Conversations in Bioethics 2014: Medical Error

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 breasts 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 in 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 other's 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 son's 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 were 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 leveled. 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 laparoscopic 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 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 what 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 boardroom 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 boardrooms, and get the boardrooms 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, which 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 healthcare. 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 on 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 boardroom 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 mics 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 boardroom. 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 tort 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 many 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 counterproductive 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 tort 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 tort reform. But some of those things need to be worked out to get to tort reform. But even without tort reform, if we could create PSOs 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 1980s 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 patient 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 am likewise a practicing physician here in the faculties associates on campus and [unintelligible] is educating medical students about quality and safety issues. 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 than in many hours preceding, and I've been practicing 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 asked 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 everything. 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 healthcare 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 healthcare 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, 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 interpreter 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 form gets filled out and gets sent to administration, but that then gets looped back into the credentialing 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'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 MOOC. 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 panelists for a wonderful, wonderful evening. (applause)