All language subtitles for To.Err.Is.Human.2019.AMZN.WEB-DL.H.264.DDP2.0-YUNO_Track02

It was devastating.
It was very hard.

It was hard for us
to understand and believe
that this could happen

in a developed country
like the United States.

Both my husband, Pat, and my
son, Cal, experienced

what I would say
classic diagnostic errors.

Cal suffered brain damage from
his newborn jaundice when
it was misdiagnosed

and it was never tested or
treated appropriately,

and today he has
significant cerebral palsy.

At about 16 hours, the nurse
charted that he was yellow,

it was no big deal. We were
basically discharged

with a very sick baby, but we
were told he was a well baby.

I was familiar with jaundice
and it was communicated to us

that it was no big deal
and not to worry about it.

And they asked me if
I was a first-time mom.

I said I was, and they reminded
me that first-time moms are

often over-reactive, and they
didn't seem worried at all.

I didn't really know
at the time,

but I learned later on that Cal
was in the process of dying.

We actually watched our son
suffer brain damage in the
hospital before our eyes,

and... Quite honestly,
that will haunt me forever.

And Pat, my husband, died when
he was 45 from cancer,

a cancer that was
appropriately diagnosed,

but the pathology failed
to get communicated
to the doctor or Pat.

They did an MRI and they
discovered that there was a mass

in his neck at the base of the
skull, and so Pat had surgery.

Six months later, the pain
returned in Pat's neck.

A whole series of doctors
came through asking Pat

why he never got treatment
after his first surgery,

and I had all the documents,
and I said, well,
because it was benign.

And then by the time
the third doctor came through,
I said, wait a second,

what was his pathology on
the first surgery?

And the final pathology was
a high-grade malignant
synovial cell sarcoma.

And that document either never
arrived or was placed in his
chart without the doctor seeing.

And I remember showing it to
Pat, and I remember Pat crying.

You know, to think that
another error had taken place,
and this time with him,

that was difficult for us
to witness in our
healthcare system.

[somber music]

Stories like Sue Sheridan
and what happened to her,

where a small mistake can
really be a life-altering event
that remind us the human cost

of what we're talking about.
These are not
theoretical events.

These are not just things
that happen to other people.
They happen to us.

They happen to our families.
And they are things
that we need to work on.

[tense music]

[narrator] In 1999, the first
significant report on
medical mistakes

was released by the Institute of Medicine. They called it
To Err Is Human.

This report claimed that as many as 98,000 people die every year as a result of medical mistakes.

Over the next 15 years,
efforts to better understand
this number increased,

but so did the number itself.

Recent studies have raised
the projected number of deaths
to as high as 440,000.

To put this in perspective,
that's more than the number of
graves in Arlington Cemetery.

It's the equivalent of 2-3 jumbo jets crashing every single day.

So, where does that rank
medical mistakes on
the leading causes of death?

Number three. Right behind
cancer and heart disease.

Now suddenly, whoa. This isn't
just some egg-headed study.

This is a big deal. This
could be you, and they're right.

Wait a second, you mean those
hospitals, my local hospital
was killing people?

Is that what you're
really saying?

We could prevent many, many,
many of these deaths immediately

if we just put in the effort.

Things are happening.
Let's take a look at this.

I just think this is like
a massive epidemic
that we have underestimated,

and the reason is because
it's happening to people
who are already sick.

But, like, they were sick,
that doesn't mean
they were going to die.

And their death is no less
of a tragedy because they
already had a medical problem.

Every time you get on a plane,
you don't expect
that plane to crash.

And everybody who dies in
a plane crash, you say, "Well,
those people were healthy.

They were going to do fine
otherwise." I think the problem
with patient safety

is you say, "Oh, well, these
people were sick anyway."

And I think it's
a very problematic way
to look at the world.

Maybe they didn't die, but they
spend the rest of their life in
a wheelchair or a nursing home

and that accelerates their death
and obviously harms
their quality of life.

So, the numbers about
deaths are a big deal,

but in some ways they
underestimate the overall toll
of preventable harm.

We don't have a stable,
agreed way to measure
safety or injuries.

Actually, the number you get
depends on how you look.

One rule is the harder you look,
the more you find.

So, when you really throw the
book at it and you do everything

you can to look for injuries,
you're going to find
a ton of them.

When people start debating,
you know, is it 40,000
or 90,000 or 100,000?

Uh, it's a lot. It's a ton.
And our job is to make it zero.

This is urgent.
It's a public health emergency.

[narrator] While the number of deaths related to medical error is staggering,

the number of patients who
experience non-fatal errors
is even bigger.

Recent studies suggest one-third of all hospital admissions
experience a medical mistake,

and 1.7 million
hospital-acquired infections
occur every year.

69% of those infections
could have been prevented

through methods that already
exist, like hand washing.

But healthcare workers wash
their hands less than
50% of the time,

with some research suggesting
it's as low as 30%.

There are even more dramatic
examples. In a five-year span,

surgeons operated on the wrong
body part over 2,000 times,

left nearly 5,000 tools
inside patients,

and in 27 cases operated
on the wrong patient entirely.

But diagnostic errors, like the ones that left Cal Sheridan
with cerebral palsy

and delayed the detection of Pat Sheridan's cancer contribute to 1 in 10 patient deaths.

But whether it's a diagnostic
error or any other preventable
harm, the only way to fix it

is to first understand
what causes it.

[Boaz Keysar] When we study
communication in my lab, we look
at how people communicate

and what are the reasons
for miscommunication.

In very simple experiments, when
we ask people to communicate
something to somebody else,

about 50% of the time when
they thought the other person
understood them,

they were wrong.
Now, I don't know the extent of
miscommunication in medicine,

but I am sure it is more than,
uh, physicians think.

Part of the problem is that
when you, when, when,
say a doctor miscommunicates,

he or she might not know.
That's the core of
the problem, right?

They might not get
immediate feedback that
they miscommunicated.

And if that happens,
then that error

could amplify without anybody
realizing that the source was

just a minor miscommunication.

Now I know how-- what happened
to my husband. Now I understand
how it happened,

that there's been no
system-based intervention
to ensure

that lab tests are
followed up on,

that pathologies and radiology
reports are followed up on.

To know that this happens in our
country, that's unacceptable.

[siren wailing]

[tense music]

[narrator 2] Most of us think of
a hospital as a place

where people go after they have an accident,

not as a place where people go
to have accidents.

However, like just about
any place, there are safety
hazards in a hospital.

Some are unique to the hospital environment, and some are not.

Generally, the hospital staff
is very aware of medical
safety practices,

such as the proper handling
of infectious cases,

careful checking
of patient ID before
administering any medication,

keeping things sanitary
and disinfected.

Yet, all of us at times tend to overlook some potential hazards that we are around every day.

We must try to learn to think
safety in everything we do.

But safety doesn't come just
by learning a lot of rules.
It comes from an attitude.

For everyone who works in
a hospital, safety has to be
a full time job.

[Albert Wu] This is a problem
that's, you know,
hiding in plain sight.

And I think that no one is
really surprised when they
think about it for a minute.

If we think the amount
of harm that is currently
existing is just fine,

then maybe it's not a
crisis, it's not a problem.
If that's okay, then we're done.

Most of us in medicine just
said, "Well, that's
the way it is, you know.

Things go wrong.
People make mistakes. There's
nothing you can do about it."

It's pretty obvious that safety
is not number one priority
in most hospitals.

When it is,
wonderful things happen.

What is the problem you're
trying to solve?

And the answer is, for most
hospital administrators,

life is too short to get
the doctors angry at you.

Building a new cancer center,
your oncologists love you,

the other doctors love you,
it brings in revenue,
the community loves you.

If you reduce medical error,
you can't advertise it because

the patients all think that
everything's safe anyway.
Nobody knows the problem exists.

The doctors are angry because
you start to talk about
medical error.

So, that's why you have
an invisible problem.

Every human being will make
mistakes, and will-- so the goal
cannot be zero errors.

Our goal needs to be zero harm,
because we know
errors will occur.

So, how do we make sure
those errors don't actually lead
to harm and are caught early?

10 or 15 years ago, we thought
central line infections were not
preventable.

We thought that was part of
kind of doing business
in healthcare that, okay,

people have central lines,
occasionally they'll
get infections,

and that's just-- Now we know
infections can go down to zero.

Preventing preventable harm is
a skill and a commitment
and a technology

all of its own.
It's not glamorous, but it's
what keeps all of us safe.

If you believe,
"First, do no harm",

there is no excuse for
not investing in things
which will prevent harm.

Health care nowadays is
incredibly complicated.

A patient has literally hundreds
of things done to them,

having blood drawn for a test
or getting an x-ray or whatever.

And so, there are many, many,
many opportunities for things
to go wrong.

So, even when nurses and doctors
and technicians and radiologists

are functioning at a 99% level,
which is, you know, pretty good
for human activity,

that still means a lot of
opportunity for things
to go wrong.

I think this is a general
problem that you have when
you deal with people.

We are not built to not make
mistakes. We are not built
to be perfect.

Are you going to try and change
the person or are you going to
try and change the situation?

One way to do it is to design,
say the work environment,

in a way that would not
necessarily prevent the error,

but would assume the error.

We have to acknowledge that
to err is human, and then
to figure out

what do we do with that fact
in terms of building a system
that's safe for patients.

[tense music]

[Sue Sheridan] Between Cal's
patient safety event and Pat's
patient safety event,

we had Mackenzie in the middle
there. Exactly at 16 hours,
just like Cal,

she also had a very high
bilirubin, which the hospital
took action.

They tested it and they treated
it. I took a shower.

And it was the first shower
after delivery and I remember

I stayed in the shower for
an hour and they sent a female
chaplain in, and I was crying.

And the chaplain thought I was
crying because my daughter was
getting treated for her jaundice

and I explained to them I was
not crying because of that.
I was crying because

I witnessed what the only thing
they had to do with my son,

that it was so easy to prevent
what happened to my son.

[tense music]

[Mackenzie Sheridan]
When I got into about first
grade, people started asking me,

"What's wrong with your brother?
Why, like, can't he move like
the rest of us?"

I didn't really get it, because
I was never told necessarily,

you know, your brother
has cerebral palsy,
your brother has kernicterus.

You know, to me,
he was just my brother.

[ambient music]

[Mackenzie Sheridan] Recently,
I became more interested in
the case, my brother's case,

because I knew, before
looking it up, I knew that he
wasn't given a bilirubin test

and because of that he got
cerebral palsy and kernicterus.

And I got frustrated and I got
angry and confused and

my mom has taught me that I can
do something positive with that
kind of anger and fervor.

I can, you know, go out
and make sure that those
kind of things don't happen.

So, I used to be a little scared
hearing all of the things

that could go wrong in
the health system.

I just learned to be cautious
and to ask questions
and to, you know,

ask the doctors, "What are you
doing? Have you washed your
hands? Have you done this?"

I look at doctors in
a different sense than, I think,

a lot of people do
and as a child I looked at
doctors differently as well.

I know why kids would think like
a doctor don't make mistakes,
but I knew from a very young age

that they do, and that their
mistakes could cost a life.

The first thing that we wanted
was to tell somebody.

Some kind of high authority that
could tell all of the hospitals

about what happened,
so all hospitals
could implement change.

And I thought somebody was
in charge of patient safety
in the United States,

and I learned that
that simply does not exist.

When people think about science
in healthcare, they think
about genes and cells

and drugs and chemistry.
Yeah, that's science.
That's one science.

But, there's another science,
which is the science of
organizing care,

which is how to you actually get
the help, what are the flows
like, how do you do surgery.

How do you take care of
a chronic illness.
There's science there too,

and luckily this country began
investing in that really
in the past few decades.

The Agency for Healthcare
Research and Quality, for
example, it's an American

investment in developing
the sciences for delivering
better care.

[narrator] In 2000, after
speaking with leaders in
healthcare,

President Bill Clinton made a
bold statement regarding

the country's new efforts in
managing medical errors.

Just think about it, we can
cut preventable medical errors
in half in five years.

[narrator] The Agency for Healthcare Research and Quality took on this task.

Today, AHRQ remains focused on
improving the quality

and safety of healthcare
for Americans.

It does so by funding research, developing tools and training,

and collecting measures and
data on the healthcare system
as a whole.

In 2016, a report was released
on the recent progress
in patient safety efforts.

The report showed that from 2010-2015, there were 3 million

fewer hospital-acquired
conditions, showing
a 21% reduction.

125,000 deaths were prevented,
saving $28 billion
in healthcare costs.

All with a budget that
annually hovered between
$400-$450 million.

But it's part of a healthcare
system that spends over
$3 trillion,

and has more than 5,000
hospitals, with over 800,000
physicians, 4 million nurses,

and 330 million patients. That means the agency is working with 1/100th of a percent

of national health spending
and is tasked with improving
the other 99.99%.

It is such an underinvestment
that, you know, a doubling
of the amount

for the agency would be
a vast improvement, but
it still is not nearly enough.

We need this information for us
to take care of our patients
properly, for health plans,

for leaders of large clinics
to say, "Actually, no, I need
to better understand

the choices I make,
how it impacts our ability
to deliver safe care."

It has funded some of the
seminal studies that have had
massive improvements

in patient safety. So, it funded
the studies that led us to
create the checklists for

central line infections.
That alone has saved the
American healthcare system

hundreds of millions of dollars,
if not billions of dollars,

but more importantly,
has probably saved tens
of thousands of lives.

[Ashish Jha] There are tens
of thousands of Americans
walking around today

who would be dead if it had not been for some of the work
that AHRQ has funded.

It's really about how we apply
the best of science

to your individual needs
and preferences.

To some extent I do know
some systems that are doing
a terrific job,

and when I learn from them
about how they are doing it,
a lot of them

are using the tools and
methods pioneered by AHRQ.

[ambient music]

Much of the work that we use to
train around patient safety

and how to make healthcare safer
is actually derived from AHRQ
research and tools.

When they put out a toolkit
or research tools, I know
that they've been vetted

and they've been tried
and investigated and shown
to be of benefit.

So, a big problem that we face
in safety in hospitals is really
improving handoffs,

which is when a patient moves
from one area to another

or when their doctors
or nurses change shifts.

Handoffs are somewhat invisible
to patients, but they actually
have a huge impact on them.

Like, if an average patient got
hospitalized tomorrow,

they would face upwards
of 15 handovers.

And we know from AHRQ-funded
research, it's got to be
more than just

a passive listening where you're
like, uh-huh, okay, I got it,

but really engage,
ask questions, because often
times you'll pick up things.

Combining AHRQ TeamSTEPPS,
with a standardized tool
to improve handoffs

actually led to a 30% reduction
in preventable adverse events.

We also develop our own
home-grown patient safety
teaching programs.

One of my personal favorites
that we've actually

developed here is called
the Room of Horrors.

We take 10 patient
safety hazards

and we embed it into a hospital
room, into a simulation.

This is training where
you're walking into a room

and you're actually seeing
with your own eyes,
can you spot what's wrong?

[Trainee 1] Ammonia. C-diff
positive. So, probably should be
some kind of like precautions.

[Trainee 2] Yeah, he should be
contacted less.

Allergies, latex and penicillin.
That's fine.

Umm. Let's see here.
Oh, those are gloves over there.

[Trainee 2] Are these
latex gloves? Uh-oh, we got
latex gloves.

So, it looks like he's got some
[unintelligible] hanging,

and he's allergic to penicillin
so that's definitely not ideal.

[Trainee 1] Yes, absolutely.
Why does he have magnesium?

I don't know.
It's actually not for his name.
His name is Washington, right?

[Trainee 1] Yeah.
Michael Johnson. Alright.

-Different Michael. I'm also
going to put the stress ulcer.
-Okay. Good call.

[Vinny Arora] They have
10 minutes to identify all
the hazards that they can,

and then right after,
when they come out,
I actually debrief with them,

so we go over how they did,
not only what they got right,

where did they miss things,
and perhaps why did they miss
those things.

If you train people this way,
this is the way their brain
is running in the background.

Every time they enter a room
they can automatically spot it
from the corner of their eye.

As an organization, we cannot
improve patient safety unless
we have front line personnel,

including our residents and
nurses and everyone else that
works in healthcare

raising their hand to say,
"Hey, I saw something wrong."

And so that's why it's really
important to embed people into
a clinical situation

where they are able
to recognize what types of
events they should report.

[somber music]

[Bob Wachter] Probably
the most important foundational
thinker in the field of

patient safety is a gentleman by
the name of James Reason,

who is now retired or
semi-retired psychologist in
Manchester, England.

What Reason was doing was, as
a psychologist, studying what he
called organizational accidents.

How did terrible errors
and accidents and harm happen
in industries,

whether it was nuclear power or
space shuttles or intelligence
failures in the CIA?

So, he studied a bunch of them,
and what he found was the same
pattern over and over again.

What he found was if you look at
it superficially, you would see
a human being who screwed up.

That was the superficial
understanding. It was easy
because it fit with

the human model that
I need to blame somebody

and if I can just point
a finger, you know, I have
solved a problem.

What was really right was
that in unsafe organizations,

these organizational accidents
happen because of
a long chain of events

that allowed that human error,
sometimes several human errors
to cause terrible harm.

So, he came up with a model
that, to me, I remember the
first time I read this,

it's called the Swiss Cheese
Model. A little lightbulb
went off and I said,

"Aha! Oh, now I get it."
And now I look back on errors

I have seen through my entire
career, and now it makes sense.

Organizations build in
protections to block

those simple human glitches
from causing harm.

The problem is,
those layers of protections

he likened to pieces of Swiss
cheese, they all have holes.

If I kind of blow something one
day, I kind of forget something,

or write something in the wrong
space, most days the first layer
of Swiss cheese blocks it.

But, on a bad day,
the first layer misses.
It goes through the hole

and it hits the second layer
and the second layer blocks it.

When we kill someone in
medicine because we gave them
the wrong medicine or cut off

the wrong leg or there's a
space shuttle crash or Three
Mile Island and you look back,

you realize there were
a lot of layers, each one
of them had a lot of holes,

and also that particular day
the karma was pretty terrible

and it just happened to be
that all of the holes aligned.

And that's how the error
made it through all of
these quote "protections"

to cause terrible harm.
My instinct was no longer, "Let
me figure out who screwed up."

My instinct was now Swiss
cheese. It became automatic.

Here's a bad error, what's the
Swiss cheese? What are the
layers of protection that we had

that failed, how do we shrink
the size of the holes, and how
do we create enough overlap

in layers of cheese so an error
never makes it through all those
layers to cause terrible harm?

[ambient music]

[Sue Sheridan] With Pat,
I actually spoke to the
pathologist about why he didn't

pick up the phone and call
the neurosurgeon when
they learned it was cancer,

and it was a rare kind of
cancer, and his answer was,
"It's not my job."

[Mackenzie Sheridan]
The doctor told our family,
you know, your dad is fine.

He's benign, the tumor is
benign, everything's great,
go on and live your life.

A few months later
my dad got very sick.

[Sue Sheridan] And I got the
documents from the neurosurgeon
and it said that the pathology

was an atypical spindle cell
neoplasm, which the doctor said
was benign.

We expected the hospital
to fully describe to us
what had happened, to...

you know, take care of us,
and we were discharged
without any explanation.

So, we left there with all
the documents in our hands

with absolutely no explanation
that this was an error.

[sighs]

I think our first reaction
was fear. We were scared.

It scared us that a hospital,
a well-known hospital,
with professionals,

would intentionally cover up
that kind of information.

So, the first,
the first emotion was fear.

One day, Pat woke up paralyzed
from his waist down,

and we're at home in Boise,
Idaho, and we thought maybe
he had a stroke.

We learned then that his cancer
had returned explosively.

They estimated
he had about 10 days to live.

[Mackenzie Sheridan]
And I remember my mom sitting
Cal and I down right before

and she said, "You know,
your dad is sick, and he is
going to no longer be with us."

[Sue Sheridan] I requested
a meeting with the doctor,
and with the CEO,

and with the risk manager.
They agreed to it
and I flew down there

and nobody showed up,
except the chaplain.

I demanded that they implement
a disclosure procedure that
when there was an error at their

hospital that they sit down with
the family, which, you know,
which they did not with us.

[David Mayer]
Historically, you've probably
heard the term deny and defend.

That was the model that is still
existent today unfortunately
at many hospitals;

That if we cause a preventable
medical harm, the goal has
always been to shut things down,

let the lawyers handle it,
don't talk to the patients
and families,

and then it turns into a legal
battle for 4, 5, 6 years where

the hope is that the patient
and family will just give up
and go away

and that's been the model.
And now we've moved to more open
and honest communication.

[Heather Young]
We do a simulation on

how to tell someone that
you've made an error,

and that's a skill that's very
difficult to develop,

to do in a way that
conveys that you care and
that you are concerned about

the person's safety
and that you are going
to do something about it

when you may face a family
member who is irate,
very upset by the news.

And you know, as a new
clinician, you need to have
the skills to be open and

transparent and talk honestly
and authentically with people.

So, I'm about to go in and see
a standardized patient,
is what we call it.

It's an actor that I have no
idea how he's going to react.

We're going to break him some
bad news about a test result
that we missed 3 months ago.

They are told to react
differently to each student.

So I don't know what
I'm going to get when
I break him the news.

He could be angry, frustrated,
or he could go easy on me.
I just don't know.

One of the things that was
ordered a couple weeks ago
was a CT scan, uh, which,

umm, indicated, umm, some
results that could indicate
colon cancer.

[Doctor] Listen, I've got to cut
this. Um, you don't want to say
there was another

test result that might indicate
colon cancer at this short intro
into it, right?

-Ah?
-Oh.

I mean you went right to:
"That could be colon cancer."

His dad died of colon cancer.
You could have a patient
falling apart in moments.

Do you want to look at
those pearls on effective
communication?

Lay out the facts,
that you know them, and say
that 3 months ago on the CT--

And then as he's like,
and I know your dad passed,

it could be a cancer,
but we don't know that yet.

You know, all that gingerly,
careful stuff.

-Hey, Walt. How's it going?
-Hey, Jason. I'm alright.

-It's good to see you again.
-Thank you.

-How was the drive in?
-Uh, fine.

-Three months ago, remember
you came in three months ago?
-I do.

It showed that you had some
thickening of your colonic wall

and some enlarged
mesenteric lymph nodes.

We need to do
a colonoscopy immediately.

We want to make sure, and I'm
not saying it's colon cancer,

but we want to make sure
that it's not colon cancer
and rule it out.

Why did it take 3 months to,
uh, that I know this?

That was my mistake.
We were looking for structural
abnormalities on your kidneys

and I overlooked that part of
the report 3 months ago.

[sigh] I mean,
I would have been upset

hearing it first
when the CT scan happened,

but now I'm really pissed off
that it's been 3 months,
that it was delayed.

Right, and, I mean,
I understand that you're angry,
I can see that you're frustrated

and I can't, I can't do
anything to fix that
mistake 3 months ago.

But, what I can do now is
make this a priority as
your primary care provider,

and I can't even imagine
how you're feeling right now
with the mistake,

but let's take it from here, and
we'll figure this out together.
I'll make this a priority, OK?

-[Charlie] Good morning.
-Good morning. Hi Charlie.

Hi Walt, nice to meet you.

I'm sorry. Wait,
I've met you before.

Yeah. We've known
each other for years.

[Heather Young] The closer
you are to the error, the more
important it is that you have

some accountability for it,
and that you communicate

with the people who
might be harmed by it.

And so all of us need to learn
the skills to be able to

acknowledge what we've done wrong and what we're planning to do to fix it.

[Don Berwick]
We built it completely wrong.
We were trained, I was trained,

"No, you don't talk about
your mistakes with a patient,

that's liability, the lawyers
will be all over us."

This is a time for openness
and honesty, and so we can learn
and grow together.

Healthcare is not like
a toaster where I make it
and I sell it to you,

and you take it and plug it in.
No, it's always a cooperative
enterprise so that

the patient and the family,
and the doctor and the nurse,
they're co-producing the care.

And now that we're more
aware of that over time,

there's a lot of possibility for
much more participation by both.

[John Eisenberg] I recalled a
woman whom I took care of.

We had had a pap test done to
screen her for cervical cancer.

The result was suspicious,
but I never knew that,

because I never got the report
back. And I didn't realize

that I hadn't gotten the report
back until she called me and
asked about the report.

I tracked it down. I found out
that it was suspicious. We
followed it up and fortunately

it turned out not to be
anything serious.
But that was a near miss.

It was a near miss that
could have been a tragedy
had she not called me.

Senator, when I spoke at
three medical school
graduations last Spring,

I asked all the students
who were graduating,
and I asked all of the faculty

to raise their hands if they
had ever made a mistake in
taking care of a patient,

and every single student raised
his or her hand, every faculty
member raised his or her hand.

When I was a medical student on
one of my very first rotations,

I inadvertently,
during a code,

gave a full syringe of
morphine to a patient IV and
they had a respiratory arrest.

Fortunately, the person was
intubated and resuscitated
and did just fine.

That was
a shocking experience,

and made me aware at a very
early point in my medical career

that we have the potential
to do things wrong and
to potentially harm patients.

No one ever heard about it
besides me and that nurse.

So, it's not clear to me that
any changes were ever made

as a result, and I don't think
the patient ever heard.

I've made medical errors;
I have, uh,

I prescribed the wrong
medication on a patient.
There were two patients of mine

with very similar names
and I just prescribed it
on the wrong patient.

I felt terrible.
I felt incompetent.
I felt a little ashamed.

And I, my first instinct was not
just to fix the problem,
but then not to tell anybody.

That's just a normal
human instinct.

It is completely understandable
why people's first reaction is

cover it up, don't talk about
it. It's a very human response.

Doesn't make it the right thing,
it's actually clearly

not the right thing, it's
clearly bad to do that.

But I think we have to begin
by acknowledging that
it's a very human response.

You can feel very
self-righteous. You can say,

"Well, the patient got the wrong
drug, fire the nurse.

There's a complication of the
surgery, bad surgeon."

You're wrong.
You're almost always wrong.

It feels good to blame someone.
You've got a culprit? Put them
in jail, fire them.

Many things caused it.
So, who's responsible?
Everybody's responsible.

Everybody can contribute to
the enterprise of closing
the vulnerabilities,

of making the whole thing
less likely to go wrong.

The most recent survey
I have seen is that nearly
50% of nurses in America

still don't feel it is safe
to talk about a mistake
they've made.

That's an absolute disgrace.

If something bad is going to
happen to you when you speak up

about something you've seen
or done that could help.

If you're going to get punished
for that, why would you speak
up? You don't.

You run and hide. You lie.
That's normal human behavior.

We're not talking about bad
people; we're talking about
normal people become frightened.

And so leaders, you got a
choice: you can scare your
workforce and give up the hope

for improvement, or you can
celebrate, invite,
work with your workforce,

and have a chance of
learning together to get
to a better world.

What we have learned from other
industries is that if you could
change the culture

and reward people for
being open, reward people
for being honest,

reward people for coming
forth and talking about
their errors,

then you being to counter
that kind of normal instinct
that we all have,

and begin to create a culture
of patient safety where people
are much more open.

And the system gets better
because it learns from mistakes
and doesn't hide them.

And we found in the food
industry they were years ahead
of us. They had programs.

For instance, Burger King had
a program if the employee
saw another one

not washing their hands, they
went over and they tapped them
and said, "Got you",

and then they got either two
hours compensation off

or some other reward.
I mean, they're on board.

Safety reporting is like
democracy. Democracy isn't about
having a free and fair election.

We can do that. Democracy is
about having a second free and
fair election.

The same thing is true
with safety reporting.
It's not about

filing a safety report,
it's about filing a second.

And where you see
an organization with
a high rate of reported error,

what that tells you is it tells
you that they must be doing
something about those reports,

because if they are just
sitting on them, people
will stop reporting.

Because even if you
tell people they have to,
in the end it's all voluntary.

I mean, you can't solve it if
you can't see it. We can see it.

And more and more
people are aware of it.
That's the good news.

Bad news is you're still at
risk, really at risk.

I mean we haven't pervaded
healthcare with the designs
and approaches and cultures

that actually make you super
safe and that's the task ahead.

It's amazing how quickly
hospitals can completely
overhaul their safety

when they know that it's
important to their patients.

Hospitals had to hear the
message from their own patients

that it matters that they wash
their hands, it matters that
they keep a safe environment,

it matters that they put
the safety and protection
of their patients first

every minute of every day.
The only way they're really
going to get that message

is when the American public
gets involved and pushes.

[narrator] One way to improve
the quality of hospitals
in America

is to put a microscope
on the data they do
actually provide.

[narrator] Leah Binder and her
team at the Leapfrog Group
in Washington, DC,

worked with leaders in patient
safety to create a new way

to rate the quality of hospitals that patients can understand.

We worked with the foremost
experts in patient safety

and we asked them to look at all
this data and decide which of
the data is most reliable,

which gives us the best
information about the safety
of a hospital,

and then help us figure out
a reliable criteria to put it
all together.

And then, we did something else.
We decided to issue
a letter grade.

The letter grade would apply to
each hospital on how safe they
are relative to other hospitals.

So, were they an
A, B, C, D, or F?

When we first did it,
we got calls from some
hospital CEOs who said

to me, memorably,
"I've decided I don't want
a letter grade from you."

And I said, "Well, I've decided
you're getting one anyway,
because you serve the public,

and the public you serve
deserves to know
how you're doing."

It's very important to do these
kinds of ratings because

who wants to work in a terrible
organization? And so if you can
make it very obvious to all the

doctors and nurses in that
hospital that this is a highly
unsafe hospital,

I think there is going to be
internal pressure to reform and
internal pressure to get better.

But, certainly I think
it's true that, like,
if you're in an isolated area,

there's one hospital
in town or you could be
in the middle of Chicago,

but your insurance company
covers one hospital only,

it's going to be a challenge of
choices. But that doesn't mean
you couldn't go to your doctor

who works in that hospital
and be like, "Hey,
why are you guys a D hospital?"

And I think if consumers
started talking to doctors
and nurses that way,

it would actually begin
to change the conversation,
where doctors would say,

"Why do I work at a hospital
that has such high
infection rates?"

Virtually every other industry
in this country has their
products and services

in a transparent market,
and people choose.

So, if you're buying a car,
you can look up auto reviews

and you can compare
among different cars
and different features.

In New York, which I know
particularly well,

restaurants that had,
for many years,
been getting public ratings

from the health department
on how safe they were;

those were all public,
but nobody paid any
attention to them.

So, the health department said,
from now on you're going
to get a grade

on how safe you are and you have
to post it in your window.

So, restaurants started posting
it, and within six months any
restaurant that didn't have an A

was either out of business
or they were very quickly
getting to their A.

So we said, "Well, let's do
the same thing with hospitals."

I mean in our dream, hospitals
would put their letter grade on

you know, their front door
and everyone would know that
this hospital was safe or not.

[sombr music]

[Helen Burstin] John Eisenberg
used to tell a great story of
the drunk who lost his keys.

And he's out in front of
the bar in the street
looking for his keys

and some guy comes over and
goes, "What are you doing?"

He says,
"I'm looking for my key."

"Well, why are you only
looking right here?"

He said, "Well, that's where the lamplight is."

[clock ticking]

[narrator] This is known
as the streetlight effect.

Many in the patient safety field have been looking outside

healthcare for solutions to
preventable errors.

Industries like nuclear power,
aircraft carriers,
and commercial aviation

have become known as
high-reliability organizations

due to significant efforts
to improve safety.

High reliability is different
in healthcare because it points
directly at examples

of very hazardous industries,
organizations

that have solved the problem
of getting to zero harm
that healthcare has not solved.

Tools and methods
and lessons from that work

are very directly
applicable to healthcare
and we're starting to see

healthcare organizations
use them to make improvements

at a level that
we have never seen before.

So over here we have
the complex system of
the modern American hospital,

and over here we have
other industries
that have learned to

simplify and deal with
these complex systems.

In the last calendar year there
has been no fatality worldwide

in commercial aviation
due to an accident.

Compare that to our business
where we have 20 wrong-site
surgeries every week.

[David Mayer] Pilots make one
error per hour in the cockpit
every day they work

and yet we wonder why planes
aren't falling out of the sky.

If aviation had said, "Well, you
know what, to fly you 600 miles
an hour it's going to

come with some mishap. And you
got to expect a plane or two to
fall out of the sky,"

and thank god they didn't say
that and they said, "No, we can
drive it to zero.

We can drive it down to
virtually no mishap,"
and they have.

The aviation industry is the
safest it's ever been since the
invention of the jet engine.

What we're really doing when we
go up in an airliner is pushing
a tube filled with people

through the upper atmosphere,
7 or 8 miles above the earth,
at 80% the speed of sound,

in a hostile environment with
outside air pressure one-quarter
that at the surface,

and we must return it safely
to the surface every time,
and we do.

In this country alone,
28,000 times a day,
10.2 million times a year.

In a little over
100 years you've gone
from quite a dangerous

industry to the first ultra-safe
mode of transport bar none.

One of the reasons is because
it is studied so well,
and every single event

is clearly understood
and is made public so
others can learn from them.

I had been flying airplanes
for 42 years. I had 20,000 hours
in the air.

And throughout that entire time,
I had never been so challenged
in an airplane

I doubted the outcome. I never
thought I would be. I was wrong.

[narrator] In January of
2009, Captain Sullenberger's
training and instincts

saved the lives of all
155 passengers aboard
US Airways Flight 1549

after it struck a flock
of geese and lost
all engine power.

The dramatic landing on the Hudson River reminded Americans

of the importance of experience
in the cockpit.

In an industry in which we work
very hard to make everything
easy and routine and safe,

100 seconds after takeoff we
were suddenly confronted with an

ultimate challenge of
a lifetime, to do something
we'd never done before

and get it right the first time
never having practiced it.

In a similar fashion
in medicine, there are
some things that just can't be

practiced safely any other way
than in a simulation for the
first time.

And it gives you a chance
to practice things over
and over and over again.

And so it's important that
the simulations be done
not simply individually,

but also collectively
as a whole team.

[narrator] Flight simulators
have been used to train pilots
for nearly 100 years.

And while medicine has used
cadavers to train doctors
for much longer,

only recently have institutions begun using robotics

to simulate any kind of
situation a care provider
may face.

[Heather Young] Simulation is
a very big part of
our educational program here

and it involves anything from
patients who come in as actors
and will work with a student,

all the way up to very
high-fidelity robots,
and environments that

are tricked out to look out
exactly like a hospital
operating room

or an emergency department
or hospital ward.

The airline industry is the
prototype of using simulation

where you can practice landing
in San Diego with a terrible
storm or a tsunami

or on a very calm day
and you can practice

all different kinds of failures
within the airplane.

It's newer in healthcare,
but it's really something
that's catching on,

and you can really put people
through the steps of handling
many important situations.

[Ian Julie] So we're going to be
practicing our new simulated
protocol

for our actual sepsis
patients. Sepsis care can be
very, very difficult.

We know the science behind it,
we know what helps,
but we don't necessarily know

how to do it in a way that's
organized and consistent.

We'd rather practice on our
friend the mannequin here who
it's very hard to injure,

rather than on real patients.
That way we can standardize
things within our hospital

and give our nurses and doctors
a chance to practice what it is
their doing,

before they have to do it
on real patients.

Hi Robert. My name is Emily.
I'm going to be you nurse today.

I'm here to do your morning
assessment and take your vital
signs. How are you feeling?

[mannequin] I'm not feeling
very well.

[Nurse 1] You're not?
What's going on?

[mannequin] I just can't catch
my breath this morning and

I feel like my cough is worse.

He's remaining stable.
Based on the alert, um,

and the lactic acid, I think I'm
going to start some oxygen.

[Nurse 2] Okay, are there signs
or symptoms of an infection?

[Nurse 1] Well,
he's saying that he has an
increased work of breathing.

He has a white count of 16.

[Nurse 2] OK, sound good.
I'll be right over.

-OK, thank you!
-[Nurse 2] Alright.

-[Nurse 2] Hi, Mr. Robert!
-[mannequin] Hi!

-How are you feeling?
-[mannequin] I've had
better days.

-Are you short of breath?
-[Mannequin] Yeah.

[Nurse 2] OK and when
did this start?

Here you go. You've drawn
cultures already, correct?

-[Nurse 2] This is Robert Doe?
-[Nurse 1] Yes, Robert Doe.

[Ian Julie] We can make
the scenario more complex,
and we do on occasion.

We could have the patient enter
a state of shock,

or not respond properly to
the fluids or the antibiotics.

So, much of what we've done is
related to the need to kind of

fulfill the recommendations
that have been given.

In addition to wanting to do
what's right for the patient

and following through on
the best available
scientific evidence.

When I graduated as a nurse, the
first time I ever had a chance

to shock a person
whose heart had stopped

was in the middle of
the night in a rural hospital

and it was my first time
I had ever turned on
the paddles in my life.

And someone's life depended on
that. That's not acceptable.

We want our students to practice
and practice and practice
how to shock people

in a simulated situation,
so that when someone is
really depending on them,

they do it right
the first time.

I shudder to remember how
I was trained as a doctor
to learn how to do stuff.

Lumbar punctures, spinal taps,
put IVs in, or even chest tubes.

You practiced on the patients.
I mean, that was
the only option.

Some patient, some time,
was the first patient
I ever put a chest tube in,

and that person paid the price.
They were paying for my tuition.

You know, we don't do that
with pilots, we put them
in the simulator

and they fly something that
isn't really a plane for
a while, first,

with high fidelity. Now we know
how to do that in health care.

The growth of simulation so that
the first chest tube doesn't go
into a human being,

it goes in a mannequin that
looks like a human being,
that's great. And I think that

it's one of the emerging ways
to help build skills

hmm, in a work force without
the patients paying the tuition.

[narrator] Many aspects of
the aviation industry have
been applied to medicine,

from checklists before an
operation to monitoring
physicians for fatigue.

But there are still elements
of safety in aviation that
have not been explored.

One of the most well-known
improvements in airline
safety is the black box.

A surgeon in Toronto
has been working with
a group of designers

to create a similar
tool for the operating room.

[Teodor Grantcharov]
I want my patients to feel
the same way when

they enter the operating room
as I feel when I enter
a modern aircraft.

Unless we create a system where
we understand, that we tolerate,

and we learn from our errors,
we will never be able
to improve.

We've tried for many years
to create something
like the black box.

Finally, in 2012 we were able
to create a technology
that allows us to capture

video and audio and data from
everything that's happening in
an operating room.

We've been developing and
implemented a number of sensors.

So, we know how many times a
door opens and closes.

We know how we wash our hands
prior to a surgical procedure.

And all these data feeds
are combined

and perfectly synchronized on
the same platform.

When we talk with our patients
about the black box
and what we are doing here,

the first reaction,
the most common reaction
in 90% of the patients is,

"I can't believe
this hasn't been done before."

From the point we started
recording our surgeries,

we had a tremendous amount
of media attention.

Everybody believed in the
transparency doctor,
that's what he was nicknamed.

He doesn't have anything
to hide. I'm definitely going
to go to him.

Patients need to know that
when they walk into a hospital,

everything is being done
to learn from mistakes and
possible risks that take place.

This has to be
common standard practice.

We've heard for too long that
healthcare is complex, that
our patients are not aircraft,

that surgeons are not pilots.
I just want us to start doing
something and changing it.

We're trying to create
a system that identifies

performance deficiencies
and improves safety.

A new gadget comes out from an
industry provider all the time.

Usually it's a very
emotional attachment like,
"Oh, this looks sexy,"

or "I like how this handle
feels when I'm using
it during surgery."

You need something
deeper beyond that.

So, this is what we call
a full surgical timeline
and you can see

the entire procedure broken
down from beginning to end.

As you scroll down
this timeline, you'll start
to see little beeps here,

and that's where our surgical
expert analysts have coded
where they saw errors.

This screenshot establishes
what one of the errors is.
So in this case

an error took place during
the suturing task, and it was
inadequate visualizations.

As the surgeon was suturing with
the needle and driver, he might
have gone off frame,

which is incorrect because now
you have no idea where that
needle is.

You even see issues in say,
leadership or communication,

and we have a whole toolset
determining exactly that.

This points a really interesting
storyline because
the blue bar establishes

that the surgical resident, the
trainee under the main surgeon
was doing the actual case,

and then when a cluster
of errors takes place,

you can see the switch over
to the main surgeon,
to Dr. Grantcharov.

This entire timeline
is the data quantified.

We're breaking down
the entire set of errors
into tangible areas

to provide further education on
it to essentially improve it.

Analytics is at the heart
of what the black box does,

but we're jumping
into different areas.

Our engineers are working on
tools to improve handwashing

to essentially create
a detector that lets you know,

yes, you've spent the right
amount of time and the right
technique to wash your hands.

So over here, one of our
engineers, Kevin, has been
working on just that.

It's a motion sensing tool
that will look at
how you wash your hands

and look at the surface plane
you are working with,
the amount of time

spent on washing your hands,
and give you real time feedback.

The key here is the data. So, I
can go and tell any surgeon

you have to wash your hands
this many number of times
in this fashion,

but if I have hard data
showing... because of doing it
this particular way

we have reduced site infections
by this much, it's irrefutable.

[piano music]

[Sue Sheridan] Cal has gone on
to become part of
a comedy community.

He's producing.
He's produced two comedy shows.

Cal uses his comedy
in really novel ways

that helps him deal
with losing a dad.

Everybody develops their own
way to deal with death
or loss or grief

and I think that comedy
is Cal's, uh, his outlet.

[Sue Sheridan] He feels
like he doesn't suffer, but he
sometimes struggles

to be understood because his
speech is impaired. He struggles
when he rides on airplanes

because sometimes his scooters
or walkers are broken.

He struggles in environments
where it's not easy
to get around.

The first year, or year and
a half, we had 183 separate
medical visits

for physical therapy, and ENT,
eyes and ears and teeth,
and neurology,

and during that time,
in my heart, I knew something
was wrong with Cal.

Our local doctors were
really not willing to offer
a diagnosis.

We took-- I took Cal out of
state to a leading university
where a team of specialists

reviewed Cal's charts
that I had never looked at.

I didn't think that there was
any reason for me to look at my
birthing charts,

and back then charts weren't
that available to patients.

And they showed to me a report
from an MRI that they did on Cal
when he was 5 days old

that clearly shared
abnormalities in his brain
from his jaundice.

And our healthcare system
really didn't...

Well, they covered up.
They covered up
Cal's injury and, umm...

I wasn't empowered with
information and knowledge

to challenge some of it or
ask the appropriate questions.

You know, in healthcare they say
that patients, we need to ask
more questions,

but sometimes we simply
don't know what to ask.

[Michael Millenson]
Understand, before you go in
for any particular procedure,

what are the questions you need
to ask to keep yourself safe?

And if we all start asking
those questions,

then pretty soon it will
become clear to any hospital

that's not doing those things
that there is pressure
on them to do it.

If you're in a hospital, by
definition today, you're seeing
a lot of different doctors,

there's a lot of caregivers
coming in and out of the room,

most of whom work to communicate
with each other, but sometimes
they miss.

So, if you see something that
doesn't look right, or sound
right, you say,

"Whoa, wait a minute,
that's not what they told me."

Patient safety is a team sport.
And one of the ways

to really make a difference
is you've got to get
patients engaged.

So, if patients begin
walking into hospitals
with an expectation

that they are not going
to get an infection
and they start saying,

"Hey, have you washed your hands
before you come over to see me?"
That's how it happens.

If they've done it outside
the room, or they've done it
at the nurse's station,

on the way into the room
they're touching the door,
they're touching things,

and then they are coming in,
so that doesn't count.

It has to be before and
after patient contact.

Here's what I look for
in a hospital that's really
outstanding on safety;

the sink is placed in a way that
it is easy to walk into a room
and immediately wash your hands.

You'll see charts on patient
floors, right there for anyone
to see, that will show

how they are doing on patient
falls, for instance, or how they
are doing on infections.

People have an attitude about
safety, you just can feel it.

There's an apocryphal story of
President Kennedy visiting Cape
Canaveral during his presidency

and he takes aside a custodian
and says, "What's your job?"
And the custodian says,

"Mr. President, my job is to
help get a man to the moon and
return him to earth safely."

Everybody has a job to do
to protect patients,
not just doctors.

Every nurse, pharmacist,
physician, custodian,
has a role in safety.

I think it's deeply unfair
to expect patients who are sick,
in the middle of an illness,

to try and sort this out
on their own. Now,
it may be unfair,

but the reality is
that's where we are.

The best thing they can do
is have a family member or
a friend around, because again,

when in the middle of
an illness it's very hard
for you to pay attention

to know what's going on, but
your friend can, your family
member can.

If somebody says you're going
to get medication X,

is that the medication
that actually showed up?

And asking in a very
friendly and respectful way,

when a nurse comes by to hang
a medication or give you a pill,

you know, what is this?
What am I getting? It's
a totally reasonable question.

Patients should feel
comfortable doing it.
And if you have a provider

that responds badly to that,
you should try to figure out
if you can switch providers.

My father was a doctor in
a small town in Connecticut.

For a lot of time he was
the only doctor there
and he was revered.

You didn't question him.
It wasn't my father's fault
in any way.

He was a proud and successful
professional honored by his
community.

That's not actually adaptive
if we really want care to be
what it can be.

I think, I understand
the hesitation people may feel
to ask the doctor,

"What's going on here?"
But that's healthy, that's good,
and we need to train doctors to,

not just to accept that,
but to absolutely welcome it.
It's better medicine.

[tense music]

[Sully Sullenberger] If,
as reports indicate, there are
as many as 440,000 preventable

medical deaths in this
country alone every year,
that is the equivalent of

7 or 8 airliners crashing every
day with no survivors.

Before the first day of that
kind of carnage was complete,
airplanes would be grounded,

airlines would stop operating,
airports would close,
no one would fly

until some of the fundamental
issues had been resolved.

But because aviation
accidents are dramatic,

they receive the kind of
attention that they do,
and the public awareness.

Medical deaths occur singly and
often behind the scenes, but in
aggregate the harm is huge.

We need to change
the way we think about
these medical deaths.

We need to think about
them not as unavoidable,
but as unthinkable.

We've got to get better at
making sure whatever hospital
you go into in the U.S.

you're getting the same quality
care, and we are not there.

I mean, you're asking people
to do things differently.

You're asking doctors
to think differently
and work differently.

You're asking architects
to build different spaces,
nurses to work

differently in teams, patients
to have a different role.

To change patient safety, you
have to change everything. If
you look at preventable harm

across American hospitals,
it has gone down considerably,

you know, saving hundreds
of thousands of lives

and billions of dollars.
That doesn't mean we fixed it.

It is quietly, slowly,
but definitely becoming
the professional norm

to take certain precautions,
to do things in a certain way
so that patients are safe.

Because you can be satisfied if
you have very low expectations
and the reality is that all of

our expectations should be
raised, that we all get very
high quality, safe healthcare.

We all want to do well.
We all want to get better.
Nobody comes to work

to harm a patient
or wanting to harm a patient
or to give bad care.

We haven't made this
a public health issue
where the public is really

thinking about this, and yet
when you talk to any person

who's had a family member
or themselves in healthcare,
they all have a story.

I've also talked to doctors
and nurses who have committed
a terrible error and they say,

"I know I can't take that back,
but what will really give
that meaning is

if I do something that makes
the system safer for
the next person."

I think, in part,
the job of people like me
in leadership roles

is to harness that passion,
harness that energy.

All of the rest of these guys
are much more serious about
medical error reduction

than they ever were.
Is it going as fast as it could?
No, of course not.

It is not
"stuff happens" anymore.

That's where we're going,
and that's the good future
that we're moving towards.

It feels like we should be
further along than we are,
but actually

I think we've made tremendous
progress in 15 years.
It is on the map.

We have these examples in the
U.S. and around the world.

It's not any longer
a question of possibility,
it's a question of will.

Many of us go kind of through a
self-blame. Although we know it
wasn't our fault,

we feel like we didn't...
protect our son.

And so there was really, really
significant grieving,

so the anger at first
was immeasurable.

When we discovered Pat's error,
we both felt tremendous fear.

I think at that point
it was just plain disbelief.

He said: "Whatever you do, do
not give up on patient safety."

So, that led me onto a journey
to... I wanted to make sure
our healthcare system,

our government knew
what happened to Pat and Cal.

So, it took us 8 years, but
we really did make some changes
in our healthcare system

where babies being discharged
would have a bilirubin test
before they were discharged.

[Mark Graber] Thanks to Sue
and the work that she's done,
there are now processes

in place in every hospital to
screen for that condition.

And the odds that that's going
to happen again are now
approaching zero,

and that's what we'd like to see happen throughout medicine.

And the work that Sue has done is our model for how to do that.

She turned what she had gone
through into empowerment
and positivity,

and if she can do it, so can I,
and so can a lot of people.

I've obviously always idolized
my Mom and I understood
her job very well

and people would ask me, "What
does your Mom do?" I would say,
"Well, she saves lives."

Having witnessed these
tragic outcomes in
our healthcare system,

the one place that we should
feel unquestionably safe.

[Mackenzie Sheridan] And it kind
of ignited a fire inside me
that wanted to, you know,

do what my Mom does, which is,
you know, talk with hospitals
and talk with doctors

and figure out how we
can make those kind of things
not happen again.

So, I went to Portland State
University and I chose to do
Public Health

because I wanted to feel like
I was making a difference
and feel like I, you know,

could help prevent things
that happened to my family,
happening to other people.

I am unwilling to believe that
we have done all that we can do.

My experience with diagnostic
errors and the healthcare system
has been without a doubt

the most powerfully emotional
experience in my life.

However, my family's story
is also a story of awakening,

of passion, of change,
and hope for the future.

I cannot change what happened
to Cal and Pat,
but I've always felt

that I can somehow be part
of it and make a difference.

My teacher in courage, in hope,

in determination, in passion,

of course he's my teacher
in sense of humor which he
believes his mother has none of,

but he's the reason
for what's in me.

[audience applauding]

[Sue Sheridan] You know, when
Pat was dying he said, "Never
give up on patient safety."

At that time, I did not envision
my whole family being engaged.

Before we went on stage today,
I thought about Pat,
my daughter in the front row,

my son on stage.
It was, umm, just surreal.

[singing Happy Birthday]

[Mackenzie Sheridan]
On March 8th, which is the day
that my dad passed away,

we spread his ashes
on Table Rock.

Whenever we go there
I always feel like a warm,
just like, presence.

It's because it's such a
beautiful place,

and it's beautiful that
he's there as well.

[Sue Sheridan] Pat will always
be alive in our hearts
and in our memories,

and it was very hard for them
to lose a Dad when
they were only 4 and 6.

They will continue to honor and miss and wonder about their Dad.

I've always had this hope:

I will not believe that our
leadership in our country, in
our healthcare system,

will continue to think
this is okay.

Because it's not.

[piano music]