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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]