power of apology to both parties, right.
Owning and trying to make whole to whatever extent
you can so that the idea that patients shouldn't
have to sue to get just compensation, right,
if our error has harmed you we should do what
we can to make you whole, but instead often the opposite happens.
Beth, take us back to your story which wasn't one of the best,
one that wasn't a shiny moment for the medical hospital.
Beth: I wish I had a different story to tell
in so many respects, but after we took my son off
life support we buried him on Sunday and on
Monday morning at 7 a.m. I went back and sat down
with the medical team and I said we all know
this was an error and this was preventable,
so what can we do to learn from this?
What are we going to do to retrain staff,
what policies are we going to change, and I
had my whole little list and I don't know how
in that moment I possibly had the clarity to
pull that together, but, you know, I said I
don't want this to be in vain and I heard
things that just, you know, as a mother frankly
now my heart just breaks that I would never want
my child to ever say things like well, it was
a busy Saturday night, or we don't know why
God needed your baby more than you.
And then the aftermath of the fetal monitoring that
I was on the strips were destroyed and the computer
backup of the strips was deleted, so not only
was it devastating to lose your child.
I mean my milk was coming in and I was binding
my *** and I just delivered a full-term baby.
You know, how you own up to it and share that
experience with the person who was harmed it
would have just been so different had they
said, "you're right, this didn't turn out like
any of us wanted it to, and let's work together."
I love stories like Sorrel's where the organization
did get to that point and my experience was 10 years
ago, and many organizations are starting to move
and many have moved on a much better journey of
owning errors and harm and being transparent with patients.
My organization wasn't there then.
I'm working with them now very extensively
and I'm very proud to say that they're much further along in that journey.
So, you know, culturally trying to make it more
acceptable to report errors even when they're
small errors or near misses structurally
building into the organization a system of learning
so that whenever an error happens it's pushed out
so that everybody in the organization can learn from that
error involving the patient so that their perspective is heard.
These are some things structurally that we need to do.
Also, reducing the heirarchery so that anyone can
report that one person can't shut it down.
Some other things that organizations have
structurally done are multi-disciplinary peer reviews
meaning don't just allow it to be doctors in the room,
but allow doctors, nurses, the janitor, whoever
can be in that room to provide thoughts about that
event can join and especially across speciality
areas that helps foster a more robust learning
experience and an improvement experience.
There are all sorts of things that organizations
can do and many are doing to try to move
themselves culturally to be more transparent,
to move themselves structurally to have the systems
needed to support people who work in those
organizations to be transparent, and those are supportive
things we can do not just punitive things that we can do.
Maggie: Well let's stay with that topic about the culture of medicine.
Brian, I know this is a topic near and dear to your heart.
So, you know, medicine is a culture.
It's not just a profession. Hospitals are ecosystems
that have their own languages, their own norms,
their own habits, and we do a lot in the way we
train doctors, you've argued, that actually makes
it very hard for doctors to acknowledge to
themselves and certainly to others that they're
human and they will possibly make mistakes.
Can you talk to us about that a bit.
Brian: Sure, I can, and before I do, Beth, I was
touched by your story and the reaction and I'm
glad things are better, but I know something
of the culture that reacted to you that day and
I don't know if you've had the opportunity to
hear it from my side of the gurney, but my sense
is that we are incredibly, and I'm going to use
the not so royal we, we're very defensive about mistakes.
I think what you were encountering was defensiveness,
and if you find people who are defensive in
health care that's, I think, emblematic of a culture
that not only doesn't tolerate mistakes, but
can't handle this whole human side of it.
This fact that we're human.
They just can't handle it.
We have a saying in medicine.
It's not that we are repulsed by error,
especially our own, we don't commend each other
when we do a good job, you know, we're constantly
geared towards who's the smartest person in the
room, that's the leader, everybody else is nothing.
We have a saying in medicine, as far as feedback,
"No news is good news." No news is good news,
you can go through an entire career with no news,
you must have had a good career because nobody
ever said anything bad about you.
We are intolerant of mistakes.
In my TED talk I talked about the batting average
of a good baseball player being 300 and a
Hall of Famer of 350, and so what's the batting
average of a surgeon supposed to be, and silence it's 1,000.
You're supposed to never, ever make a mistake,
so your story was a reminder to them of their
human fallibility which they thought they could
purge by studying and by knowing everything,
and by staying up at night and being hypervigilant,
and you can't because one day the system will fail.
Something's going to happen.
The person you're used to, you know, the nurse
that I'm used to counting on to catch my mistakes
won't be there to catch my mistakes, or a
hundred other ways that that happens, but
when the error hits then there's no denying it when it's happened.
What's the significance of a mistake?
Well it's two things in many cultures.
One of them is that you're either lazy or it's a lapse, or you're incompetent.
Which one do you want?
I think most of us would choose the lazy lapse,
but with that in mind all of us are living terror
when we've made a mistake that they'll be a second
one uncovered within three or four weeks, and
if that happens, oh that's a pattern doctor,
that's a pattern, and so what does that make you do?
That makes you not want to talk about mistakes.
If nobody ever talks about their mistakes and
you talk about yours very soon you'll feel as if you're
the only one who's ever made a mistake in the last 15 years.
You know, if I talk about something that happened
last week or if a resident talks about something
that happened last week and talks to their attendant,
and the attendant talks about a mistake they made
in their first two years of practice
the hidden message is they haven't made a mistake
since their first two years of practice.
If we don't talk about it how will we learn
from each others mistakes and it's not just my mistakes.
We have this thing about vicarious shame.
If I know, if I'm walking through the hospital
I make eye contact, well if I happen to pass by
a surgeon who I know through the scuttlebutt
has taken the wrong leg off or operated on the
wrong lung, opposite the one with the cancer in it,
I'd probably have trouble making eye contact with him.
That's how we fail to support each other.
And I could go on and on about this, but the
ramifications are that we don't learn from our mistakes.
We don't share the knowledge because it's a
repudiation of what we are supposed to be.
Which to me it's ridiculous and what keeps me going
is that I accepted the fact that I'm human.
Maggie: Well let's move to some of the hopeful news.
Things that we can do and things that places are doing,
beginning to do to make a real difference, and
John I wanted to start with you and your concept
of a Patient Bill of Rights around these issues which I've read.
By the way after the event we're publishing a web resource
on all of these great ideas and we'll send out the information.
I read the Patient Bill of Rights and it is first of all beautiful.
Second of all, utterly compelling.
You're not asking for the moon.
You're reminding us of some basic entitlements.
Tell us a bit about this idea.
John: I'm afraid I am asking for the moon,
but we got there once, maybe we can get there again, huh.
Thank you for the NASA lead-in.
Maggie: Okay.
(laughter)
John: Yeah, as I looked at my sons care and also
began to read what was going on in the
medical culture, if you will, and what was appearing
in medical journals it appeared to me that there
was about 8 or 10 things that really needed
to happen to level the playing field.
Okay, so you're really sick, you're not really yourself,
and you're going into a hospital.
You're very vulnerable, you're afraid, and
you enter this strange new world where everybody
seems to know what they were doing, they know
everybody and the playing field is terribly unlevelled
so that if all the people on their side are not
altruistic and at the top of their game and all that,
you can be harmed because of things that,
because of their power and their knowledge
they can do to you or forget that you need,
and so how do you level that playing field?
And here are some of the thoughts I had.
First of all is informed consent.
Everything I've read from oncology to cardiology
is that most patients do not understand how to
get the information to make informed choices.
There's a mantra now of patient-centered care.
Well if you as a patient don't understand the
options you have in your care you can't make
an informed decision and it takes a lot of time
in most cases for a physician to give a patient
enough information to make an informed decision
and listen to the questions, but that has to get better.
Informed choices by the patient in consultation with the physician.
Other things, drugs. One-fifth of all drugs are prescribed off label.
That means they were approved by the FDA for a specific
kind of use, but what the doctor is doing is
prescribing it off label which means you're
not in the population base that was studied.
You're old, you're young, or you don't have the illness
for which the drug is targeted at.
That puts you at extra risk of harm because
basically you're being a little bit of a
"guinea pig" and the doctor may have a very good
reason for prescribing that drug for you, but
I think the doctor should be compelled to write
it down and explain to you that you're being
given this drug off label and there are certain
extra risks with that that haven't been worked out yet.
Things like that. Another thing is cost.
If there is anybody in here that hasn't been
stung once in a while by the surprising cost
of medical care in this country I'd be surprised.
Beforehand, you should know the cost of what
a routine procedure is going to go for in the hospital,
and some of that is happening now.
They're getting bundled procedures where if you go
in for a tonsillectomy it's going to cost you
X amount whether there's complications or not.
Another thing is feedback when it's all over.
A system that captures your opinion, your insight,
and your wisdom about what went on while you were in
there, and it's made public not personally attached
to you, but about your hospital and about the
doctors you saw so that others can go into this
big database and find out how effective a certain
doctor has been through the eyes of the patients.
That's starting to be worked up a little bit,
but it really needs to get going.
There's no reason that shouldn't be in place,
now, given the IOM estimate from 2000 years ago.
The other thing in a hospital I feel you should be
given your medical records every day to look at,
to have them explained to you.
If you want to add something or say "doctor,
this isn't the way I understood it," or
"didn't you tell me this. I don't see it here."
Or you can ask the nurses. There's just a number of things.
The other thing perhaps is an advocate.
Patient advocates are very critical to care in
the hospital and I think back to the system
when you talked about it a woman named Jody Hoffer Gittell.
I don't know if you've read her book called
High Performance Healthcare. I would bet you had,
but she found when she looked at hospitals that the
only person that really integrated the care of
a patient in the hospital was the patient advocate.
Often a family member, but not always, and
there's actually a profession growing now for
hospital patient advocates that will go in there
and be with you and look out for you in an integrated way.
In fact, you can go hire those people now.
If you've got an elderly parent somewhere
that really needs one of these you can go buy one
to sit with your elderly parent if they're not busy.
So anyway, a Patient Bill of Rights, you know,
workers have rights, you know, companies can't abuse workers.
Minorities have rights because they needed the playing field levelled.
We need a level playing field with a hospital.
Maggie: Brian, you've talked about some concrete
suggestions that have come up for changing that culture of medicine.
I liked your phrase about instead of having a
sort of shame and blame based medical culture
becoming almost scientists about error that,
of course, error is going to happen. Let's be curious about it.
You had an example about doing something different in the OR.
Can you share that?
Brian: There's a remarkable laparoscopic surgeon named
Teodor Grantcharov. He works at St. Michael's Hospital in Toronto.
His background is not only in laproscopic surgery
doing keyhole surgery, gallbladder surgery,
appendix, appendectomies, but also in using
the simulator, using simulated education to
teach young physicians, medical students, residents.
Early on in his residency he took up the game,
the [unintelligible] game of golf and had some lessons and
discovered that he was videotaped and "oh,
what's that all about?" and his trainer said
"so that you can learn by watching how you
swing a golf club and improve as you go."
And he wondered why we didn't do that in medicine.
And from that time, from the beginning of his
residency, we're now going back about 12 or 13 years
he started to videotape himself performing
surgery in the operating room. The only one.
He has terabytes of himself performing surgery,
and here's a man who is in a very concrete way
curious about his performance in the operating room,
and he's taken it a step further. He's tried
to standardize error reporting and recently did
a study in which he had surgeons around the
world videotape themselves. It hasn't been published yet,
but the notion here first of all is to determine
what is an acceptable error rate and I know
a lot of people will recoil at that, but people aren't perfect.
So the kinds of things he would count as an error,
when you're doing keyhole surgery you're operating
instruments outside the belly while you're looking
at a TV monitor and there's a no-no, for instance,
there's several. One of them would be to have a
sharp instrument attached to one of the instruments
drop out of the view. If it drops out of the view
of the monitor it could be doing harm, so he
was counting the number of times that that sort
of thing happened. It's only by going back to
the beginning and figuring out how many mistakes
we make we can figure out what's acceptable
and what isn't and begin to standardize training
and standardize error reporting,
so that's one thing that he's doing.
The other thing he's doing is mind-blowing.
Taking a page from the airline
industry he's developed the first flight data recorder
for the operating room and the whole idea is
that it will record everything from videotape
to vital signs to all kinds of parameters and
he is testing it right now. He has tried it
on a number of patients and that's just the
beginning and I can tell you, I mean, it's
wonderful and it's hopeful, but he's not described as the
most dangerous man in medicine for no reason at all,
but makes him dangerous is that through his work
people will discover what really goes on,
and I applaud him for it. He's very brave for doing it.
Maggie: Beth, you've been working on something
that really intrigues me. Dashboards and the
science of apology both. Tell us about.
Beth: Two separate things. You know, I think
when I go put my McKenzie hat on you can't
think about how to get better unless you know
where you stand relative to the competition
and who's best in class, so one of the biggest
barriers to me to improving on medical errors
is comparative information, and one of my
personal passions is making that comparative
information present in the board room and
accountable to the senior leadership teams,
and part of their financial incentives and their compensation.
So if you only compensate the executive leadership
team of a hospital based on operating profit
then they're going to focus on operating profit.
But if you compensate them, also, on a bundle
of safety metrics that are compared to other
hospitals then they're going to start to focus
on safety as well as operating profit.
So how do we get that more comparative data
available, accessible to the board rooms, and get
the board rooms to make it part of the senior
leadership team compensation. That's a really
critical thing in my view. One group that I'm
really proud of is the pediatric network called
Solutions for Patients Safety that I work with.
It's a network of 78 pediatric hospitals who've
all agreed that we're going to share all
our safety data and we created a common dashboard
that all these hospitals use to share and compare
how you stand on surgical site infections,
relative to the other 77 hospitals, and how you
stand on central line infections, and how you
stand on serious reportable events or falls
or readmissions. These are, you know, just to
have that information was revolutionary which
is kind of pathetic when you compare it to other industries.
Could you imagine buying a car and not knowing
the price, not knowing the safety information,
not knowing anything from consumer reports about
how much people like that car, but that's
effectively what we do in health care.
We buy that product with no comparative information
and that's really frightening, so the groups that are starting
to really put this comparative safety information
out there I think are really revolutionary for
this industry. They're 50 years behind every
other industry in business who already does
this sort of thing, so that's one thing.
Maggie: You also mentioned that the hospital does
best on, again metric has to teach the others.
Beth: Yes, so the other key part of this is I'll teach, I'll learn.
Whoever does this the best that particular metric
their responsibility is to teach the other hospitals,
the other 77 pediatric hospitals how they do this.
That's extraordinary learning, really impactful,
but we need to get those metrics in the board room
so frankly the boards are holding the senior managers
accountable on quality and that needs to happen.
The other thing that I'd love to talk about.
Maggie: Can you pause one sec. I'm going to hear about that,
but we're about to turn to hearing from you all, too,
so while we're hearing Beth's story about the
science of apology if we could bring up the lights
and have the mic's available so people can cue up,
and there's also somebody if you have a hard time
getting to them that will hold a mic and come to you.
Thank you. Go ahead.
Beth: Thank you Maggie. So that's one personal
passion of mine if just comparative metrics
and getting that education about the importance
of those into the board room. The other thing
since I had such a bad experience with apology,
I really have thought about over the last 10 years
how can we teach apology like a science and
how can we build the tools for that science
so that it's done in a less variable way and
a more consistent way and in a way that people
feel confident that this is the best way to
have this difficult conversation so that's
another thing that I'm working on with quite
a number of organizations is how to spread the
science of a good apology and what that looks like.
Maggie: Let's bring up the lights in here
what your questions and comments are. Or not.
Kelly, can you help them figure out the lights. Please go ahead.
Male voice: So I'm a physician in private practice
in the Virginia area and I think one thing that
hasn't been brought up is the near misses.
I think near misses is probably something where
if you look at any catastrophe that happens
in medicine invariably there probably have been
five, or six, or seven near misses where that
could have been avoided, and I think that one
thing that we really need to work on as a society
especially with congress is torte reform because
I think invariably what happens is that people
are afraid to say I almost had a near miss and
how do we investigate this because of the concern
of being viewed as incompetent, but as you said
it's a system error and may times, you know,
there have been cases with insulin and babies dying
because unfortunately they got they thought it
was the saline flush, but it was, in fact,
insulin because it all looked the same, and
those near misses must have occurred probably hundreds
of times before an actual catastrophe occurred.
The one thing I would say I think your Patient Bill of Rights
is very good. The one thing I would be cautious
with is the social media. Unfortunately, people
can be particularly mean spirited just because
they didn't necessarily have a good experience
they may vilify the physicians which potentially
becomes counter-productive in regards to good care,
so how you actually mediate that I think is something important.
Maggie: Near misses.
John: I didn't mean to suggest that it would be
mediated through social media. It would be
very well organized and the data would be
validated to the extent that it could at least selectively.
Yeah, we don't want some vilification of anybody
by an individual patient or two. That's not
what it's about. It's about the overall pattern
of quality that a physician in a hospital
delivers to the patient.
Maggie: I'm so glad you brought up the issue
about near misses. In a different culture that's
an opportunity to learn and instead what we get
is that sort of culture of silence and shame
where you just say thank God nothing bad happened,
and let's pretend it didn't go wrong.
Brian: And the leap to who was incompetent is
an unfortunate one and that's what I mean by
changing the culture. Changing the culture so
that in the same way that you've got a culture
of reporting in aviation, for instance, where
anybody is empowered to say if they notice something,
if you see something say something about it.
We need to have that but, we have to overcome
our shame that says that if I in my lowly position
am pointing out this mistake that I saw being
made what does that say about that person, and
that's the kind of attitude that we need to remove,
that's what I mean by being curious about mistakes,
just turning it around and almost embracing
near misses, for instance, and all errors as
an opportunity to learn and grow and get better.
Beth: And the legal barrier that you mentioned
is a piece of that because, you know,
right now you learn within your system. Wouldn't
it be so much more effective if you're a new
cardiac resident to learn what happened in the
other systems and get a daily alert. New cardiac
residents let's learn what's going on everywhere, right.
Instead we just kind of learn within our own
little hospital and the legal barrier is part of that.
One of the challenges in torte reform is there's
so much value on the economic piece of it that
a lot of times babies, children, non-working mothers
are not assigned. I think that to me is one of, we could
have a whole another one of these discussions
about torte reform, but some of those things
need to be worked out to get to torte reform,
but even without torte reform if we could create
PSO's that give some liability coverage to share ideas.
If we can create ways within the legal structure
to share ideas about near misses, good catches,
and harm, so that everyone can learn.
Maggie: And I love that shift from it's terrible to a good catch. Yes.
Female Voice: I am distressed that nobody, nothing
has been said about the fatigue in these professions.
I mean nurses working 12 hour shifts, three days
in a row and then having to come back to do
eight hours so they do 40 hours in a week.
I think that a lot could be prevented if people
weren't so tired in these hospitals and I don't
think anybody is addressing it because of the economic
issues that are involved it's considered very efficient.
Maggie: Thank you for bringing it up. Brian, I know you
talk about sleep deprivation.
Brian: An unfortunate oversight on our part and
I hope you'll forgive us for our error.
Sleep deprivation and fatigue are a particular interest of mine.
They have been for a long time.
There are certainly pockets where there has been
some research and some action and probably the
most significant example that I can cite would
be the example of residents. I don't want to tell
a long story, but for a long time the culture,
once again, the culture of medicine was
suck it up buttercup, the idea that somehow you
toughened up and you learned how to handle
sleep deprivation by experiencing it and then
the case of Libby Zion in the 1980's really changed that.
Libby Zion was an 18-year-old who died of a
series of errors and the fatigue of the residents
who were looking after her was a significant factor.
That led to significant changes to reduce the
number of hours that residents worked per week.
To reduce the number of hours that they work in a row.
Just to give you a sense of how complex that is
I would say that the administrative changes have
gotten ahead of the science and there are actually
studies now that are questioning how much of a role
sleep deprivation plays in errors, for instance,
in the operating room there was a study last Fall
in the Journal of the American Medical Association that
questioned that paradigm, so that's one thing I wanted to say.
The other thing I wanted to say is that a lot
of these rules exist for residents and the
nanosecond they get their fellowship and go out
into practice it's as if the rules have been thrown
out the window, so I don't know how you make the
system safer by making it safer by changing things
only at the resident level. I believe that one
of the ways to solve the problem is to have more
people involved in care, more overlapping care,
moving to shift work and away from on call stretches.
These will have an economic cost.
You will have to pay for more people to be around, and
I think it's up to society to decide if it's worth it
and certainly there are some important things still to be worked out.
Maggie: Yes.
John: I might add just a little bit to that right quick.
As far as nurses go I believe California has
adopted a rule for that state that every hospital
has to have a certain number of nurses per patients ratio,
and I think that's going to go well, so you know,
it's being addressed even at the legislative level,
but it also needs to be addressed at the cultural level.
Maggie: Yes.
Female Voice: Thank you. [Eileen Mora.] I'm likewise a practising physician
here in the faculties associates on campus and
[unintelligible] is educating medical students about quality
and safety issues and so first I'd just like
to thank the panel for your incredible courage
and generosity in sharing your stories to
enlighten the rest of us. I've learned more
in this last hour and change then in many hours
preceding and I've been practising about 15 years,
so thank you for that most assuredly. Secondly,
I want to just give you a little bit of the local
culture here, if you will, myself with my
colleague and friend [Dr. Mac and Dr. Hauser,]
and others here. Actually now we have a center
for patient safety in the hospital and we had
the education division so we had the very interesting
charge of trying to wrestle with how to best train
medical students and residents in quality and safety,
so I'm offering an invitation. You've created
a [see] change here in this area and I'm very
grateful to you for it. I'd ask you to continue
with that and please come into the medical school
and teach with us because the power of the stories
that you are sharing need to be heard in their
young learners minds as they're wrestling between
the scientist and the artist and how they'll
practice medicine they very much need to hear
those stories, so thank you for sharing them
in this venue and please know I will look you up
to share it additionally across the street in the med school.
Maggie: Thank you. Yes sir.
Male Voice: So I want to make an observation that
I can have a bad day at work so it's okay for me
and I don't even just mean in the sense of the
impact of an error I'd make versus an error
in somebody in the medical profession, but also
my efforts don't imprint themselves until a
final analytical, deliverable that I give which
could be after a week, five weeks, two months
of study, so in fact, some days I know that I'm
not at a certain part of my best so I can even
just go in and I can just get ideas down and
let some of them be wrong because I know I get
to be creative today and then next week I can be
analytical about what I did and over the course
of a study having these different kinds of days
and getting to have bad days they all actually
sort of even themselves out and sometimes kind
of combine for a better product. In the medical
profession it seems that most every action imprints
itself so in that sense not just the sort of weights
of the importance of what you do, most every action
imprints itself and so I just wanted to make
that observation for your comments for two reasons.
One is from kind of a compassionate acceptance
perspective of I just have to be compassionate
and accepting of the fact that our standards
are such that you don't get to have a bad day
even though when I hold myself to a really high
standard I'm actually comfortable with the fact
that every now and then I do, and the second
is more from an analytical perspective of you
think of this kind of lost function, again, right,
where almost every action has sort of been printing
itself so there's this notion of every action
kind of carries more risk than for other professions,
so the risk profile is different, so you know,
you presumably treat that differently, so I
just want to get your reactions both on the kind of
compassionate acceptance perspective
as well as how do you approach that kind of a
risk differently?
John: One of the things I would do if I were
on a hospital board is think about allowing
physicians to have a bad day. You got five
surgeries scheduled and my kid kept me up all night
and I'm not myself. I don't want to imprint on
these patients me at 60 or 50 or 40 percent.
I can put my hand up and say I can't do it,
somebody else is going to have to do it or you're
going to have to reschedule, and I don't think
that happens very often in hospitals.
Brian: Correct. So not being met with hostility
I fell off my chair when I took a critical incident
review course with an intensive care physician
who talked about coming into work saying I had
a fight with my spouse, with my partner, and
didn't sleep very well last night and then asking
the nurses, gathering the nurses around him the
people he was going to be working with that day,
and ask them could you please watch me a little
bit more carefully today. The ego strength that
went into being able to say that to let the guard down,
the perpetual guard, was so important to what you
were talking about that it's not bad day equals
inevitable preventable harm to patients and we don't
want to portray that in black and white.
A bad day, and in fact, even the word bad may
be more than it actually is, but the other important
part of what you're talking about is asking for help,
and it's part of the culture of medicine to not
feel comfortable asking for help so I'm having
trouble intubating a patient passing a breathing tube
in the resuscitation room and asking a colleague
can you come and help me. A lot of us are very
uncomfortable doing that and that's one of the things
that we have to change about the culture of medicine
to make it acceptable to do that.
Beth: I just want to add one last thing.
There are a lot of other industries where people have
to bring their A game, you know, if you're in
the nuclear industry, if you're a commercial
airline pilot, you can't have a bad day that day, right,
when you're flying a jumbo jet, so we have examples
from other industries where there's that kind of
perfection standard and that's culturally an issue
for those industries as well so let's not just
look within medicine, let's look what other industries
that have high risk, high performing expectations
do to manage that and learn from each other.
Maggie: To manage, right, the imperfection. Yes.
Bob: Bob [Rucetta], I work for the president of the university. Hi Maggie.
Maggie. Hi.
Bob: I have three daughters, a wife, myself,
we've all had hospital experiences. There's nothing
in the world more debilitatingly powerful than
putting on that robe and becoming a patient. It changes every,
it doesn't matter what you do in life, the second
that you can't button that thing behind you,
and you feel helpless changes everything, and
the doctors are acutely aware of that, and they
play, most of them, many of them, some of them,
play that and you're helpless and that's a real
problem and I'm fortunate enough not to have had
crisis situations, but I've been to the hospital
enough to know that it's an enormous problem
because you're totally helpless and they've got
you and they don't care and there's a secret.
So two things I want to say is that patient education
so that you can empower the patient to me is one
of the most important things that can be done
because first of all it puts the doctors on notice
that you're not going to bring somebody in there
that's totally helpless, that people are going to
understand doesn't necessarily mean it's going to
be the patient. It may be the patient's spouse,
the patient's parent, but somebody that's connected
to the patient and can advocate within that family,
number one, and number two, that public advocate
which is a word I've used seven times and with
absolutely remarkable results. Every time I've
said I'm going to call the public advocate my
treatment has been changed. The speed in which
we've been treated and the kind of treatment we've
gotten it's been different so I would tell everybody
that if you're in a hospital situation and you're
not happy, particularly in an emergency room use the
word public advocate or whatever the word that the
hospital uses and they always give you a sheet
of paper to tell you. It works because once you
invoke that it starts a process. They don't want
the public advocate to show up because it gets
into the record, so I feel very, very strongly
about patient power.
Beth: I completely agree, so how do we have it
be part patient education, but also structurally
built into the system that the patient has to
be present at rounds, that the patient has to
be informed when the medical team is having a discussion,
and given the choice of being part of that discussion,
that the patient has to be informed that there is
maybe an internal hospital and the best person
that they can call if they don't feel like they're
being heard and, you know, I think back to my
own situation I went up multiple times to the nurses
desk and I kept saying I think something's wrong.
I think I need a C-section. The pain doesn't let
up between contractions and to not be heard
and that feeling of being powerless is just,
nobody should feel that way, so how do we both
educate patients and structurally build them into
the regular hospital system so they're part of
the team and their voice is heard and matters.
Brian: In Canada Kingston General Hospital has developed,
has bought into the patient engagement,
patient and family centered care model and the
phrase that they use is nothing about us,
without us, nothing about me without me, so
they're involved. Patients are involved and
their families are involved in every aspect of care.
Everything that's done in the hospital whether
they're building a new wing, hiring a new nurse,
changing the menu in the cafeteria, deciding
whether you should have visiting hours or
just visiting, you know, where the visitors
should be, the health care professionals, and
the patients and their families should not be the
visitors because they live with each other. Paradigm shift.
Maggie: I want to add just one thing to what Bob said,
and this is in a sense on behalf of health care
providers there is a way in which patients in that
position of vulnerability and sometimes terrible fear
want the doctor and the nurse to be infallible.
We want them to be God to have a guarantee that
it's going to be all right, and if that's the
expectation we take to them, you know, that that's
the model of what it is to care for us, we are
encouraging them to think that they can't be
human, so one of the things the class did, we
were talking about a poster that hospitals might
put on their walls up with Johns Hopkins University
or Georgetown, top university in its class,
and then another poster right next to it with
pictures of medical care providers that says
"To Err is Human Even for Us."
We train hard, we work hard, we will do our best for you,
but doctors and nurses are human like anyone else
so that it can be a partnership of imperfect humans
doing the very best they can. Yes.
Female Voice: I'm so sorry. I'm the timekeeper for the evening,
appointed by Maggie we are nearly out of time.
There's one question up here, somebody's been so
patiently waiting, so I'm actually going to
turn the microphone over there, and I hope everybody
in the cue will be able to bring their further
comments up to the speakers after we close.
Female Voice: I'm sorry, I'm nervous, okay.
I wanted to add a few layers to the discussion
which is some of which I'm sorry I don't know your
name, brought up, about patient power. How much
of medical error is due to patients not having power
and also how much of bioethics has to be thought of
in more diverse experiences such as people with
disabilities. For example, to give some context.
Recently a few months ago my friend was in and
out of the hospital a lot and she's deaf and
a wheelchair user and wasn't provided an interpretor
one single time in the whole month that I visited
her every day, and also medical staff refused to
transfer her from her wheelchair to the bed and
back and forth which she needed to eat and use the restroom,
so I think maybe part of that is not realizing
the impact and what ethics looks like for patients
who are at the edge in that [ball] curve and how
can we broaden the discussion, raise questions
like communication rights for deaf patients,
and other rights for disabled patients.
I'm wondering if you guys have any ideas for how
to start that dialogue happening.
John: I don't know about the dialogue, but what
I think would fix that is for the staff of the
hospital to know that your friend is going to
fill out some kind of form when they leave that
talks about how the quality of care was and that
form could very well go to the hospital administrator
to be dealt with. In other words the patient's
voice is sought and it's listened to, and I don't
think that happens very much now. It's starting
to happen in a few places so we can have a
dialogue all you want, you can try to push the
culture around, but until you make that the norm,
I think it's going to be a struggle.
Beth: And I would add to that not just that the
forms gets filled out and gets sent to administration
but that then gets looped back into the credentialling
and privileges process for those who are
providing the care so that if they have a certain
number of patient complaints they get put on sort
of a disciplinary review process not where they're
suspended, but where they're watched more carefully,
and that affects their credentials and
privileging process and similarly for the
administration if they're getting a complaint
level over a certain amount or within a certain
band then the administration that should affect
their compensation that that's something if they're
not being compensated on patient engagement score
or patient complaints then they're not focused
on it because it doesn't matter to their own
incentive structure.
Maggie: And I do want to add just one last thing.
Randy mentioned that we are doing a MOEC.
Lord help us. Massive Open On-line Course, and
the very first topic we'll be doing is
disability and disability not just as a marginal
case, but disability as a lens to look through
all of bioethics at, so I'm going to send you the link.
I want to thank everybody so much for the conversation
and thank our panellists for a wonderful, wonderful evening.
(applause)