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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 manyas 98,000 people

die every yearnas 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
jumbonjets 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 ofdeaths
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 ofPat 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

Nwhere 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 tooverlook 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 forHealthcare
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
fromn2010-2015, 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 donewrong 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, nthat'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 thenHudson
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 donenis
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
andnmiss 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]