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WELCOME TO THE CLINICAL
CENTER GRAND ROUNDS,

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A WEEKLY SERIES OF EDUCATIONAL
LECTURES FOR PHYSICIANS AND

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HEALTH CARE PROFESSIONALS
BROADCAST FROM THE CLINICAL

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CENTER AT THE NATIONAL
INSTITUTES OF HEALTH IN

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BETHESDA, MD.

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THE NIH CLINICAL CENTER IS THE
WORLD'S LARGEST HOSPITAL TOTALLY

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DEDICATED TO INVESTIGATIONAL
RESEARCH AND LEADS THE GLOBAL

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EFFORT IN TRAINING TODAY'S
INVESTIGATORS AND DISCOVERING

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TOMORROW'S CURES.

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LEARN MORE BY VISITING US ONLINE
AT HTTP://CLINICALCENTER.NIH.GOV

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GOOD AFTERNOON!

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AND WELCOME TO TODAY'S CLINICAL

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CENTER GRAND ROUND.

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THE NEW HOPKINS CME ACTIVITY

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CODE FOR TODAY'S GRAND ROUND IS

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50565.

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IT IS ALSO SHOWN ON THE SLIDE.

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PLEASE TEXTSEDECO TO THE

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JOHNS HOPKINS CME PHONE NUMBER

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ON THE SLIDE TO RECEIVE CME

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CREDIT FOR THIS LECTURE.

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WE KINDLY INVITE YOU TO PROVIDE

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FEEDBACK ON TODAY'S LECTURE BY

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SCANNING THE QR CODE SHOWN ON

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THE CME SLIDE.

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FOR THOSE APPLYING FOR CME, YOU

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WILL RECEIVE FEEDBACK SURVEY

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LINK VIA EMAIL.

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THE SURVEY WILL BE USED TO

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PROVIDE US WITH IMPORTANT

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FEEDBACK ABOUT THIS PRESENTATION

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AND ALLOWS YOU TO SUBMIT ANY

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SUGGESTIONS FROM FUTURE GRAND

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ROUND TOPICS.

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FOLLOWING THE PRESENTATION,

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QUESTIONS FOR THE SPEAKER WILL

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BE TAKEN FROM THE MICROPHONES IN

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THE AISLE.

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ADDITIONALLY,ON VIDEOCAST VIEWES

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MAY SUBMIT QUESTIONS AT ANY TIME

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DURING THE LECTURE, SCROLLING

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DOWN AND CLICKING  TG 

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FEEDBACK BUTTON AT THE VIDEOCAST

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WEBSITE.

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QUESTIONS WILL BE ANSWERED AS

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TIME PERMITS AT THE CONCLUSION

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OF THE PRESENTATION.

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NOW, IT IS MY DISTINCT HONOR TO

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WANT TO WELCOME LAURA LEE TO THE

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NIH CLINICAL CENTER.

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AND I NOTICE A LOT OF PEOPLE

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HERE HAVE BEEN GREETING HERE AND

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THERE HAS BEEN A LOT OF GREAT

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CONVERSATIONS ALREADY.

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SO I WILL GO TO INTRODUCE HERE,

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LAURA LEE HOLDS A BACHELOR OF

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SCIENCE OF NURSING FROM THE

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CATHOLIC UNIVERSITY OF AMERICA,

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A BACHELOR OF ARTS IN BUSINESS

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ADMINISTRATION, AND A MASTER OF

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SCIENCE IN PATIENT SAFETY

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LEADATROM THE COLLEGE OF

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MEDICINE AT THE UNIVERSITY OF

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ILLINOIS, CHICAGO.

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AT MEDSTAR HEALTH, SHE IS

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CURRENTLY ASSISTANT VICE

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PRESIDENT FOR PATIENT SAFETY,

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LAURA LEE WAS THE OFFICE OF

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PATIENT SAFETY AND CLINICAL

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QUALITY HERE AT THE NIH CLINICAL

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CENTER.

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A ESSENTIAL ASPECT OF HER

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RESPONSIBILITIES AT THE HOSPITAL

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WAS ENSURING THE PROVISION OF

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SAFE AND HIGH QUALITY PATIENT

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CARE INRE A CLINICAL RESEARCH

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ENVIRONMENT.

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IN HER CURRENT ROLE AS ASSISTANT

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VICE PRESIDENT, SHE PLAYS A

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CRUCIAL PART IN DEVELOPING AN

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OPERATIONINALLIZING MEDSTAR

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HEALTH STRATEGIC INITIATIVES AND

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MEDSTAR HEALTH IS QUITE A LARGE

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HEALTH SYSTEM HERE IN THE DC

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AREA.

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LAURA LEE BRINGS THE HIGHER

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LIABILITY TO LIFE AT THE FRONT

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LINE OF CARE DELIVERY AND

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HEALTHCARE OPERATIONS AND

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STST TO ADVANCE MEDICAL

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EDUCATION WITH A SAFE AND JUST

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CULTURE AND PROACTIVE SAFETY

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PROVISIONS THAT ANTICIPATE AND

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PREVENT HAZARDS AND UNSAFE

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CONDITIONS.

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LAURA LEE HAS BEEN AWARDED A NIH

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HONOR AWARD FOR SAFETY

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IMPROVEMENTIM IN 2020 AND HHS

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SECRETARY AWARD FOR SERVICE, AND

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NIH CLINICAL CENTER CEO AWARD

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FOR PATIENT SAFETY CHAMPION IN

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2019.

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THE TITLE OF TODAY'S

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PRESENTATION IS STRUCTURED

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PATIENT SAFETYIONS.

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 WELCOMINGE JOINT  ME IN

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TODAY'S GRAND ROUND SPEAKER, 

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LAURA LEE.

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[ APPLAUSE ]

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>> LAURA:  THANK YOU FOR
THE

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WONDERFUL INTRODUCTION.

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I MET YOU AT THE DOOR LIKE I HAD

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IN 30 YEARS.

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IT IS WONDERFUL.

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WE WILL GET STARTED IN THE

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INTEREST OF TIME.

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I WILL TALK TO YOU ABOUT SAFETY

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SCIENCE.

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WHERE I COME FROM, MEDSTAR

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HEALTH IS THE BIGGEST HEALTH

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SYSTEM HERE IN THE

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BALTIMORE/WASHINGTON AREA.

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10 HOSPITALS, ALMOST 300 PRIMARY

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CARE SITES.

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32 EMPLOYEES.

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WE'VE GOT ABOUT 1100 RESIDENTS

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AND INTERNS AND FELLOWS AND

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TRAINEES.

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WE HAVE RESEARCH INSTITUTE, OUR

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MEDSTAR HEALTH RESEARCH

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INSTITUTE.

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WE HAVE OUR INSTITUTE FOR

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QUALITY AND SAFETY.

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WE HAVE A HUMAN FACTORS

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INSTITUTE.

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SO IT IS SORT OF LIKE A

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PLAYGROUND TO GO AND DO PATIENT

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SAFETY.

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SO WE DO HAVE A PRETTY

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SUBSTANTIAL RESEARCH PORTFOLIO.

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SO WE GET TO DABBLE A LITTLE BIT

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IN THAT, I SORT OF GET MY

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CLINICAL RESEARCH JUICES FLOWING

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A LITTLE BIT EARLY ONCE IN A

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WHILE.

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IT IS GOOD TO HAVE THAT

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CONNECTION.

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SO WHAT ARE WE GOING TO DO

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TODAY?

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WE ARE GOING TO TALK ABOUT HOW

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WE ARE NOT SAFE IN HEALTHCARE,

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AND SAFETY SCIENCE AND HUMAN

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FACTORS ENGINEERING AND THE SORT

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OF THEORY BEHIND ERRORS.

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BECAUSE IN OUR VIEW, YOU HAVE TO

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HAVE THAT FOUNDATION IN ORDER TO

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MAKE CHANGES THAT ARE FEASIBLE

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AND SUSTAINABLE.

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TALK A LITTLE BIT ABOUT

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REPORTING EVENTS AND HOW

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IMPORTANT THAT IS TO YOUR

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PATIENTS, TO YOU, AND TO YOUR

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ORGANIZATION.

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REALLY GETTING TO WHY EVENTS

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OCCUR AND TAKING THAT SYSTEM'S

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VIEW.

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AND THEN, TALKING A FAIR AMOUNT

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ABOUT HOW WE CAN DESIGN SAFETY

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INTO SYSTEMS SO THAT WE KEEP

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HARM OUT.

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SO, WE'RE GOING TO START WITH A

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LITTLE QUIZ.

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SOME OF YOU MAY BE FAMILIAR WITH

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THIS.

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THIS IS A GRAPH THAT SHOWS US

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THE RELATIVE RISK ASSOCIATED

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WITH ACTIVITIES ACROSS

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EVERYTHING THAT WE DO IN LIFE.

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SO ON THE Y AXIS WE HAVE THE

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TOTAL LIVES LOST PER YEAR.

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ON THE X AXIS THE NUMBER OF

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ENCOUNTERS FOR EACH FATALITY.

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ALL OF THE WAY ON THE LEFT-HAND

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SIDE, WE SEE DANGEROUS

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ACTIVITIES LIKE MOUNTAIN

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CLIMBINGS AND BUNGEE JUMPING.

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IN THE MIDDLE MORE REGULATED,

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DRIVING, CHARTERED FLIGHTS,

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CHEMICAL MANUFACTURING.

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AND ON THE RIGHT ARE THE ALTER

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SAFE ORGANIZATIONS, HIGH

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RELIABILITY ORGANIZATIONS THAT

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ARE REALLY RIFFINGY BUSINESS AND

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IF SOMETHING BAD HAPPENS THERE

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OUTCOME CAN BE CATASTROPHIC, BUT

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FOR WHATEVER REASON, THEY ARE

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HIGH RELIABILITY ORGANIZATIONS

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THERE IS VERY FEW INCIDENCES.

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SO WHERE DO WE THINK HEALTHCARE

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FALLS ALONG THIS CONTINUE!

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HOW MANY PEOPLE SAY ULTRA SAFE?

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OKAY, HOW MANY PEOPLE SAY

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REGULATED?

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HOW MANY PEOPLE SAY DANGEROUS.

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OKAY.

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YEP, RIGHT THERE.

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WE'RE RIGHT THERE WITH BUNGEE

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JUMPING.

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SO, OUR PATIENTS GO THROUGH THE

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THRESHOLD ANY DOOR IN ANY

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HOSPITAL IN THE UNITED STATES,

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THEY THINK THEY ARE GOING TO BE

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CARED FOR, WE THINK WE ARE GOING

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TO TAKE CARE OF THEM, BUT IT IS

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THE SAME AS WRAPPING A RUBBER

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BAND TO SOMEONE'S WAIST AND

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PUSHING THEM OFF A BRIDGE.

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TO US, THAT IS UNACCEPT.

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WE NEED TO FIGURE OUT WHAT IS

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KEEPING US, WHAT INFLUENCES ARE

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OUT THERE THAT ARE KEEPING US

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FROM DOING THE RIGHT THING.

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SO I LOVE THIS QUOTE, MEDICINE

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USED TO BE SIMPLE, INEFFECTIVE,

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AND RELATIVELY SAFE.

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THINK LEECHES.

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NOW, IT IS COMPLEX, EFFECTIVE,

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AND POTENTIALLY DANGEROUS.

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AND ACTUALLY, IN THIS

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ENVIRONMENT, IN THE CLINICAL

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CENTER, THAT HOLDS REALLY TRUISM

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ESPECIALLY SINCE WE'RE DOING

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CLINICAL TRIALS, WE, I SAID

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WE'RE DOING, Y'ALL ARE DOING

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CLINICAL TRIALS, PHASE I, PHASE

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II, PROOF OF PRINCIPLE, FIRST IN

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HUMAN.

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IF THERE IS EVER A PLACE WHERE

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THIS STATEMENT IS HOLDS TRUE IT

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IS HERE AT THE CLINICAL CENTER.

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YOU KNOW, THE INSTITUTE OF

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MEDICINE REPORT WAS ISSUED IN

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1999, THE FIRST TIME THIS WHOLE

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ISSUE OF HARM RELATED TO

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MEDICINE AND GOING INTO A

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HOSPITAL REALLY CAME OUT.

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WE'RE STILL REALLY NOT THAT MUCH

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SAFER.

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THIS A STUDY DONE BY FOLKS,

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DAVID BITES AT THE HARVARD

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GROUP, PUBLISHED IN 2024,

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EARLIER THIS YEAR, AND THEY

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LOOKED AT ALL OF THE DATA FOR

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THE LAST, IN 2023 AND EARLIER

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AND WE REALLY HAVEN'T GOTTEN

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MUCH SAFER.

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SO WE AS AN ORGANIZATION, AS A

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HEALTHCARE COMMUNITY, HAVE TO

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FIGURE OUT HOW TO DO BETTER AND

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00:08:13,991 --> 00:08:15,259
RELYING ON SAFETY SCIENCE AND

261
00:08:15,259 --> 00:08:17,628
THINGS LIKE THAT WILL HELP US DO

262
00:08:17,628 --> 00:08:17,829
THAT.

263
00:08:17,829 --> 00:08:21,632
SO WE ARE A REALLY COMPLICATED

264
00:08:21,632 --> 00:08:22,166
AND MESSY INDUSTRY.

265
00:08:22,166 --> 00:08:24,802
WHERE THIS COMPLEX SOCIAL

266
00:08:24,802 --> 00:08:25,770
TECHNICAL ENVIRONMENT THAT HAS

267
00:08:25,770 --> 00:08:27,405
THESE THREE BIG FACTORS THAT

268
00:08:27,405 --> 00:08:29,040
INFLUENCE EVERYTHING WE DO.

269
00:08:29,040 --> 00:08:31,509
WE HAVE ALL OF THE SYSTEMS

270
00:08:31,509 --> 00:08:33,277
ISSUES, WHERE IT IS

271
00:08:33,277 --> 00:08:34,612
ORGANIZATIONAL STRUCTURE,

272
00:08:34,612 --> 00:08:36,948
CULTURE, HOW WE'RE FINANCED, HOW

273
00:08:36,948 --> 00:08:38,282
WE'RE FUND FROM CONGRESS.

274
00:08:38,282 --> 00:08:40,384
THOSE ARE INFLUENCE HOW WE CAN

275
00:08:40,384 --> 00:08:40,852
MANAGE SAFETY.

276
00:08:40,852 --> 00:08:42,720
THEN WE HAVE PROCESSES.

277
00:08:42,720 --> 00:08:44,922
YOU KNOW, WE ARE JUST ONE BIG

278
00:08:44,922 --> 00:08:47,625
BALL OF PROCESSES.

279
00:08:47,625 --> 00:08:48,559
WHETHER IT'S CLINICAL RESEARCH

280
00:08:48,559 --> 00:08:51,596
PORT CALL OR CLINICAL PRACTICE

281
00:08:51,596 --> 00:08:53,231
GUIDELINES.

282
00:08:53,231 --> 00:08:55,633
SOPs WE'RE NOT DOING THEM IN A

283
00:08:55,633 --> 00:09:00,571
NICE TIDY COP PIT OF AN

284
00:09:00,571 --> 00:09:03,641
AIRPLANE, OR A NICE PRES STEIN

285
00:09:03,641 --> 00:09:05,109
FACTORIES WERE WIDGETS COME OFF,

286
00:09:05,109 --> 00:09:07,445
WE'RE DOING IN THE IN A MESSY

287
00:09:07,445 --> 00:09:08,346
INDUSTRY, LIKE HEALTHCARE, AND

288
00:09:08,346 --> 00:09:11,582
THEN WE ADD ON HUMANS WHICH WE

289
00:09:11,582 --> 00:09:14,418
ARE NOT PREDICTABLE AND MAKE

290
00:09:14,418 --> 00:09:15,887
MISTAKES, US AS HUMANS, PATIENTS

291
00:09:15,887 --> 00:09:17,021
THAT ARE SICK AND HAVE IMPORTANT

292
00:09:17,021 --> 00:09:18,823
NEEDS AND WHEN YOU PUT ALL OF

293
00:09:18,823 --> 00:09:22,059
THOSE THINGS TOGETHER IT IS

294
00:09:22,059 --> 00:09:22,593
REALLY, REALLY COMPLICATED

295
00:09:22,593 --> 00:09:22,894
ENVIRONMENT.

296
00:09:22,894 --> 00:09:23,527
WE NEED TO RELY ON SAFETY

297
00:09:23,527 --> 00:09:26,030
SCIENCE AND NEED TO RELY ON WAYS

298
00:09:26,030 --> 00:09:27,732
TO UNDERSTAND EVENT HASICATE

299
00:09:27,732 --> 00:09:28,799
HAPPEN TO KEEP OUR PATIENTS SAFE

300
00:09:28,799 --> 00:09:30,768
IN THE FUTURE.

301
00:09:30,768 --> 00:09:31,636
SO, SAFETY SCIENCE, WE'RE GOING

302
00:09:31,636 --> 00:09:34,071
TO TALK ABOUT HUMAN FACTORS

303
00:09:34,071 --> 00:09:36,173
ENGINEERING AND SORT OF THE

304
00:09:36,173 --> 00:09:38,009
THEORY OF ERRORS.

305
00:09:38,009 --> 00:09:41,245
SO, WE USE THIS STATEMENT A LOT

306
00:09:41,245 --> 00:09:42,246
WHERE I COME FROM.

307
00:09:42,246 --> 00:09:45,383
WE CAN'T REDESIGN HUMANS BUT WE

308
00:09:45,383 --> 00:09:45,950
CAN REDESIGN THE SYSTEMS IN

309
00:09:45,950 --> 00:09:47,985
WHICH WE ASK PEOPLE TO DO THE

310
00:09:47,985 --> 00:09:48,786
WORK.

311
00:09:48,786 --> 00:09:50,187
THAT'S WHERE HUMAN FACTORS

312
00:09:50,187 --> 00:09:51,756
ENGINEERING COMES IN.

313
00:09:51,756 --> 00:09:53,157
SO HUMAN FACTORS ENGINEERING IS

314
00:09:53,157 --> 00:09:54,425
SIMPLY THE SCIENCE OF HOW PEOPLE

315
00:09:54,425 --> 00:09:55,026
DO WORK.

316
00:09:55,026 --> 00:09:57,695
OR HOW THEY CONNECT WITH OTHER

317
00:09:57,695 --> 00:09:58,195
PEOPLE.

318
00:09:58,195 --> 00:09:59,397
OR THEIR ENVIRONMENT OR THEIR

319
00:09:59,397 --> 00:09:59,697
TECHNOLOGY.

320
00:09:59,697 --> 00:10:03,267
AND BY LOOKING AT THAT, IT

321
00:10:03,267 --> 00:10:03,701
UNDERSTANDING HUMAN

322
00:10:03,701 --> 00:10:05,303
CAPABILITIES, THEN WE CAN

323
00:10:05,303 --> 00:10:06,938
REDESIGN OUR PRODUCTS, OUR

324
00:10:06,938 --> 00:10:08,039
PROCESSES, OUR TOOLS BASED ON

325
00:10:08,039 --> 00:10:11,976
WHAT IT MEANS TO BE HUMAN.

326
00:10:11,976 --> 00:10:13,344
SO, THE TWO GRAPHICS AT THE

327
00:10:13,344 --> 00:10:16,113
BOTTOM OF THE SLIDE, ERGONOMICS,

328
00:10:16,113 --> 00:10:17,148
HOW YOU DESIGN A PIECE OF

329
00:10:17,148 --> 00:10:20,551
EQUIPMENT SO SOMEONE THAT IS 5-2

330
00:10:20,551 --> 00:10:23,754
CAN USE IT AS EASILY AS SOMEONE

331
00:10:23,754 --> 00:10:25,089
WHO IS 6-5.

332
00:10:25,089 --> 00:10:27,458
I DON'T KNOW HOW MANY ARE

333
00:10:27,458 --> 00:10:30,161
FAMILIAR WITH THE ONGOING WAR OF

334
00:10:30,161 --> 00:10:31,262
SUNS VERSUS SERIF FONT, YOU NEED

335
00:10:31,262 --> 00:10:33,431
TO GOOGLE IT, BUT IT IS THE

336
00:10:33,431 --> 00:10:35,099
SAME, WHICH OF THESE FONTS IS

337
00:10:35,099 --> 00:10:37,068
BETTER FOR WHICH TYPE OF PERSON

338
00:10:37,068 --> 00:10:37,468
DOING THE READING.

339
00:10:37,468 --> 00:10:39,070
THESE ARE ALL HOW WE AS HUMANS

340
00:10:39,070 --> 00:10:41,238
INTERACT WITH SOMETHING THAT IS

341
00:10:41,238 --> 00:10:43,174
PUT IN FRONT OF US.

342
00:10:43,174 --> 00:10:44,675
SO, HOW MANY OF YOU HAVE PUSHED

343
00:10:44,675 --> 00:10:47,178
A DOOR WHEN YOU WERE SUPPOSED TO

344
00:10:47,178 --> 00:10:47,378
PULL?

345
00:10:47,378 --> 00:10:47,979
RIGHT?

346
00:10:47,979 --> 00:10:51,215
I KNOW.

347
00:10:51,215 --> 00:10:54,085
AND IF ANYBODY'S BEEN TO

348
00:10:54,085 --> 00:10:55,720
BETHESDA BAGELS, THAT DOOR I RUN

349
00:10:55,720 --> 00:10:57,688
INTO WITH MY NOSE EVERY TIME I

350
00:10:57,688 --> 00:10:58,089
GO IN.

351
00:10:58,089 --> 00:11:00,524
THIS WITH A REALLY BAD DESIGN.

352
00:11:00,524 --> 00:11:03,761
AS A HUMAN I'M GETTING SO MANY

353
00:11:03,761 --> 00:11:04,795
MIXED MESSAGES, I SHOULD PULL

354
00:11:04,795 --> 00:11:06,797
THAT HANDLE, BUT YOU'RE TELLING

355
00:11:06,797 --> 00:11:07,098
ME TO PUSH.

356
00:11:07,098 --> 00:11:08,499
I'M NOT GOING TO MAKE THE

357
00:11:08,499 --> 00:11:09,333
MISTAKE HERE.

358
00:11:09,333 --> 00:11:11,602
THIS DESIGN HELPED ME AVOID

359
00:11:11,602 --> 00:11:13,204
ERROR AND HARM TO MY NOSE.

360
00:11:13,204 --> 00:11:15,606
HERE ARE EXAMPLES HOW HUMAN

361
00:11:15,606 --> 00:11:17,174
FACTORS HAVE INFLUENCED DEVIBE.

362
00:11:17,174 --> 00:11:19,744
SO IT HELPS ANTICIPATE ERRORS.

363
00:11:19,744 --> 00:11:21,946
THIS IS AN EMAIL THAT SAYS I

364
00:11:21,946 --> 00:11:22,947
ATTACHED THIS MONTH'S REPORT, I

365
00:11:22,947 --> 00:11:25,316
TRY TO SEND IT AND GET A NICE

366
00:11:25,316 --> 00:11:27,451
NOTE THAT SAYS, HEY, YOU FORGOT

367
00:11:27,451 --> 00:11:28,419
TO ATTACH SOMETHING, DID YOU?

368
00:11:28,419 --> 00:11:31,655
IT KEPT ME FROM MAKING AN ERROR.

369
00:11:31,655 --> 00:11:33,290
THIS DESIGN PREVENTS ME FROM

370
00:11:33,290 --> 00:11:33,958
DOING AN ERROR.

371
00:11:33,958 --> 00:11:35,993
YOU CAN'T START YOUR MICROWAVE

372
00:11:35,993 --> 00:11:38,496
WITH THE DOOR STILL OPEN, IT IS

373
00:11:38,496 --> 00:11:38,929
JUST IMPOSSIBLE.

374
00:11:38,929 --> 00:11:39,797
MAKING IT HARD TO DO THE WRONG

375
00:11:39,797 --> 00:11:42,433
THING IS SORT OF A MAJOR TENANT

376
00:11:42,433 --> 00:11:43,567
OF HUMAN FACTORS AND MAKING IT

377
00:11:43,567 --> 00:11:45,836
EASY TO DO THE RIGHT THING.

378
00:11:45,836 --> 00:11:48,506
SO MANY OF YOU IN THE ROOM MAY

379
00:11:48,506 --> 00:11:50,408
REMEMBER WHEN NOZZLES ON GAS --

380
00:11:50,408 --> 00:11:52,576
WHATEVER THE THING ON THE GAS

381
00:11:52,576 --> 00:11:53,878
TANK, WHAT IS THAT CALLED?

382
00:11:53,878 --> 00:11:55,212
THE NOZZLE, WHERE, WERE THE SAME

383
00:11:55,212 --> 00:11:59,383
SIZE, SO YOU COULD EASILY PUT

384
00:11:59,383 --> 00:12:00,851
DIESEL FUEL INTO A REGULAR

385
00:12:00,851 --> 00:12:02,720
ENGINE, MOUTH THEY ARE DIFFERENT

386
00:12:02,720 --> 00:12:02,920
SIZES.

387
00:12:02,920 --> 00:12:04,488
SO YOU CAN'T POSSIBLY DO THAT

388
00:12:04,488 --> 00:12:04,722
ANYMORE.

389
00:12:04,722 --> 00:12:07,324
THEN THIS IS ONE OF MY FAVORITE

390
00:12:07,324 --> 00:12:08,759
HUMAN FACTORS DESIGN ISSUES,

391
00:12:08,759 --> 00:12:11,262
THIS IS, YOU KNOW, YOU HAVE TO

392
00:12:11,262 --> 00:12:14,665
HAVE 10, 10 CHARACTERS IN YOUR

393
00:12:14,665 --> 00:12:15,966
PASSWORD, I CAN NEVER REMEMBER

394
00:12:15,966 --> 00:12:16,600
IF HAVE DONE THE SPECIAL

395
00:12:16,600 --> 00:12:17,701
CHARACTER OR NOT.

396
00:12:17,701 --> 00:12:19,136
THIS IS JUST MY CUE CARD FOR

397
00:12:19,136 --> 00:12:19,336
THAT.

398
00:12:19,336 --> 00:12:21,272
SO IT MAKES IT REALLY EASY FOR

399
00:12:21,272 --> 00:12:24,975
ME TO DO THE RIGHT THING IN LESS

400
00:12:24,975 --> 00:12:25,176
TIME.

401
00:12:25,176 --> 00:12:26,377
BUT CAN WE DO THAT IN HEALTHCARE

402
00:12:26,377 --> 00:12:28,813
WITH ALL OF THE COMPLEXITY?

403
00:12:28,813 --> 00:12:29,480
TAKE A QUICK LOOK AT THIS

404
00:12:29,480 --> 00:12:30,281
PICTURE.

405
00:12:30,281 --> 00:12:32,983
AND WHAT YOU SEE ARE A BUNCH OF

406
00:12:32,983 --> 00:12:34,819
MACHINES AND, YOU KNOW, I'M SURE

407
00:12:34,819 --> 00:12:37,421
IF WE HAD AUDIO FOR THIS, WE

408
00:12:37,421 --> 00:12:38,989
WOULD HEAR A LOT OF BEEPS AND

409
00:12:38,989 --> 00:12:40,758
ALARMS AND WORDS AND THINGS LIKE

410
00:12:40,758 --> 00:12:40,958
THAT.

411
00:12:40,958 --> 00:12:43,294
THE VERY CENTER OF IT, THOUGH,

412
00:12:43,294 --> 00:12:45,429
IS OUR, WAS VULNERABLE PATIENT.

413
00:12:45,429 --> 00:12:47,031
A LITTLE NEONATE.

414
00:12:47,031 --> 00:12:49,133
SO THINK ABOUT THE COMPLEXITY OF

415
00:12:49,133 --> 00:12:49,867
HEALTHCARE IN EVERYTHING THAT'S

416
00:12:49,867 --> 00:12:51,402
GOING ON IN THAT ROOM.

417
00:12:51,402 --> 00:12:52,803
AND THE CONTEXT OF KEEPING THAT

418
00:12:52,803 --> 00:12:53,771
LITTLE ONE SAFE.

419
00:12:53,771 --> 00:12:55,539
AND HOW DO WE DO THAT?

420
00:12:55,539 --> 00:12:56,974
WE CAN APPLY HUMAN FACTORS TO

421
00:12:56,974 --> 00:12:57,174
THAT.

422
00:12:57,174 --> 00:12:59,276
SO THIS IS AN EXAMPLE OF A CASE

423
00:12:59,276 --> 00:13:01,078
THAT WAS MANY YEARS AGO, BUT WE

424
00:13:01,078 --> 00:13:02,947
LOVE THIS QUOTATION.

425
00:13:02,947 --> 00:13:06,383
THIS WAS A CASE OF A NURSE WHO

426
00:13:06,383 --> 00:13:07,718
GAVE A CATASTROPHIC

427
00:13:07,718 --> 00:13:08,752
MISADMINISTRATION, SHE JUST

428
00:13:08,752 --> 00:13:10,354
SIMPLY HUNG THE WRONG IV.

429
00:13:10,354 --> 00:13:12,423
THEY INTERVIEWED HER PART OF THE

430
00:13:12,423 --> 00:13:13,491
ANALYSIS.

431
00:13:13,491 --> 00:13:16,894
THIS IS WHAT SHE SAID, I THINK

432
00:13:16,894 --> 00:13:17,561
SHE WAS CHARGED.

433
00:13:17,561 --> 00:13:19,096
I GOT HER IV.

434
00:13:19,096 --> 00:13:21,031
HER ANTIBIOTIC AND HER EPIDURAL

435
00:13:21,031 --> 00:13:22,066
BAG.

436
00:13:22,066 --> 00:13:25,035
BOTH BAGS HAVE ENDS THAT

437
00:13:25,035 --> 00:13:26,237
RECEIVED IV TUBING.

438
00:13:26,237 --> 00:13:29,006
I HAD HER ANTIBIOTIC IN MY HAND.

439
00:13:29,006 --> 00:13:32,409
I KNEW THAT, BUT I DIDN'T HAVE

440
00:13:32,409 --> 00:13:34,545
HER ANTIBIOTIC AND HAD HER

441
00:13:34,545 --> 00:13:35,146
EPIDURAL MEDICATION.

442
00:13:35,146 --> 00:13:36,647
AND IT RESULTED INNING A

443
00:13:36,647 --> 00:13:40,184
CATASTROPHIC INJURY TO  TO THE

444
00:13:40,184 --> 00:13:40,417
PATIENT.

445
00:13:40,417 --> 00:13:41,519
I APOLOGIZE FOR THE BLURRINESS

446
00:13:41,519 --> 00:13:44,388
OF THESE SLIDES, BUT IT IS VERY

447
00:13:44,388 --> 00:13:46,924
EASY, MULTITASKING, HAVE A BUNCH

448
00:13:46,924 --> 00:13:50,261
OF SICK PATIENTS, OVERLY

449
00:13:50,261 --> 00:13:51,929
STRESSED IN  IN -- HURRY, YOU

450
00:13:51,929 --> 00:13:53,297
CAN MAKE A MISTAKE.

451
00:13:53,297 --> 00:13:53,931
SHE KNEW BETTER.

452
00:13:53,931 --> 00:13:55,733
SHE KNEW SHE WAS SUPPOSED TO BE

453
00:13:55,733 --> 00:13:58,869
HANGING THE ANTIBIOTIC AND NOT

454
00:13:58,869 --> 00:13:59,203
THE EPIDURAL.

455
00:13:59,203 --> 00:14:00,871
BUT SHE JUST MADE A SLIP.

456
00:14:00,871 --> 00:14:03,507
SO, WHAT WOULD HAPPEN IF YOU

457
00:14:03,507 --> 00:14:04,074
CONFUSE THESE PRODUCTS?

458
00:14:04,074 --> 00:14:05,709
ON THE LEFT-HAND SIDE, YOU SEE

459
00:14:05,709 --> 00:14:07,845
TWO VIALS, VERY SIMILAR IN SIZE,

460
00:14:07,845 --> 00:14:10,514
SHAPE, COLOR OF THE FLUID, ONE

461
00:14:10,514 --> 00:14:13,350
IS POTASSIUM CHLORIDE AND THE

462
00:14:13,350 --> 00:14:15,252
OTHER IS SODIUM CHLORIDE.

463
00:14:15,252 --> 00:14:17,354
THAT COULD BE A CATASTROPHE

464
00:14:17,354 --> 00:14:18,222
ERROR AS WELL.

465
00:14:18,222 --> 00:14:19,256
MY FAVORITE ONE IS IN THE

466
00:14:19,256 --> 00:14:21,425
MIDDLE, THEY ARE EYE DROPS FOR

467
00:14:21,425 --> 00:14:22,359
SOMEONE HAVING VISION PROBLEMS,

468
00:14:22,359 --> 00:14:23,961
HOW CAN YOU TELL THE DIFFERENCE

469
00:14:23,961 --> 00:14:24,995
BETWEEN THE TWO MEDICATIONS.

470
00:14:24,995 --> 00:14:26,797
AND THEN THE LITERATURE IS JUST

471
00:14:26,797 --> 00:14:29,166
FULL OF EXAMPLES OF WHERE WE

472
00:14:29,166 --> 00:14:32,770
HAVE MIXED UP MEDICAL GASES.

473
00:14:32,770 --> 00:14:33,571
BUT HUMAN FACTORS CAN HELP US

474
00:14:33,571 --> 00:14:34,672
WITH THAT.

475
00:14:34,672 --> 00:14:36,307
ON THE UPPER LEFT-HAND SIDE,

476
00:14:36,307 --> 00:14:38,209
THIS IS A COMPANY THAT HAS

477
00:14:38,209 --> 00:14:40,411
REALLY ENGINEERED MEDICAL GAS

478
00:14:40,411 --> 00:14:41,545
MISTAKES OUT OF OUR, OUT OF

479
00:14:41,545 --> 00:14:42,646
THEIR WORLD.

480
00:14:42,646 --> 00:14:44,348
THEY ARE DIFFERENT COLORS, THEY

481
00:14:44,348 --> 00:14:45,783
ARE COLOR-CODED WITH THE

482
00:14:45,783 --> 00:14:47,585
REGULATOR THAT NEEDS TO GO ON.

483
00:14:47,585 --> 00:14:50,454
IF YOU CAN SEE THE LITTLE KNOBS

484
00:14:50,454 --> 00:14:51,789
IN EACH OF THE -- THE OUTLETS

485
00:14:51,789 --> 00:14:53,624
THERE ARE A LITTLE BIT

486
00:14:53,624 --> 00:14:53,891
DIFFERENT.

487
00:14:53,891 --> 00:14:55,759
SO YOU COULDN'T POSSIBLY PUT THE

488
00:14:55,759 --> 00:14:57,361
WRONG REGULATOR INTO IT.

489
00:14:57,361 --> 00:15:01,098
IF YOU LOOK DOWN HERE, THIS

490
00:15:01,098 --> 00:15:05,035
IS -- THIS IS FROM EHR WORK.

491
00:15:05,035 --> 00:15:05,703
WHERE YOU, YOU -- YOU GUYS HAVE

492
00:15:05,703 --> 00:15:08,305
THAT HERE IN YOUR EHR AS WELL.

493
00:15:08,305 --> 00:15:10,007
JUST LOOKS LIKE, LIKE DRUGS.

494
00:15:10,007 --> 00:15:12,843
MAYBE ONE OF THE MOST, THE BEST

495
00:15:12,843 --> 00:15:15,646
PUBLIC HEALTH HUMAN FACTORS

496
00:15:15,646 --> 00:15:17,348
DESIGN WAS MAKING AEDs REALLY

497
00:15:17,348 --> 00:15:20,317
EASY FOR LAY PEOPLE TO USE.

498
00:15:20,317 --> 00:15:21,952
THIS IS ALL HUMAN FACTORS IN

499
00:15:21,952 --> 00:15:22,152
PLAY.

500
00:15:22,152 --> 00:15:24,655
ON THE BOTTOM HOW WE DESIGN OUR

501
00:15:24,655 --> 00:15:27,057
ENVIRONMENT MARY SHOWED ME THE

502
00:15:27,057 --> 00:15:28,993
NEW HOLE IN THE GROUND IN THE

503
00:15:28,993 --> 00:15:30,227
BUILDING GOING UP.

504
00:15:30,227 --> 00:15:31,562
I HOPE THAT YOU HAVE A GOOD

505
00:15:31,562 --> 00:15:33,897
HUMAN FACTORS ENGINEER ON YOUR

506
00:15:33,897 --> 00:15:35,232
CONSULTANT TEAM TO REALLY DESIGN

507
00:15:35,232 --> 00:15:37,968
THAT NEW SPACE SO IT WORKS.

508
00:15:37,968 --> 00:15:39,336
SO, THIS IS THE SCIENCE BEHIND

509
00:15:39,336 --> 00:15:41,338
HOW WE CAN MAKE OURSELVES

510
00:15:41,338 --> 00:15:42,139
BETTER.

511
00:15:42,139 --> 00:15:44,041
BUT WE'RE, AS WE SAID, WE'RE

512
00:15:44,041 --> 00:15:47,444
HUMANS AND WE'RE GOING TO MAKE

513
00:15:47,444 --> 00:15:47,911
MISTAKES.

514
00:15:47,911 --> 00:15:49,380
SO HUMAN BEINGS BY THEIR VERY

515
00:15:49,380 --> 00:15:51,649
NATURE MAKE MISTAKES.

516
00:15:51,649 --> 00:15:53,183
EVERY HUMAN BEING, EVERY HOUR

517
00:15:53,183 --> 00:15:54,952
MAKES UP TO FIVE MISTAKES OR

518
00:15:54,952 --> 00:15:55,352
ERRORS EVERY HOUR.

519
00:15:55,352 --> 00:15:56,854
WHEN YOU ARE STRESS THAT GOES UP

520
00:15:56,854 --> 00:15:57,087
TO 12.

521
00:15:57,087 --> 00:15:58,989
IT COULD BE JUST WALKING THE

522
00:15:58,989 --> 00:16:00,157
WRONG WAY DOWN THE, YOU KNOW,

523
00:16:00,157 --> 00:16:02,259
DOWN THE HALLWAY OR A

524
00:16:02,259 --> 00:16:03,627
CATASTROPHIC ERROR.

525
00:16:03,627 --> 00:16:06,096
SO NO ONE IS IMMUNE FROM THIS.

526
00:16:06,096 --> 00:16:07,531
IT IS COMPLETELY UNREASONABLE WE

527
00:16:07,531 --> 00:16:10,200
CAN MAKE HEALTHCARE THAT REALLY

528
00:16:10,200 --> 00:16:12,936
COMPLEX ENVIRONMENT ERROR-FREE.

529
00:16:12,936 --> 00:16:15,973
SO, PART OF UNDERSTANDING SAFETY

530
00:16:15,973 --> 00:16:17,341
EVENTS IS UNDERSTANDING WHY WE

531
00:16:17,341 --> 00:16:17,808
BEHAVE THE WAY WE DID.

532
00:16:17,808 --> 00:16:19,710
SO I WANT TO TAKE YOU THROUGH

533
00:16:19,710 --> 00:16:22,946
WHAT, THE DIFFERENT TYPES OF

534
00:16:22,946 --> 00:16:25,115
ERRORS SO YOU GET A SENSE OF THE

535
00:16:25,115 --> 00:16:27,618
KIND OF MISTAKES WE AS HUMANS

536
00:16:27,618 --> 00:16:27,818
MAKE.

537
00:16:27,818 --> 00:16:29,453
THEN YOU CAN ACTUALLY START TO

538
00:16:29,453 --> 00:16:31,155
úCRE

539
00:16:31,155 --> 00:16:32,723
BEHAVIOR AND ALSO THE SYSTEMS

540
00:16:32,723 --> 00:16:33,957
ISSUES THAT WE'LL TALK ABOUT IN

541
00:16:33,957 --> 00:16:36,126
A LITTLE WHILE.

542
00:16:36,126 --> 00:16:39,496
SO THREE TYPES OF BEHAVIORISM

543
00:16:39,496 --> 00:16:40,297
KNOWLEDGE-BASED, RULE-BASED, AND

544
00:16:40,297 --> 00:16:40,597
SKILL-BASED.

545
00:16:40,597 --> 00:16:44,268
WE CALL THEM ERRORS OF

546
00:16:44,268 --> 00:16:44,601
AUTOAMTICITY.

547
00:16:44,601 --> 00:16:46,937
SO KNOWLEDGE BASED, THESE ARE

548
00:16:46,937 --> 00:16:47,538
AREAS THAT WE MAKE SIMPLY

549
00:16:47,538 --> 00:16:48,872
BECAUSE WE DON'T KNOW SOMETHING.

550
00:16:48,872 --> 00:16:50,207
WE DIDN'T HAVE THE TRAINING.

551
00:16:50,207 --> 00:16:52,242
I DIDN'T TAKE THE CLASS.

552
00:16:52,242 --> 00:16:54,345
I'M NOT KNOWLEDGEABLE.

553
00:16:54,345 --> 00:16:56,547
SO, ONE EXAMPLE NONMEDICAL IS

554
00:16:56,547 --> 00:16:58,982
EVERY TIME YOU GET INTO A NEW

555
00:16:58,982 --> 00:17:00,284
RENTAL CARE, I, AT LEAST I

556
00:17:00,284 --> 00:17:02,953
ALWAYS SIT THERE AND LOOK AT THE

557
00:17:02,953 --> 00:17:04,755
WINDOW, YOU KNOW, THE WASHING

558
00:17:04,755 --> 00:17:06,056
GAUGE, NOT HAVING ANY IDEA HOW

559
00:17:06,056 --> 00:17:07,124
TO USE IT.

560
00:17:07,124 --> 00:17:08,359
THERE IS NO STANDARDIZATION.

561
00:17:08,359 --> 00:17:09,159
SOMETIMES IT IS TON THE RIGHT,

562
00:17:09,159 --> 00:17:11,962
SOMETIMES IT IS ON THE LEFT, I

563
00:17:11,962 --> 00:17:13,630
TURN ON MY BACKWASHER INSTEAD OF

564
00:17:13,630 --> 00:17:16,967
THE FRONT WASHER OR TURN ON THE

565
00:17:16,967 --> 00:17:18,435
LIGHTS OR MY, MY BLINKER.

566
00:17:18,435 --> 00:17:19,303
THAT'S A KNOWLEDGE-BASE.

567
00:17:19,303 --> 00:17:21,305
I DIDN'T TAKE THE TIME TO READ

568
00:17:21,305 --> 00:17:23,707
THE MANUAL WHEN I GET IN THE

569
00:17:23,707 --> 00:17:24,842
RENTAL CAR.

570
00:17:24,842 --> 00:17:26,710
FROM A MEDICAL STANDPOINT, A NEW

571
00:17:26,710 --> 00:17:29,346
INTERN PUTTING A CHEST TUBE IN

572
00:17:29,346 --> 00:17:30,781
AND NOT HAVING AD "KNOWLEDGE TO

573
00:17:30,781 --> 00:17:31,081
DO THAT.

574
00:17:31,081 --> 00:17:32,316
SOMETHING WE CAN TEACH PEOPLE,

575
00:17:32,316 --> 00:17:34,084
BUT WE HAVE TO UNDERSTAND IF

576
00:17:34,084 --> 00:17:35,619
THERE IS A MISTAKE WHY THAT

577
00:17:35,619 --> 00:17:37,321
PERSON DIDN'T GET THAT

578
00:17:37,321 --> 00:17:37,855
INFORMATION.

579
00:17:37,855 --> 00:17:40,124
RULE BASED ARE WHEN YOU APPLY,

580
00:17:40,124 --> 00:17:42,593
YOU FOLLOW THE RULE, BUT YOU

581
00:17:42,593 --> 00:17:45,129
JUST APPLY IT IN THE WRONG

582
00:17:45,129 --> 00:17:46,730
SITUATION.

583
00:17:46,730 --> 00:17:48,132
SO, ONE EXAMPLE IS I'M GOING TO

584
00:17:48,132 --> 00:17:49,266
BOSTON IN JANUARY.

585
00:17:49,266 --> 00:17:51,668
IT'S GOING TO BE COLD IN BOSTON,

586
00:17:51,668 --> 00:17:52,503
BECAUSE IT IS ALWAYS COLD IN

587
00:17:52,503 --> 00:17:54,538
BOSTON IN JANUARY.

588
00:17:54,538 --> 00:17:56,940
SO I PACK A PARKA, BUT I GET TO

589
00:17:56,940 --> 00:17:58,742
BOSTON IT IS 80 DEGREES.

590
00:17:58,742 --> 00:18:01,178
RIGHT RULE, WRONG SITUATION.

591
00:18:01,178 --> 00:18:02,746
I COULD HAVE CHECKED ACT TO

592
00:18:02,746 --> 00:18:03,814
WEATHER, BUT I DIDN'T.

593
00:18:03,814 --> 00:18:05,315
NOW, MEDICINE, YOU WALK INTO A

594
00:18:05,315 --> 00:18:07,718
PATIENT'S ROOM THAT IS

595
00:18:07,718 --> 00:18:10,487
UNRESPONSIVE, NO PULSE, NOT

596
00:18:10,487 --> 00:18:11,121
BREATHING, YOU INITIATE CPR.

597
00:18:11,121 --> 00:18:14,124
BUT THE PATIENT WAS A DNR.

598
00:18:14,124 --> 00:18:17,327
RIGHT RULE, I SHOULD HAVE

599
00:18:17,327 --> 00:18:18,862
RESUSCITATED THAT PERSON, BUT

600
00:18:18,862 --> 00:18:19,563
THE WRONG SITUATION.

601
00:18:19,563 --> 00:18:20,664
IN THOSE CASES YOU HAVE TO

602
00:18:20,664 --> 00:18:23,000
UNDERSTAND WHY THEY APPLIED THE

603
00:18:23,000 --> 00:18:23,834
RULE THE WRONG WAY.

604
00:18:23,834 --> 00:18:25,803
WHAT DIDN'T THEY KNOW, THEY

605
00:18:25,803 --> 00:18:27,704
DIDN'T HAVE INFORMATION ABOUT

606
00:18:27,704 --> 00:18:30,374
THE PATIENT BEING A DNR WHY NOT,

607
00:18:30,374 --> 00:18:31,575
NOT THE WRISTBAND ON OR IN THEIR

608
00:18:31,575 --> 00:18:32,743
MEDICAL RECORD.

609
00:18:32,743 --> 00:18:35,312
AND THE LAST ERRORS OF

610
00:18:35,312 --> 00:18:37,114
AUTOMATICITY, SLIPS IN AND

611
00:18:37,114 --> 00:18:37,314
LAPSE.

612
00:18:37,314 --> 00:18:39,082
SO A SLIP IS WHEN YOU JUST MAKE

613
00:18:39,082 --> 00:18:41,118
A MISTAKE.

614
00:18:41,118 --> 00:18:43,487
YOU JUST DIDN'T DO WHAT YOU WERE

615
00:18:43,487 --> 00:18:46,256
SUPPOSED TO DO.

616
00:18:46,256 --> 00:18:47,191
SO ME GOING, MY BOWL OF CEREAL

617
00:18:47,191 --> 00:18:49,259
IN FRONT OF ME IN THE MORNING,

618
00:18:49,259 --> 00:18:51,562
GO TO THE REFRESHER AND PUT MILK

619
00:18:51,562 --> 00:18:54,298
ON MY CEREAL, AND INSTEAD I GRAB

620
00:18:54,298 --> 00:18:58,168
THE ORANGE JUICE AND POUR IT ON

621
00:18:58,168 --> 00:18:59,970
MY CEREAL I DIDN'T TEEN TO DO

622
00:18:59,970 --> 00:19:00,471
IT.

623
00:19:00,471 --> 00:19:01,538
NO POLICY CHANGE IS GOING TO

624
00:19:01,538 --> 00:19:03,040
KEEP ME FROM DOING THAT.

625
00:19:03,040 --> 00:19:04,942
THOSE ARE THE FIRST TWO THINGS I

626
00:19:04,942 --> 00:19:05,175
GO FOR.

627
00:19:05,175 --> 00:19:08,045
SO, MAYBE I NEED TO PUT MY MILK

628
00:19:08,045 --> 00:19:09,847
INSIDE OF THE REFRIGERATOR AND

629
00:19:09,847 --> 00:19:11,615
MY ORANGE JUICE ON THE DOOR AND

630
00:19:11,615 --> 00:19:12,850
GIVE ME A CUE.

631
00:19:12,850 --> 00:19:17,621
IN MODESON IT IS PICKING UP THE

632
00:19:17,621 --> 00:19:19,323
WRONG MEDICATION AS IT SITS

633
00:19:19,323 --> 00:19:19,523
THERE.

634
00:19:19,523 --> 00:19:21,091
LAMPSES ARE WHEN YOU FORGET A

635
00:19:21,091 --> 00:19:22,993
STEP IN THE PROCESS.

636
00:19:22,993 --> 00:19:25,295
HERE WE HAVE OUR SHERIFF WHO HAS

637
00:19:25,295 --> 00:19:28,165
OBVIOUSLY GASSED UP HIS CAR OR

638
00:19:28,165 --> 00:19:29,666
HER CAR AND THEN FORGOT THAT KEY

639
00:19:29,666 --> 00:19:31,668
LAST STEP OF TAKING THE

640
00:19:31,668 --> 00:19:32,903
BECAUSELING OUT OF THE CAR AND

641
00:19:32,903 --> 00:19:36,006
PUTTING IT BACK IN THE PUMP.

642
00:19:36,006 --> 00:19:39,176
HERE'S ONE, AN EXAMPLE WHERE --

643
00:19:39,176 --> 00:19:41,378
A PHYSICIAN WAS ORDERING BLOOD.

644
00:19:41,378 --> 00:19:42,279
THEY ORDERED THE RIGHT TYPE TO

645
00:19:42,279 --> 00:19:44,047
THE RIGHT PERSON THE RIGHT TIME,

646
00:19:44,047 --> 00:19:47,117
BUT THEY FORGOT THE LAST STEP OF

647
00:19:47,117 --> 00:19:48,385
MAKING IT IRRITATED.

648
00:19:48,385 --> 00:19:50,521
SO A LAPSE IS SIMPLY WHEN YOU

649
00:19:50,521 --> 00:19:52,155
FORGET TO DO SOMETHING AND A

650
00:19:52,155 --> 00:19:54,791
SLIP, YOU JUST, IT IS AN

651
00:19:54,791 --> 00:19:56,460
AUTOMATIC, I DON'T KNOW WHY I

652
00:19:56,460 --> 00:19:58,695
DID IT.

653
00:19:58,695 --> 00:19:59,196
AND FINALLY VIOLATIONS.

654
00:19:59,196 --> 00:20:00,931
THIS IS JUST WHEN SOMEBODY SORT

655
00:20:00,931 --> 00:20:02,466
OF KNOWINGLY VIOLATES A RULE,

656
00:20:02,466 --> 00:20:03,500
SPEEDING, MAYBE A NURSE MAKING

657
00:20:03,500 --> 00:20:06,236
ALL OF HER MEDS AND PASSING THEM

658
00:20:06,236 --> 00:20:07,604
AS ONCE OPPOSED TO DOING IT ONE

659
00:20:07,604 --> 00:20:09,406
AT A TIME.

660
00:20:09,406 --> 00:20:11,542
SO WHEN WE LOOK AT ERROR

661
00:20:11,542 --> 00:20:12,309
CLASSIFICATION.

662
00:20:12,309 --> 00:20:12,943
THERE IS INTENDED ACTIONS.

663
00:20:12,943 --> 00:20:15,012
THAT'S THE KNOWLEDGE BASE AND

664
00:20:15,012 --> 00:20:16,547
THE RULE BASED.

665
00:20:16,547 --> 00:20:18,115
AND THEN UNINTENDED ACTIONS

666
00:20:18,115 --> 00:20:20,217
THOSE ARE SKILL BASED OR HOOT

667
00:20:20,217 --> 00:20:21,518
MUTICITY ERRORS THAT ARE SLIPS

668
00:20:21,518 --> 00:20:21,919
AND LAPSE.

669
00:20:21,919 --> 00:20:23,754
SO, WE WILL DO A QUIZ.

670
00:20:23,754 --> 00:20:25,856
HERE IS THE FIRST CASE.

671
00:20:25,856 --> 00:20:27,524
DURING THE PROCEDURE THE CRNA

672
00:20:27,524 --> 00:20:29,226
NOTICED THAT THE PATIENT'S HEART

673
00:20:29,226 --> 00:20:31,461
RATE AND BLOOD PRESSURE WERE

674
00:20:31,461 --> 00:20:33,463
ELEVATED LEADING TO A CHECK OF

675
00:20:33,463 --> 00:20:34,765
THE INFUSION PUMP.

676
00:20:34,765 --> 00:20:37,868
THE INFUSION PUMP SHOWED THE

677
00:20:37,868 --> 00:20:42,306
CRNA MISPROGRAMMED THE PUMP FOR

678
00:20:42,306 --> 00:20:45,042
50 MICRO GRAMS, NOT

679
00:20:45,042 --> 00:20:45,943
150 MICROGRAMS.

680
00:20:45,943 --> 00:20:47,611
AND THE PATIENT NOTICED

681
00:20:47,611 --> 00:20:50,414
AWARENESS FOR MINUTES OF THE

682
00:20:50,414 --> 00:20:50,681
PROCEDURE.

683
00:20:50,681 --> 00:20:55,118
WHICH ONE DO YOU THINK THIS IS,

684
00:20:55,118 --> 00:21:05,596
KNOWLEDGE BASED, RULE BASED,

685
00:21:06,964 --> 00:21:07,631
AUTOMATICITY, SLIP OR LAPSE.

686
00:21:07,631 --> 00:21:10,901
IT IS A SLIP, SHE MISPROGRAMMED,

687
00:21:10,901 --> 00:21:14,271
POURED THE ORANGE JUICE OUT

688
00:21:14,271 --> 00:21:15,339
INSTEAD OF THE MILK.

689
00:21:15,339 --> 00:21:17,240
NEXT ONE, PATIENT WAS TO RECEIVE

690
00:21:17,240 --> 00:21:20,444
RADIATION TREATMENT FOR A LEFT

691
00:21:20,444 --> 00:21:21,878
SHOULDER TUMOR, THE TECHNOLOGY

692
00:21:21,878 --> 00:21:25,449
STARTED THE MACHINE TO SEE A

693
00:21:25,449 --> 00:21:27,284
VERY AMBIGUOUS ERROR MESSAGE

694
00:21:27,284 --> 00:21:29,786
THAT WE HAVE SEEN IN OUR OWN

695
00:21:29,786 --> 00:21:31,088
PRACTICE.

696
00:21:31,088 --> 00:21:31,688
THE TECHNOLOGIES ASSUMED THAT

697
00:21:31,688 --> 00:21:33,991
THE DOSE WAS NOT DELIVERED WHEN

698
00:21:33,991 --> 00:21:35,759
THE ERROR MESSAGE OCCURRED.

699
00:21:35,759 --> 00:21:38,295
SHE TRIED, SHE RESET THE MACHINE

700
00:21:38,295 --> 00:21:39,730
AND TRIED TWO MORE TIMES.

701
00:21:39,730 --> 00:21:41,732
THE PATIENT RECEIVED THREE

702
00:21:41,732 --> 00:21:44,034
DOSES, THREE TIMES THE DOSE OF

703
00:21:44,034 --> 00:21:46,937
THE RADIATION.

704
00:21:46,937 --> 00:21:49,439
SO, WHICH ONE IS THIS?

705
00:21:49,439 --> 00:21:50,240
IT IS RULE-BASED.

706
00:21:50,240 --> 00:21:51,775
BECAUSE SHE HAD A RULE THAT

707
00:21:51,775 --> 00:21:52,909
WORKED FOR ANOTHER MACHINE.

708
00:21:52,909 --> 00:21:54,678
BUT SHE JUST APPLIED IT TO THE

709
00:21:54,678 --> 00:21:55,846
WRONG SITUATION.

710
00:21:55,846 --> 00:21:58,749
SO, AGAIN, YOU KNOW, THAT WAS,

711
00:21:58,749 --> 00:22:01,084
AN ERROR BY THE TECHNOLOGIST.

712
00:22:01,084 --> 00:22:02,953
BUT WHY DID SHE ASSUME THAT.

713
00:22:02,953 --> 00:22:05,355
HAD SHE BEEN, THERE WAS A NEW

714
00:22:05,355 --> 00:22:06,490
MACHINE HAD PEOPLE NOT SHARED

715
00:22:06,490 --> 00:22:08,492
WITH HER THAT THERE WAS THIS

716
00:22:08,492 --> 00:22:08,792
DIFFERENCE?

717
00:22:08,792 --> 00:22:10,227
SO, IT'S SORT OF IN BETWEEN

718
00:22:10,227 --> 00:22:13,030
KNOWLEDGE AND RULE, BUT IT IS

719
00:22:13,030 --> 00:22:13,597
REALLY A RULE-BASED ERROR.

720
00:22:13,597 --> 00:22:14,865
THIS IS THE LOST ONE.

721
00:22:14,865 --> 00:22:17,668
A PATIENT ACQUIRED A FINE NEEDLE

722
00:22:17,668 --> 00:22:23,106
ASPIRATION OF THE THYROID,

723
00:22:23,106 --> 00:22:25,042
ULTRASOUND REVEALED SIX

724
00:22:25,042 --> 00:22:25,909
SUSPICIOUS NODULES, ASPIRATED

725
00:22:25,909 --> 00:22:26,910
AND PREPARED ON THE SLIDE.

726
00:22:26,910 --> 00:22:34,051
A NEW RULE WAS IMPLEMENTED.

727
00:22:34,051 --> 00:22:35,252
AND THE ULTRASONOGRAPHY WAS NOT

728
00:22:35,252 --> 00:22:35,619
GIVEN THE RULE.

729
00:22:35,619 --> 00:22:38,955
SO THIS IS KNOWLEDGE BASED.

730
00:22:38,955 --> 00:22:39,489
THEY DIDN'T KNOW ABOUT IT.

731
00:22:39,489 --> 00:22:40,957
AGAIN, WE CAN RESTRAINT THAT

732
00:22:40,957 --> 00:22:42,993
PERSON, WHY WAS THIS PERSON

733
00:22:42,993 --> 00:22:44,995
ASKED TO DO THAT PERSON WITHOUT

734
00:22:44,995 --> 00:22:45,328
THE TRAINING.

735
00:22:45,328 --> 00:22:48,331
WAS IT THEY DIDN'T HAVE TIME?

736
00:22:48,331 --> 00:22:50,000
OR SHORT-STAFFED SHE WAS THROWN

737
00:22:50,000 --> 00:22:50,767
INTO THE SITUATION?

738
00:22:50,767 --> 00:22:51,968
WE CAN ALWAYS LOOK AT WHY THE

739
00:22:51,968 --> 00:22:52,536
PERSON DID WHAT THEY DID.

740
00:22:52,536 --> 00:22:54,137
BUT THEY CAME TO WORK EVERY DAY

741
00:22:54,137 --> 00:22:55,505
TO DO THE RIGHT THING.

742
00:22:55,505 --> 00:22:58,475
WHAT WE NEED TO DO IS LEADERS IN

743
00:22:58,475 --> 00:23:00,377
PATIENT SAFETY AND COLLEAGUES IS

744
00:23:00,377 --> 00:23:02,345
TO TRY TO FIGURE OUT WHY THEY

745
00:23:02,345 --> 00:23:05,048
ENDED UP DOING WHAT THEY DID.

746
00:23:05,048 --> 00:23:07,017
SO, THE WHY STATEMENT IS

747
00:23:07,017 --> 00:23:08,885
SOMETHING YOU'RE GOING TO HEAR

748
00:23:08,885 --> 00:23:10,320
QUITE A WHILE.

749
00:23:10,320 --> 00:23:12,422
WE CAN NOT ACCURATELY CHARACTER

750
00:23:12,422 --> 00:23:13,023
ERRORS UNTIL WE UNDERSTAND WHY

751
00:23:13,023 --> 00:23:15,926
THEY HAPPEN AND WE CANNOT

752
00:23:15,926 --> 00:23:16,693
IMPLEMENT GREAT SOLUTIONS UNTIL

753
00:23:16,693 --> 00:23:18,261
WE HAVE A DEEP UNDERSTANDING OF

754
00:23:18,261 --> 00:23:19,229
WHY THEY HAPPENED.

755
00:23:19,229 --> 00:23:20,831
AND BEFORE WE CAN UNDERSTAND WHY

756
00:23:20,831 --> 00:23:22,699
THEY HAPPENED, WE HAVE TO KNOW

757
00:23:22,699 --> 00:23:23,066
ABOUT THE EVENT.

758
00:23:23,066 --> 00:23:24,234
WE ARE GOING TO TALK A LITTLE

759
00:23:24,234 --> 00:23:26,303
BIT ABOUT EVENT REPORTING AND

760
00:23:26,303 --> 00:23:28,872
THE REALLY, REALLY, IT IS REALLY

761
00:23:28,872 --> 00:23:29,740
IMPORTANT TO REPORT EVENTS IN

762
00:23:29,740 --> 00:23:35,312
AND ALL KINDS OF EVENTS.

763
00:23:35,312 --> 00:23:37,547
OUR TAGLINES IS SECRETS CAN'T BE

764
00:23:37,547 --> 00:23:37,748
FIXED.

765
00:23:37,748 --> 00:23:39,249
AS HEALTHCARE PROVIDERS WE FIX

766
00:23:39,249 --> 00:23:40,484
THE PROBLEM, PUT A PIECE OF DUCT

767
00:23:40,484 --> 00:23:41,618
TAPE OVER IT AND MOVING ON.

768
00:23:41,618 --> 00:23:43,854
AND THE NEXT PERSON PUTS A PIECE

769
00:23:43,854 --> 00:23:45,455
OF DUCT TAPE OVER THE SAME

770
00:23:45,455 --> 00:23:46,590
THING.

771
00:23:46,590 --> 00:23:48,492
AND ONE OUT OF 10 DUCT TAPE

772
00:23:48,492 --> 00:23:49,226
APPLICATIONS AND LEPT YOUR

773
00:23:49,226 --> 00:23:51,194
SAFETY TEAM KNOW ABOUT THE ISSUE

774
00:23:51,194 --> 00:23:52,295
AND WE CAN MAKE YOUR ENVIRONMENT

775
00:23:52,295 --> 00:23:52,929
SAFER.

776
00:23:52,929 --> 00:23:55,766
I'M GOING TO START ABOUT EVENT

777
00:23:55,766 --> 00:23:57,200
REPORTING AND EVENT REVIEW,

778
00:23:57,200 --> 00:23:58,201
THOUGH, TALKING ABOUT

779
00:23:58,201 --> 00:23:59,770
PSYCHOLOGICAL SAFETY.

780
00:23:59,770 --> 00:24:01,104
SO, PSYCHOLOGICAL SAFETY IS A

781
00:24:01,104 --> 00:24:04,174
TERM THAT AMY EMENSON IS A

782
00:24:04,174 --> 00:24:08,111
THOUGHT LEADER IN THIS WORLD

783
00:24:08,111 --> 00:24:08,345
COINED.

784
00:24:08,345 --> 00:24:09,713
THE SHARED BELIEF AMONG TEAM

785
00:24:09,713 --> 00:24:10,981
MEMBERS THAT THE TEAM IS SAFE

786
00:24:10,981 --> 00:24:14,251
FOR RISKTAKING.

787
00:24:14,251 --> 00:24:16,753
SO AMY STARTED HER TEAM UP WITH

788
00:24:16,753 --> 00:24:19,089
DAVID BITES, THE DOC WITH THE

789
00:24:19,089 --> 00:24:21,324
ARTICLE A FEW MINUTES AGO, HE

790
00:24:21,324 --> 00:24:23,026
WANTED TO STUDY THE REPORTED

791
00:24:23,026 --> 00:24:24,995
MEDICATION ERRORS ON A COUPLE OF

792
00:24:24,995 --> 00:24:27,531
PATIENT UNITS IN THE HARVARD

793
00:24:27,531 --> 00:24:28,999
HOSPITAL.

794
00:24:28,999 --> 00:24:31,334
AND AMY IS A SOCIAL RESEARCHER

795
00:24:31,334 --> 00:24:34,437
AND INTERESTED IN TEAM DYNAMICS

796
00:24:34,437 --> 00:24:35,405
AND PSYCHOLOGICAL SAFETY.

797
00:24:35,405 --> 00:24:38,375
HER HYPOTHESIS WAS THAT TEAMS

798
00:24:38,375 --> 00:24:39,609
THAT HAD REALLY BAD

799
00:24:39,609 --> 00:24:41,011
PSYCHOLOGICAL SAFETY AND DIDN'T

800
00:24:41,011 --> 00:24:41,678
WORK WELL TOGETHER WOULD

801
00:24:41,678 --> 00:24:43,313
ACTUALLY HAVE WAY MORE ERROR

802
00:24:43,313 --> 00:24:44,314
REPORTS BECAUSE THEY JUST

803
00:24:44,314 --> 00:24:45,816
WEREN'T WORKING WELL TOGETHER.

804
00:24:45,816 --> 00:24:49,252
WELL, IT WAS ACTUALLY THE

805
00:24:49,252 --> 00:24:49,519
OPPOSITE.

806
00:24:49,519 --> 00:24:52,455
WHAT THEY FOUND WAS

807
00:24:52,455 --> 00:24:53,089
HIGH-PERFORMING PSYCHOLOGICALLY

808
00:24:53,089 --> 00:24:55,725
SAFE TEAMS HAD HIGHER RATE OF

809
00:24:55,725 --> 00:24:57,594
REPORTING BECAUSE PEOPLE FELT

810
00:24:57,594 --> 00:24:58,428
SAFE TO DO IT.

811
00:24:58,428 --> 00:24:59,196
WE'RE ENCOURAGED TO DO IT.

812
00:24:59,196 --> 00:25:01,331
AND WHEN THEY WERE REPORTED,

813
00:25:01,331 --> 00:25:04,234
THINGS WERE DONE ABILITY THOSE

814
00:25:04,234 --> 00:25:04,935
REPORTS AND THE, ENVIRONMENT,

815
00:25:04,935 --> 00:25:06,203
THE CARE ENVIRONMENT WAS

816
00:25:06,203 --> 00:25:06,469
IMPROVED.

817
00:25:06,469 --> 00:25:08,338
SO PSYCHOLOGICAL SAFETY IS SO

818
00:25:08,338 --> 00:25:08,605
IMPORTANT.

819
00:25:08,605 --> 00:25:09,539
NOT ONLY FOR SPEAKING UP AND

820
00:25:09,539 --> 00:25:11,541
GETTING PEOPLE TO SPEAK UP, BUT

821
00:25:11,541 --> 00:25:14,878
IT IS REALLY IMPORTANT TO GIVE

822
00:25:14,878 --> 00:25:16,646
PEOPLE ACROSS OUR ORGANIZATION

823
00:25:16,646 --> 00:25:17,247
AGENCY TO HELP INVENTOR.

824
00:25:17,247 --> 00:25:20,016
BECAUSE WHEN WE'RE TRYING TO FIX

825
00:25:20,016 --> 00:25:21,718
THINGS, WE DON'T WANT THE PEOPLE

826
00:25:21,718 --> 00:25:22,619
WITH MANY LETTERS BEHIND THEIR

827
00:25:22,619 --> 00:25:25,856
NAMES AND ALL OF THE WINDOWS IN

828
00:25:25,856 --> 00:25:27,657
THEIR OFFICES MAKING DECISIONS

829
00:25:27,657 --> 00:25:29,626
ABOUT WHAT HAPPENS AT THE

830
00:25:29,626 --> 00:25:30,093
BEDSIDE.

831
00:25:30,093 --> 00:25:31,461
WE WANT THE FRONT LINE STAFF

832
00:25:31,461 --> 00:25:32,963
DOING THAT.

833
00:25:32,963 --> 00:25:34,064
IT'S REALLY HARD IF YOU ARE A

834
00:25:34,064 --> 00:25:35,699
FRONT LINE STAFF AND YOU WALK

835
00:25:35,699 --> 00:25:36,733
INTO A ROOM AND THERE'S A LOT OF

836
00:25:36,733 --> 00:25:38,468
WHITE COATS AND A LOT OF LETTERS

837
00:25:38,468 --> 00:25:40,003
AND A LOT OF WINDOWS SITTING

838
00:25:40,003 --> 00:25:41,471
THERE NEXT TO YOU.

839
00:25:41,471 --> 00:25:42,706
WE HAVE TO MAKE IT SAFE FOR

840
00:25:42,706 --> 00:25:43,940
PEOPLE TO DO THAT.

841
00:25:43,940 --> 00:25:47,377
SO WHAT DO WE WANT FOLKS TO

842
00:25:47,377 --> 00:25:47,611
REPORT?

843
00:25:47,611 --> 00:25:47,911
EVERYTHING.

844
00:25:47,911 --> 00:25:49,613
I KNOW PEOPLE TEND TO JUST

845
00:25:49,613 --> 00:25:51,815
REPORT THINGS THAT HURT

846
00:25:51,815 --> 00:25:52,649
PATIENTS, BUT THAT DOESN'T HELP

847
00:25:52,649 --> 00:25:53,884
US IMPROVE.

848
00:25:53,884 --> 00:25:55,418
THAT MAKES US IMPROVE ABOUT THAT

849
00:25:55,418 --> 00:26:00,223
ONE THING, BUT DOESN'T GIVE US A

850
00:26:00,223 --> 00:26:00,857
CHANCE TO IMPROVE PERSPECTIVELY.

851
00:26:00,857 --> 00:26:03,159
WE WANT YOU TO TALK ABOUT AND

852
00:26:03,159 --> 00:26:03,960
REPORT UNSAFE CONDITIONS.

853
00:26:03,960 --> 00:26:06,463
NEAR MISSES, THOSE ARE ERRORS

854
00:26:06,463 --> 00:26:07,898
THAT OCCURRED BUT NEVER QUITE

855
00:26:07,898 --> 00:26:08,465
REACHED THE PATIENT, EITHER

856
00:26:08,465 --> 00:26:10,433
BECAUSE WE WERE REALLY GOOD AND

857
00:26:10,433 --> 00:26:12,502
CAUGHT IT OR JUST DARN LUCKY.

858
00:26:12,502 --> 00:26:15,572
SO A LOT OF PEOPLE CELEBRATE

859
00:26:15,572 --> 00:26:15,872
NEAR MISSES.

860
00:26:15,872 --> 00:26:18,008
WE ACTUALLY, WE ACTUALLY TAKE A

861
00:26:18,008 --> 00:26:19,743
PAUSE AND SAY, OKAY, WERE WE

862
00:26:19,743 --> 00:26:22,579
GOOD OR LUCKY AND THEN WE

863
00:26:22,579 --> 00:26:22,879
CELEBRATE.

864
00:26:22,879 --> 00:26:24,581
SO REALLY UNDERSTANDING THOSE

865
00:26:24,581 --> 00:26:26,383
NEAR MISSES AND PRECURSORS AND

866
00:26:26,383 --> 00:26:28,118
UNSAFE CONDITIONS WILL MOVE THE

867
00:26:28,118 --> 00:26:30,120
DIAL INNING TERMS OF SAFETY.

868
00:26:30,120 --> 00:26:31,554
AND PROCESS ISSUES, THE SILLY

869
00:26:31,554 --> 00:26:32,355
LITTLE THINGS THAT KEEP YOU FROM

870
00:26:32,355 --> 00:26:35,125
DOING THE WORK YOU NEED TO DO IN

871
00:26:35,125 --> 00:26:36,960
AN EFFICIENT AND EXPENSIVE WAY.

872
00:26:36,960 --> 00:26:37,994
TAKE TIME TO PUT THOSE INTO

873
00:26:37,994 --> 00:26:38,561
STARS.

874
00:26:38,561 --> 00:26:42,465
PEOPLE WANT TO HEAR ABOUT THOSE.

875
00:26:42,465 --> 00:26:43,233
SORRY.

876
00:26:43,233 --> 00:26:43,466
WHOOPS.

877
00:26:43,466 --> 00:26:45,135
GOT A LIFE OF ITS OWN.

878
00:26:45,135 --> 00:26:45,635
OKAY.

879
00:26:45,635 --> 00:26:47,671
AND THEN, OF COURSE, ERRORS AND

880
00:26:47,671 --> 00:26:48,571
GOOD CATCHES.

881
00:26:48,571 --> 00:26:49,673
YOU KNOW, HEALTHCARE IS TOUGH

882
00:26:49,673 --> 00:26:50,774
RIGHT NOW.

883
00:26:50,774 --> 00:26:51,841
LET'S SEPBRAILLE ONE ANOTHER.

884
00:26:51,841 --> 00:26:54,044
SO IF SOMEONE IS DOING REALLY

885
00:26:54,044 --> 00:26:55,145
GOOD STUFF, LET'S CELEBRATE

886
00:26:55,145 --> 00:26:55,345
THAT.

887
00:26:55,345 --> 00:26:58,315
BUT REALLY THAT BLUE BOX AT THE

888
00:26:58,315 --> 00:26:59,816
BOTTOM IS TAKE AWAY FOR THIS

889
00:26:59,816 --> 00:27:00,650
SLIDE.

890
00:27:00,650 --> 00:27:02,719
EVENTS DON'T HAVE TO REACH OR

891
00:27:02,719 --> 00:27:03,253
IMPACT YOUR PATIENTS TO BE

892
00:27:03,253 --> 00:27:03,553
REPORTABLE.

893
00:27:03,553 --> 00:27:06,122
WE WANT TO KNOW WHEN YOU AS

894
00:27:06,122 --> 00:27:07,157
HEALTHCARE PROVIDERS JUST HAD A

895
00:27:07,157 --> 00:27:08,091
BAD FEELING ABOUT A SITUATION

896
00:27:08,091 --> 00:27:10,293
BECAUSE YOU KNOW THAT THE NEXT

897
00:27:10,293 --> 00:27:11,795
TIME IT COULD ACTUALLY RESULT IN

898
00:27:11,795 --> 00:27:11,995
HARM.

899
00:27:11,995 --> 00:27:13,797
SO I ALSO WANT YOU TO THING

900
00:27:13,797 --> 00:27:15,899
ABOUT MORE THAN PHYSICAL HARM.

901
00:27:15,899 --> 00:27:17,200
BECAUSE WE THINK ABOUT PHYSICAL

902
00:27:17,200 --> 00:27:17,500
HARM A LOT.

903
00:27:17,500 --> 00:27:19,202
BUT THERE IS EMOTIONAL HARM.

904
00:27:19,202 --> 00:27:20,103
THERE IS EMOTIONAL HARM TO A

905
00:27:20,103 --> 00:27:22,339
PATIENT THAT HAS BEEN INJURED.

906
00:27:22,339 --> 00:27:24,207
A HUGE AMOUNT OF EMOTIONAL HARM

907
00:27:24,207 --> 00:27:26,643
TO A PROVIDER WHO CAUSES HARM.

908
00:27:26,643 --> 00:27:27,243
THERE IS INTER GENERATIONAL

909
00:27:27,243 --> 00:27:27,444
HARM.

910
00:27:27,444 --> 00:27:29,346
I WORK WITH A LOT OF FAMILIES

911
00:27:29,346 --> 00:27:31,247
WHO HAVE LOST CHILDREN AS A

912
00:27:31,247 --> 00:27:33,817
RESULT OF HARM FROM ALL OVER THE

913
00:27:33,817 --> 00:27:34,150
UNITED STATES.

914
00:27:34,150 --> 00:27:35,785
THAT NEXT CHILD OR THE OLDER

915
00:27:35,785 --> 00:27:37,687
CHILD, THEY HAVE A REALLY HARD

916
00:27:37,687 --> 00:27:39,856
TIME, THERE'S A VERY HIGH RATE

917
00:27:39,856 --> 00:27:42,993
OF DEPRESSION AND SUICIDE

918
00:27:42,993 --> 00:27:44,861
AMONGEST KIDS THAT ARE, FAMILY

919
00:27:44,861 --> 00:27:46,329
MEMBERS WHERE THEY LOST A CHILD

920
00:27:46,329 --> 00:27:48,565
TO, A MEDICAL ERROR.

921
00:27:48,565 --> 00:27:49,733
AND THEN FINANCIAL HARM.

922
00:27:49,733 --> 00:27:51,668
AND MEAN, WE DON'T REALLY SEE

923
00:27:51,668 --> 00:27:53,403
OUR PATIENTS AFTER THEY LEAVE.

924
00:27:53,403 --> 00:27:54,371
I DON'T KNOW IF THE MAN WE MADE

925
00:27:54,371 --> 00:27:57,874
NOT BE ABLE TO WALK IS ABLE TO

926
00:27:57,874 --> 00:27:59,075
KEEP -- AN INCOME COMING IN AND

927
00:27:59,075 --> 00:28:01,378
TAKING CARE OF HIS FAMILY.

928
00:28:01,378 --> 00:28:03,780
SO YOU KNOW, THE BURDEN'S GREAT.

929
00:28:03,780 --> 00:28:04,914
OF US JUST THINKING ABOUT

930
00:28:04,914 --> 00:28:05,482
PHYSICAL HARM.

931
00:28:05,482 --> 00:28:07,751
BUT WE NEED TO EXPAND THAT AND

932
00:28:07,751 --> 00:28:09,586
THINK ABOUT THE OTHER TYPES OF

933
00:28:09,586 --> 00:28:10,353
HARM.

934
00:28:10,353 --> 00:28:11,021
OKAY.

935
00:28:11,021 --> 00:28:12,455
SO, WE KNOW ABOUT THESE EVENTS.

936
00:28:12,455 --> 00:28:14,858
SO NOW, WE HAVE TO DO SOMETHING

937
00:28:14,858 --> 00:28:15,125
ABOUT IT.

938
00:28:15,125 --> 00:28:16,526
WE HAVE TO DO THE RIGHT THING

939
00:28:16,526 --> 00:28:20,864
BECAUSE IF WE DON'T, IT CAN

940
00:28:20,864 --> 00:28:22,265
REALLY KILL SCULPTURE.

941
00:28:22,265 --> 00:28:24,367
WE NEED TO FIND THE WAYS, WHY

942
00:28:24,367 --> 00:28:25,702
DID IT HAPPEN, NOT WHO IS

943
00:28:25,702 --> 00:28:28,605
RESPONSIBLE, BUT WHY DID IT

944
00:28:28,605 --> 00:28:28,838
HAPPEN?

945
00:28:28,838 --> 00:28:29,973
WE TALKED ABOUT HOW SOMEBODY

946
00:28:29,973 --> 00:28:30,807
MAKES AN ERROR.

947
00:28:30,807 --> 00:28:33,076
I SAID IT IS ALL OF THOSE LITTLE

948
00:28:33,076 --> 00:28:37,914
DOTS AND SYSTEMS PIECES THAT

949
00:28:37,914 --> 00:28:39,482
ACTUALLY CONSPIRED TO PUT THAT

950
00:28:39,482 --> 00:28:40,183
HEALTHCARE PROVIDER IN THE

951
00:28:40,183 --> 00:28:41,584
SITUATION WHERE THEY ENDED UP

952
00:28:41,584 --> 00:28:42,685
CAUSING HARM.

953
00:28:42,685 --> 00:28:46,122
SO THIS IS FROM, WE GET TO WORK

954
00:28:46,122 --> 00:28:47,490
WITH THIS GREAT GUY, A DOC

955
00:28:47,490 --> 00:28:50,593
CALLED ED TORRE, AN EXPERT ON

956
00:28:50,593 --> 00:28:52,462
INFLUENCE, HE SAID THIS AT ONE

957
00:28:52,462 --> 00:28:53,663
OF OUR SESSIONS, I HAD TO SHARE

958
00:28:53,663 --> 00:28:55,965
IT WITH FOLKS, THE SINGLE MOST

959
00:28:55,965 --> 00:28:57,300
IMPORTANT IMPACT ON SAFETY

960
00:28:57,300 --> 00:28:59,035
CULTURE IS HOW WE RESPOND TO

961
00:28:59,035 --> 00:28:59,536
EVENTS.

962
00:28:59,536 --> 00:29:01,838
IF WE IGNORE IT IS BAD.

963
00:29:01,838 --> 00:29:03,673
DO IT THE WRONG WAY IT IS BAD.

964
00:29:03,673 --> 00:29:05,575
IF WE BLAME PEOPLE INVOLVED THAT

965
00:29:05,575 --> 00:29:06,443
IS REALLY BAD.

966
00:29:06,443 --> 00:29:08,778
BAD FOR THE PERSON, BAD FOR US,

967
00:29:08,778 --> 00:29:10,080
BAD FOR THE PATIENT.

968
00:29:10,080 --> 00:29:11,214
THIS IS HOW WE DO IT AT MEDSTAR

969
00:29:11,214 --> 00:29:11,681
HEALTH.

970
00:29:11,681 --> 00:29:13,249
THE CLINICAL CENTER HAS A

971
00:29:13,249 --> 00:29:14,884
STRUCTURED WAY TO DO IT, TOO.

972
00:29:14,884 --> 00:29:18,088
SO HOW TO LOOK AT THE STRUCTURED

973
00:29:18,088 --> 00:29:19,155
PATIENT SAFETY EVALUATIONS IS

974
00:29:19,155 --> 00:29:19,556
REALLY IMPORTANT.

975
00:29:19,556 --> 00:29:20,623
BECAUSE YOU NEED TO HAVE A

976
00:29:20,623 --> 00:29:22,826
ROADMAP TO FOLLOW.

977
00:29:22,826 --> 00:29:23,960
SO IT'S THE IMMEDIATE RESPONSE,

978
00:29:23,960 --> 00:29:24,861
YOU GET IN THERE, YOU START

979
00:29:24,861 --> 00:29:27,864
MAKING SURE THE PATIENT'S OKAY.

980
00:29:27,864 --> 00:29:28,465
HOW IS THAT CAREGIVER DOING?

981
00:29:28,465 --> 00:29:30,400
DO THEY NEED TO BE PULLED OUT.

982
00:29:30,400 --> 00:29:32,469
TALK ABOUT CARE FOR THE

983
00:29:32,469 --> 00:29:32,735
CAREGIVER.

984
00:29:32,735 --> 00:29:34,304
YOU WANT TO ENGAGE WITH THE

985
00:29:34,304 --> 00:29:35,071
PATIENT AND FAMILY AND SAY,

986
00:29:35,071 --> 00:29:36,973
LOOK, I DON'T KNOW WHAT

987
00:29:36,973 --> 00:29:38,508
HAPPENED.

988
00:29:38,508 --> 00:29:38,942
WE ARE REALLY SORRY.

989
00:29:38,942 --> 00:29:39,442
SOMETHING HAPPENED HERE.

990
00:29:39,442 --> 00:29:40,477
WE'RE GOING TO LOOK INTO IT.

991
00:29:40,477 --> 00:29:42,212
WE WILL KEEP YOU IN THE LOOP.

992
00:29:42,212 --> 00:29:44,214
JUST MAKE SURE THAT EVERYBODY'S

993
00:29:44,214 --> 00:29:44,781
ENGAGED.

994
00:29:44,781 --> 00:29:46,749
AND THEN THE REALLY HARD WORK

995
00:29:46,749 --> 00:29:48,485
COMES IN THE IN-DEPTH EVENT

996
00:29:48,485 --> 00:29:50,253
REVIEW.

997
00:29:50,253 --> 00:29:51,688
WHERE YOU'RE DOING INTERVIEWS,

998
00:29:51,688 --> 00:29:53,189
TAKING OBSERVATIONS, DOING A LOT

999
00:29:53,189 --> 00:29:54,424
OF ANALYSIS, PEER REVIEW COMES

1000
00:29:54,424 --> 00:29:57,794
IN HERE, YOU'RE LOOKING AT AN

1001
00:29:57,794 --> 00:29:59,529
INDIVIDUAL PROCEDURE MAYBE,

1002
00:29:59,529 --> 00:30:00,163
M&Ms, AND GATHER THE

1003
00:30:00,163 --> 00:30:02,031
INFORMATION, AND THEN WE DO A

1004
00:30:02,031 --> 00:30:03,199
LEARNING TEAM, WE GET EVERYBODY

1005
00:30:03,199 --> 00:30:04,734
INVOLVED IN THAT PROCESS

1006
00:30:04,734 --> 00:30:05,001
TOGETHER.

1007
00:30:05,001 --> 00:30:07,604
YOU KNOW, YOU LEARN A LOT IN ALL

1008
00:30:07,604 --> 00:30:09,839
OF THE INTERVIEWS, BUT JUST ONE

1009
00:30:09,839 --> 00:30:10,840
PERSON'S PERSPECTIVE.

1010
00:30:10,840 --> 00:30:12,809
NOW, WE HAVE TO LUXURY OF

1011
00:30:12,809 --> 00:30:13,710
GETTING TOGETHER IN THE LEARNING

1012
00:30:13,710 --> 00:30:15,845
TEAM, EVERYBODY GETS TO HEAR

1013
00:30:15,845 --> 00:30:20,150
EACH OTHER'S PERSPECTIVE AND

1014
00:30:20,150 --> 00:30:21,985
CONFIRM AND VERIFY, AND I DON'T

1015
00:30:21,985 --> 00:30:23,319
KNOW HOW IT WAS, SURGEON, THIS

1016
00:30:23,319 --> 00:30:26,689
IS HOW I WAS THINKING FROM A

1017
00:30:26,689 --> 00:30:31,528
SURGICAL TECH PERSPECTIVE.

1018
00:30:31,528 --> 00:30:32,729
BUT THE REAL BEAUTY, WE GET

1019
00:30:32,729 --> 00:30:34,664
PEOPLE TO DO SOLUTION

1020
00:30:34,664 --> 00:30:35,265
DEVELOPMENT, GETTING PEOPLE AT

1021
00:30:35,265 --> 00:30:36,232
THE FRONT LINE COMING UP HOW TO

1022
00:30:36,232 --> 00:30:36,432
DO IT.

1023
00:30:36,432 --> 00:30:44,073
WE WILL TALK ABOUT THE CONCEPT 

1024
00:30:44,073 --> 00:30:46,309
OF WORK ISMAGEAGED VERSUS WORK

1025
00:30:46,309 --> 00:30:46,676
IS PREFORMED.

1026
00:30:46,676 --> 00:30:48,444
THE CENTRAL PART OF AN EVENT

1027
00:30:48,444 --> 00:30:49,212
REVIEW IS WHY.

1028
00:30:49,212 --> 00:30:51,581
THIS IS BASICALLY GETTING TO THE

1029
00:30:51,581 --> 00:30:51,981
WHY.

1030
00:30:51,981 --> 00:30:53,016
USING A SYSTEMS LENS AND TRYING

1031
00:30:53,016 --> 00:30:55,084
TO UNDERSTAND WHY IT HAPPEN AND

1032
00:30:55,084 --> 00:30:57,120
GOING THROUGH AND IDENTIFYING

1033
00:30:57,120 --> 00:30:58,254
WHAT ARE CALLED CONTRIBUTING

1034
00:30:58,254 --> 00:30:58,788
FACTORS.

1035
00:30:58,788 --> 00:31:01,457
WE USE THE BUCKETS RELIGIOUSLY.

1036
00:31:01,457 --> 00:31:02,091
COMMUNICATION, INFORMATION, WHAT

1037
00:31:02,091 --> 00:31:03,092
IS GOING ON THERE.

1038
00:31:03,092 --> 00:31:06,229
WE WILL GO INTO THESE IN DETAIL,

1039
00:31:06,229 --> 00:31:07,497
HUMAN FACTORS AND INFLUENCES.

1040
00:31:07,497 --> 00:31:08,731
POLICY AND PROCEDURES.

1041
00:31:08,731 --> 00:31:09,666
THE HUMAN BEINGS ININVOLVED AND

1042
00:31:09,666 --> 00:31:11,000
HOW THEY WERE TRAINED AND

1043
00:31:11,000 --> 00:31:12,635
WHETHER THEY ARE COMPETENT, AND

1044
00:31:12,635 --> 00:31:14,671
LEADERSHIP AND CULTURE, AND THEN

1045
00:31:14,671 --> 00:31:17,807
TECHNOLOGY AND THE ENVIRONMENT.

1046
00:31:17,807 --> 00:31:18,508
SO, COMMUNICATION INFORMATION

1047
00:31:18,508 --> 00:31:20,343
MANAGEMENT.

1048
00:31:20,343 --> 00:31:23,713
NUMBER ONE CAUSE OF ROOT CAUSES.

1049
00:31:23,713 --> 00:31:25,281
WE ALSO, YOU CAN ALSO CALL THIS

1050
00:31:25,281 --> 00:31:27,717
PROCESS ROOT CAUSE ANALYSIS.

1051
00:31:27,717 --> 00:31:30,587
WE USE IT AT MEDSTAR HEALTH, BUT

1052
00:31:30,587 --> 00:31:32,121
IT IS ESSENTIALLY A ROOT CALL

1053
00:31:32,121 --> 00:31:33,089
ANALYSIS.

1054
00:31:33,089 --> 00:31:34,924
SO, NUMBER ONE EVENTS WHEN THEY

1055
00:31:34,924 --> 00:31:37,660
DID ROOT CAUSE ANALYSIS FOR THE

1056
00:31:37,660 --> 00:31:38,228
JOINT COMMISSION IS

1057
00:31:38,228 --> 00:31:39,662
COMMUNICATION.

1058
00:31:39,662 --> 00:31:41,064
DO YOU HAVE ACCESS TO ALL OF THE

1059
00:31:41,064 --> 00:31:44,467
AVAILABLE INFORMATION THAT YOU

1060
00:31:44,467 --> 00:31:44,667
NEED?

1061
00:31:44,667 --> 00:31:45,501
IS YOUR EHR PROVIDE YOU WITH THE

1062
00:31:45,501 --> 00:31:47,904
INFORMATION IN A TIMELY AND

1063
00:31:47,904 --> 00:31:48,338
ACCURATE WAY?

1064
00:31:48,338 --> 00:31:50,506
HOW ARE PEOPLE COMMUNICATING

1065
00:31:50,506 --> 00:31:52,141
AMONGST THEMSELVES?

1066
00:31:52,141 --> 00:31:53,009
HOW ARE HANDOFFS HANDLED?

1067
00:31:53,009 --> 00:31:55,411
IS THERE A BIG HIERARCHY WHERE

1068
00:31:55,411 --> 00:31:59,415
BETWEEN MAYBE TRAINEES AND THEIR

1069
00:31:59,415 --> 00:32:00,483
ATTENDINGS OR NURSING

1070
00:32:00,483 --> 00:32:02,719
SUPERVISORS AND THE CLINICAL

1071
00:32:02,719 --> 00:32:03,086
RESEARCH NURSES?

1072
00:32:03,086 --> 00:32:04,654
THEN YOU WANT TO LOOK AT HUMAN

1073
00:32:04,654 --> 00:32:05,054
FACTORS.

1074
00:32:05,054 --> 00:32:06,089
WE JUST TALKED ABOUT HUMAN

1075
00:32:06,089 --> 00:32:08,458
FACTORS AND ALL OF THOSE

1076
00:32:08,458 --> 00:32:08,758
INFLUENCES.

1077
00:32:08,758 --> 00:32:11,995
HOW WE INTERACT WITH OUR

1078
00:32:11,995 --> 00:32:12,962
ENVIRONMENT, EQUIPMENT,

1079
00:32:12,962 --> 00:32:14,897
USABILITY, THINGS THAT HAPPEN TO

1080
00:32:14,897 --> 00:32:16,299
US AS HUMANS, STRESS, FATIGUE.

1081
00:32:16,299 --> 00:32:19,102
ALL OF THE COGNITIVE BIAS WE

1082
00:32:19,102 --> 00:32:21,371
TAKE TO DIAGNOSES, CONFIRMATION

1083
00:32:21,371 --> 00:32:23,106
BIAS, ANCHORING BIAS, AND THEN

1084
00:32:23,106 --> 00:32:24,841
OUR PATIENTS BRING A LOT TO THIS

1085
00:32:24,841 --> 00:32:25,842
WHOLE PICTURE.

1086
00:32:25,842 --> 00:32:27,610
BECAUSE DEPENDING ON THEIR

1087
00:32:27,610 --> 00:32:29,078
ACUITY, THEIR ENGAGEMENT, THEY

1088
00:32:29,078 --> 00:32:31,514
REALLY CAN PLAY A PART IN THEIR

1089
00:32:31,514 --> 00:32:32,715
SAFETY AS WELL.

1090
00:32:32,715 --> 00:32:33,516
POLICIES AND PROCEDURES.

1091
00:32:33,516 --> 00:32:35,451
DID WE HAVE THEM IN PLACE?

1092
00:32:35,451 --> 00:32:37,086
DO PEOPLE ACTUALLY PAY ATTENTION

1093
00:32:37,086 --> 00:32:37,353
TO THEM?

1094
00:32:37,353 --> 00:32:39,222
IT THERE A CULTURE THAT WE JUST

1095
00:32:39,222 --> 00:32:41,357
DON'T ADHERE TO THEM, IT IS HOW

1096
00:32:41,357 --> 00:32:42,525
WE HAVE ALWAYS DONE IT, I DON'T

1097
00:32:42,525 --> 00:32:43,760
CARE WHAT THE POLICY ACTUALLY

1098
00:32:43,760 --> 00:32:43,960
SAYS.

1099
00:32:43,960 --> 00:32:46,929
WHAT IS THE CULTURE AROUND THAT?

1100
00:32:46,929 --> 00:32:48,731
THIS BRINGS INTO THIS WORLD THIS

1101
00:32:48,731 --> 00:32:51,200
CONCEPT OF WORK IS IMAGINED

1102
00:32:51,200 --> 00:32:52,201
VERSUS WORK IS PERFORMED.

1103
00:32:52,201 --> 00:32:54,070
ONE WAS MY GUIDING PRINCIPLES.

1104
00:32:54,070 --> 00:32:56,306
SO, YOU KNOW, WORK IS IMAGINED

1105
00:32:56,306 --> 00:32:57,040
IS ALL THAT WONDERFUL WORK THAT

1106
00:32:57,040 --> 00:32:59,542
WE DO THAT IS SO WELL-DESIGNED

1107
00:32:59,542 --> 00:33:01,577
AND IT IS ALL SCIENCE-BASED AND

1108
00:33:01,577 --> 00:33:03,146
EVIDENCE-BASED WHICH IS ALL

1109
00:33:03,146 --> 00:33:04,147
WONDERFUL.

1110
00:33:04,147 --> 00:33:06,649
WHETHER YOU'RE DOING A CLINICAL

1111
00:33:06,649 --> 00:33:08,351
RESEARCH PROTOCOL AND DESIGNING

1112
00:33:08,351 --> 00:33:10,320
A RESEARCH PROTOCOL OR A

1113
00:33:10,320 --> 00:33:11,254
CLINICAL PRACTICE GUIDELINE OR

1114
00:33:11,254 --> 00:33:13,756
SOP FOR SOMETHING, YOU KNOW,

1115
00:33:13,756 --> 00:33:14,324
TYPICALLY OFTENTIMES REALLY

1116
00:33:14,324 --> 00:33:16,759
SMART PEOPLE GET IN A ROOM AND

1117
00:33:16,759 --> 00:33:18,094
DESIGN THIS WONDERFUL PROCESS,

1118
00:33:18,094 --> 00:33:20,963
YOU CAN SEE IN THIS CARTOON,

1119
00:33:20,963 --> 00:33:23,366
A-TO-B, EASY-PEASY, SEND IT OUT

1120
00:33:23,366 --> 00:33:24,267
THERE, EVERYONE WILL DO IT THE

1121
00:33:24,267 --> 00:33:25,301
SAME WAY.

1122
00:33:25,301 --> 00:33:26,636
BUT THE SMARTEST PERSON IN THIS

1123
00:33:26,636 --> 00:33:27,870
ROOM ACTUALLY OPENED THE DOOR

1124
00:33:27,870 --> 00:33:29,472
AND SAW THE PASTA BOWL THAT IS

1125
00:33:29,472 --> 00:33:31,541
HEALTHCARE OUTSIDE OF THAT DOOR

1126
00:33:31,541 --> 00:33:33,242
AND SAID, THERE'S NO WAY THIS

1127
00:33:33,242 --> 00:33:35,511
POLICY IS GOING TO HAPPEN LIKE

1128
00:33:35,511 --> 00:33:38,514
THAT AT 3:00 IN THE MORNING IN A

1129
00:33:38,514 --> 00:33:40,383
CRAZY ICU WHERE WE ONLY HAVE,

1130
00:33:40,383 --> 00:33:43,252
YOU KNOW, THREE NURSES AND 12

1131
00:33:43,252 --> 00:33:43,519
PATIENTS.

1132
00:33:43,519 --> 00:33:45,221
SO, THAT'S WORK IS IMAGINED.

1133
00:33:45,221 --> 00:33:46,756
AND WORK IS DONE.

1134
00:33:46,756 --> 00:33:48,191
AND WE NEED TO NOT HAVE A HUGE

1135
00:33:48,191 --> 00:33:48,691
GAP THERE.

1136
00:33:48,691 --> 00:33:51,327
THIS IS ONE OF THE BIGGEST

1137
00:33:51,327 --> 00:33:51,928
DOWNFALLS IN HEALTHCARE RIGHT

1138
00:33:51,928 --> 00:33:54,897
NOW IS THAT WE ARE, WE DESIGN

1139
00:33:54,897 --> 00:33:57,633
THINGS AS WE THINK THEY SHOULD

1140
00:33:57,633 --> 00:33:59,202
HAPPEN, BUT THEY CAN NEVER BE

1141
00:33:59,202 --> 00:34:00,336
IMPLEMENTED IN THE REAL WORLD.

1142
00:34:00,336 --> 00:34:01,938
I REALLY ENCOURAGE YOU TO GO

1143
00:34:01,938 --> 00:34:03,406
BACK TO YOUR SPACES AND THINK

1144
00:34:03,406 --> 00:34:05,441
ABOUT PLACES WHERE THIS HAPPENS.

1145
00:34:05,441 --> 00:34:08,711
IT IS A FASCINATING EXERCISE.

1146
00:34:08,711 --> 00:34:09,345
OKAY, HUMAN RESOURCES, TRAINING

1147
00:34:09,345 --> 00:34:09,712
AND COMPETENCY.

1148
00:34:09,712 --> 00:34:11,147
DO WE HAVE THE RIGHT PEOPLE ON

1149
00:34:11,147 --> 00:34:13,383
THE BUS DOING THE RIGHT WORK.

1150
00:34:13,383 --> 00:34:13,883
AND TRAINING PEOPLE, AND

1151
00:34:13,883 --> 00:34:15,518
ACTUALLY KNOW THEY ARE DOING THE

1152
00:34:15,518 --> 00:34:16,352
WORK WELL THAT WHY TRAINED THEM

1153
00:34:16,352 --> 00:34:17,553
TO DO.

1154
00:34:17,553 --> 00:34:19,589
DO WE HAVE GOOD SUMMER VISION?

1155
00:34:19,589 --> 00:34:21,157
OR TRAINEES AND FOLKS OUT THERE

1156
00:34:21,157 --> 00:34:23,059
DOING WHAT THEY WANT TO DO.

1157
00:34:23,059 --> 00:34:24,560
IN 2024 STAFFING, AT LEAST OUT

1158
00:34:24,560 --> 00:34:27,363
IN THE WORLD WHERE I LIVE, IS

1159
00:34:27,363 --> 00:34:27,697
REALLY TOUGH.

1160
00:34:27,697 --> 00:34:30,366
WE MAY HAVE ENOUGH HUMANS AT THE

1161
00:34:30,366 --> 00:34:32,502
BEDSIDE, BUT THOSE NURSES AND

1162
00:34:32,502 --> 00:34:34,070
PHARMACISTS AND RESPIRATORY

1163
00:34:34,070 --> 00:34:34,771
THEORISTS, SOME OF THEM ARE

1164
00:34:34,771 --> 00:34:36,439
STRAIGHT OUT OF SCHOOL.

1165
00:34:36,439 --> 00:34:39,242
AND REMEMBER, A LOT OF THEM WERE

1166
00:34:39,242 --> 00:34:40,376
TRAINED DURING COVID.

1167
00:34:40,376 --> 00:34:41,611
SO THEY GOT VERY LITTLE CLINICAL

1168
00:34:41,611 --> 00:34:41,811
WORK.

1169
00:34:41,811 --> 00:34:44,714
AND IT CAN BE REALLY SCARY ON A

1170
00:34:44,714 --> 00:34:47,016
NIGHT SHIFT IN A REALLY BUSY

1171
00:34:47,016 --> 00:34:49,118
WARD WHERE WE HAVE REALLY

1172
00:34:49,118 --> 00:34:49,585
INEXPERIENCED FOLKS.

1173
00:34:49,585 --> 00:34:51,554
WE DON'T HAVE THAT MUSCLE

1174
00:34:51,554 --> 00:34:51,788
MEMORY.

1175
00:34:51,788 --> 00:34:53,723
SO SOMETHING STARTS TO HAPPEN, A

1176
00:34:53,723 --> 00:34:56,058
CODE IN THE MIDDLE OF THE NIGHT,

1177
00:34:56,058 --> 00:34:56,759
NOBODY ON THAT FLOOR MANAGED A

1178
00:34:56,759 --> 00:34:57,260
CODE.

1179
00:34:57,260 --> 00:34:58,694
I THINK WE HAVE TO START

1180
00:34:58,694 --> 00:35:00,563
THINKING ABOUT THAT IN TERMS OF

1181
00:35:00,563 --> 00:35:01,898
SAFETY AS WELL.

1182
00:35:01,898 --> 00:35:02,398
LEADERSHIP AND CULTURE.

1183
00:35:02,398 --> 00:35:04,333
THIS IS THE HEARTEDDEST ONE.

1184
00:35:04,333 --> 00:35:06,969
BASICALLY HOW WELL DO WE DO WITH

1185
00:35:06,969 --> 00:35:08,638
SAFETY CULTURE.

1186
00:35:08,638 --> 00:35:09,705
DO WE HAVE A KNOWLEDGE PUNITIVE

1187
00:35:09,705 --> 00:35:10,673
ENVIRONMENT WHEN PEOPLE WANT TO

1188
00:35:10,673 --> 00:35:11,841
TALK ABOUT SAFETY.

1189
00:35:11,841 --> 00:35:13,609
WHAT IS THE INFLUENCE OF

1190
00:35:13,609 --> 00:35:14,444
HIERARCHY.

1191
00:35:14,444 --> 00:35:15,678
WE WILL TALK ABOUT HEALTH EQUITY

1192
00:35:15,678 --> 00:35:17,580
AND THINGS LIKE THAT.

1193
00:35:17,580 --> 00:35:18,681
AND THEN, TECHNOLOGY AND

1194
00:35:18,681 --> 00:35:18,948
EQUIPMENT.

1195
00:35:18,948 --> 00:35:20,283
DO WE HAVE THE TECHNOLOGY WE

1196
00:35:20,283 --> 00:35:27,490
NEED THIS IS  IT UP DATE?

1197
00:35:27,490 --> 00:35:29,425
AND DONE THE PREVENTIVE AND

1198
00:35:29,425 --> 00:35:29,692
USABILITY.

1199
00:35:29,692 --> 00:35:30,760
AND FINALLY THE PHYSICAL

1200
00:35:30,760 --> 00:35:32,195
ENVIRONMENT, WITH OUR NEW SPACE

1201
00:35:32,195 --> 00:35:34,530
ARE WE ACTUALLY DESIGNING THAT

1202
00:35:34,530 --> 00:35:35,465
SPACE FOR SAFETY?

1203
00:35:35,465 --> 00:35:39,001
OR ARE WE DESIGNING IT IT FOR

1204
00:35:39,001 --> 00:35:40,269
THE CONVENIENCE OF THE HUMANS

1205
00:35:40,269 --> 00:35:41,103
DOING RESEARCH PROTOCOLS.

1206
00:35:41,103 --> 00:35:42,638
IT IS A BIT OF A TENSION

1207
00:35:42,638 --> 00:35:43,706
SOMETIMES.

1208
00:35:43,706 --> 00:35:45,842
SO, I'M GOING TO JUST TAKE YOU

1209
00:35:45,842 --> 00:35:46,709
THROUGH A CASE.

1210
00:35:46,709 --> 00:35:49,879
YOU CAN SEE THE IMPORTANCE OF

1211
00:35:49,879 --> 00:35:52,348
FIGURING OUT THE CONTRIBUTING

1212
00:35:52,348 --> 00:35:53,583
FACTORS.

1213
00:35:53,583 --> 00:35:56,018
AND A NURSE ADMINISTERED A

1214
00:35:56,018 --> 00:35:56,919
FIVEFOLD DOSE OF CHEMOTHERAPY.

1215
00:35:56,919 --> 00:36:00,356
WHEN THEY LOOKED INTO IT, THE

1216
00:36:00,356 --> 00:36:02,892
NURLS DIDN'T USE MEDICATION

1217
00:36:02,892 --> 00:36:04,126
BARCODE SCANNING AND DIDN'T DO

1218
00:36:04,126 --> 00:36:05,428
AN INDEPENDENT DOUBLE CHECK THAT

1219
00:36:05,428 --> 00:36:09,632
YOU NEED TO DO WITH A HIGH ALERT

1220
00:36:09,632 --> 00:36:10,233
MEDICATION.

1221
00:36:10,233 --> 00:36:14,337
SO IN SOME ORGANIZATIONS, A

1222
00:36:14,337 --> 00:36:16,239
PERFORMANCE IMPROVEMENT PLAN, OR

1223
00:36:16,239 --> 00:36:18,341
REORGANIZATION HER, OR FIRE HER,

1224
00:36:18,341 --> 00:36:19,075
DEPENDING ON THE ORGANIZATION,

1225
00:36:19,075 --> 00:36:21,944
BECAUSE WE'RE TRYING TO BE HIGH

1226
00:36:21,944 --> 00:36:24,313
RELIABILITY, AND SENSITIVE TO

1227
00:36:24,313 --> 00:36:25,982
OPERATIONS, WE ASK THE SERIAL

1228
00:36:25,982 --> 00:36:26,682
WHYS.

1229
00:36:26,682 --> 00:36:28,718
WHEN THEY DID THAT IT IS A

1230
00:36:28,718 --> 00:36:29,952
DIFFERENT PICTURE.

1231
00:36:29,952 --> 00:36:31,654
THE WI-FI IS UNRELIABLE.

1232
00:36:31,654 --> 00:36:32,588
HALF OF THE TIME MY SCANNER

1233
00:36:32,588 --> 00:36:34,056
DIDN'T WORK.

1234
00:36:34,056 --> 00:36:35,291
WHAT IS THE USE OF TAKING IT.

1235
00:36:35,291 --> 00:36:38,895
BY THE WAY, THEY ARE MISSING,

1236
00:36:38,895 --> 00:36:40,363
LOST, OR THE DARNEL NIGHT NURSES

1237
00:36:40,363 --> 00:36:42,765
DIDN'T PUT THEM ON THE DOCKING

1238
00:36:42,765 --> 00:36:44,133
STATION, SO THERE IS NO CHARGE

1239
00:36:44,133 --> 00:36:46,035
AT 8:00 MEDS.

1240
00:36:46,035 --> 00:36:46,869
THERE IS NO ADVANTAGE OR

1241
00:36:46,869 --> 00:36:48,304
INCENTIVE TO USE IT.

1242
00:36:48,304 --> 00:36:49,572
THE SENIOR FOLKS WERE NOT USING

1243
00:36:49,572 --> 00:36:51,741
IT FOR THE ABOVE REASONS.

1244
00:36:51,741 --> 00:36:52,942
THIS IS A NEW NURSE, SHE DIDN'T

1245
00:36:52,942 --> 00:36:54,377
GET A LOT OF TRAINING IN IT.

1246
00:36:54,377 --> 00:36:56,812
THAT SORT OF PAINTS A DIFFERENT

1247
00:36:56,812 --> 00:36:57,380
PICTURE.

1248
00:36:57,380 --> 00:36:58,948
WHAT ABOUT INDEPENDENT DOUBLE

1249
00:36:58,948 --> 00:36:59,181
CHECKS?

1250
00:36:59,181 --> 00:37:01,450
THIS NURSE HAD FOUR OTHER HIGH

1251
00:37:01,450 --> 00:37:02,451
ACUITY PATIENTS, SOMEONE COMES

1252
00:37:02,451 --> 00:37:04,153
BACK FROM AN EXTENSIVE

1253
00:37:04,153 --> 00:37:04,420
PROCEDURE.

1254
00:37:04,420 --> 00:37:06,155
THERE IS A LOT GOING ON FOR HER

1255
00:37:06,155 --> 00:37:07,023
TO GET INTO THAT ROOM.

1256
00:37:07,023 --> 00:37:11,360
AND OH, BY THE WAY, THE PATIENT

1257
00:37:11,360 --> 00:37:13,696
WAS ON ISOLATION, AND DAWN

1258
00:37:13,696 --> 00:37:14,497
ON-AND-OFF PPE WHEN SHE WENT IN

1259
00:37:14,497 --> 00:37:15,097
THERE.

1260
00:37:15,097 --> 00:37:16,966
I DON'T KNOW IF YOU HAVE TAKEN

1261
00:37:16,966 --> 00:37:19,502
CARE OF AN ISOLATION PATIENT,

1262
00:37:19,502 --> 00:37:21,671
AND ASKING A FELLOW NURSE TO DO

1263
00:37:21,671 --> 00:37:23,039
AN INDEPENDENT DOUBLE CHECK.

1264
00:37:23,039 --> 00:37:23,372
THEY SCATTER.

1265
00:37:23,372 --> 00:37:24,640
ANYBODY CAN HELP ME, BUT THERE

1266
00:37:24,640 --> 00:37:28,477
IS NOBODY ON THE UNIT.

1267
00:37:28,477 --> 00:37:31,314
SHE COULDN'T REAL ON A REGULAR

1268
00:37:31,314 --> 00:37:33,549
BASIS, BE CERTAIN THERE WAS

1269
00:37:33,549 --> 00:37:33,983
SOMEONE TO HELP US.

1270
00:37:33,983 --> 00:37:36,319
THIS WAS NOT A BAD NURSE.

1271
00:37:36,319 --> 00:37:37,386
THIS IS BAD LEADERSHIP.

1272
00:37:37,386 --> 00:37:38,888
BAD SYSTEM.

1273
00:37:38,888 --> 00:37:40,256
WHAT WE HAVE DONE IS SUCK THIS

1274
00:37:40,256 --> 00:37:43,059
POOR NURSE UP TO DO NOT HER BEST

1275
00:37:43,059 --> 00:37:43,492
WORK.

1276
00:37:43,492 --> 00:37:45,661
WHICH SHE CAME TO WORK TO DO

1277
00:37:45,661 --> 00:37:46,295
EVERY DAY.

1278
00:37:46,295 --> 00:37:48,297
YOU THINK ABOUT THOSE

1279
00:37:48,297 --> 00:37:49,565
CONTRIBUTING FACTORS IT HITS

1280
00:37:49,565 --> 00:37:50,099
ALMOST EVERY ONE OF THESE.

1281
00:37:50,099 --> 00:37:51,667
IF YOU DIDN'T TAKE THE TIME TO

1282
00:37:51,667 --> 00:37:53,569
BE VERY DELIBERATE IN DOING

1283
00:37:53,569 --> 00:37:54,904
THIS, YOU WOULD MISS THE MARK.

1284
00:37:54,904 --> 00:37:57,440
YOU DON'T HAVE TO DO THIS IN THE

1285
00:37:57,440 --> 00:37:59,775
CONTEXT OF A FORMAL ROOT CAUSE

1286
00:37:59,775 --> 00:38:00,176
ANALYSIS.

1287
00:38:00,176 --> 00:38:00,910
SOMETHING COMES UP IN YOUR

1288
00:38:00,910 --> 00:38:03,245
ENVIRONMENT, PULL THIS PIECE OF

1289
00:38:03,245 --> 00:38:04,714
PAPER OUT AND SAY, OKAY, WERE

1290
00:38:04,714 --> 00:38:06,849
THERE COMMUNICATION ISSUES?

1291
00:38:06,849 --> 00:38:07,783
AND THE POLICY CONFUSING?

1292
00:38:07,783 --> 00:38:08,651
WAS THE ENVIRONMENT WEIRD?

1293
00:38:08,651 --> 00:38:10,386
YOU CAN DO THIS IN THE CONTEXT

1294
00:38:10,386 --> 00:38:11,854
OF A CLINICAL EVENT.

1295
00:38:11,854 --> 00:38:18,060
YOU HAVE A DEVIATION OR A SAE,

1296
00:38:18,060 --> 00:38:19,962
IS IT SAE, DID I PULL THAT OUT

1297
00:38:19,962 --> 00:38:20,363
OF MY BRAIN?

1298
00:38:20,363 --> 00:38:20,563
OKAY.

1299
00:38:20,563 --> 00:38:23,466
IN THE CONTEXT OF A RESEARCH

1300
00:38:23,466 --> 00:38:24,600
PROJECT, YOU CAN USE THIS SAME

1301
00:38:24,600 --> 00:38:26,802
METHODOLOGY TO MAKE SURE THAT

1302
00:38:26,802 --> 00:38:29,038
YOU'RE JUST NOT POINTING FINGER

1303
00:38:29,038 --> 00:38:30,239
IN THE WRONG DIRECTION.

1304
00:38:30,239 --> 00:38:32,408
WHEN THERE SHOULD BE NO FINGER

1305
00:38:32,408 --> 00:38:34,877
POINTING AT ALL.

1306
00:38:34,877 --> 00:38:37,647
WE'RE STARTING TO EMBED EQUITY

1307
00:38:37,647 --> 00:38:40,282
INQUIRY INTO OUR EVENT REVIEWS.

1308
00:38:40,282 --> 00:38:40,850
SO IF WE ASK ABOUT

1309
00:38:40,850 --> 00:38:42,451
COMMUNICATION, WE THINK ABOUT

1310
00:38:42,451 --> 00:38:43,119
COMMUNICATION ISSUES, MAYBE

1311
00:38:43,119 --> 00:38:44,453
WE'RE ASKING AND LOOKING INTO

1312
00:38:44,453 --> 00:38:46,222
LITERACY LEVEL.

1313
00:38:46,222 --> 00:38:47,156
WAS THERE A LITERACY ISSUES THAT

1314
00:38:47,156 --> 00:38:48,658
COULD HAVE BEEN IN PLAY FOR A

1315
00:38:48,658 --> 00:38:49,759
PATIENT.

1316
00:38:49,759 --> 00:38:50,960
MAYBE THEY DIDN'T UNDERSTAND THE

1317
00:38:50,960 --> 00:38:54,130
INFORMATION WE GAVE AND THERE

1318
00:38:54,130 --> 00:38:55,865
FORE, THEY DIDN'T TAKE THEIR

1319
00:38:55,865 --> 00:38:57,967
MEDICATION AND HAD AN EVENT.

1320
00:38:57,967 --> 00:38:59,702
OR PSYCHOLOGICAL SAFETY IN THE

1321
00:38:59,702 --> 00:39:01,837
TEAM TO ESCALATE ISSUE TO IT

1322
00:39:01,837 --> 00:39:02,872
PERSON WITH THE MANY LETTERS

1323
00:39:02,872 --> 00:39:04,106
BEHIND THEIR NAMES.

1324
00:39:04,106 --> 00:39:06,442
FROM A POLICIES AND PROCEDURES,

1325
00:39:06,442 --> 00:39:08,678
ARE WE STILL USING CLINICAL

1326
00:39:08,678 --> 00:39:14,216
ALGORITHMS THAT USE RACE AS A

1327
00:39:14,216 --> 00:39:15,317
BIOLOGICAL KAJ STRUCK LIKE

1328
00:39:15,317 --> 00:39:18,587
KIDNEY FUNCTION, WE NEED TO GET

1329
00:39:18,587 --> 00:39:20,222
THOSE OUT OR OUR PLAYBOOK.

1330
00:39:20,222 --> 00:39:22,258
LEADERSHIP AND CULTURE, LOOK AT

1331
00:39:22,258 --> 00:39:24,226
MODELING.

1332
00:39:24,226 --> 00:39:25,361
PHYSICAL ENVIRONMENT AND

1333
00:39:25,361 --> 00:39:28,230
EQUIPMENT, ADA COMPLIANT, THINGS

1334
00:39:28,230 --> 00:39:29,298
LIKE TEMPORAL THERMOMETERS AND

1335
00:39:29,298 --> 00:39:31,567
SKIN TONE, ALL OF THESE THINGS

1336
00:39:31,567 --> 00:39:32,968
COME INTO PLAY, WE REALLY NEED

1337
00:39:32,968 --> 00:39:34,537
TO LOOK AT THEM.

1338
00:39:34,537 --> 00:39:37,039
HUMAN RESOURCES, WHAT'S THE

1339
00:39:37,039 --> 00:39:37,873
DIVERSITY OF OUR CARE TEACH LOOK

1340
00:39:37,873 --> 00:39:38,140
LIKE?

1341
00:39:38,140 --> 00:39:40,609
A PLACE WHERE EVERYBODY FEELS

1342
00:39:40,609 --> 00:39:41,177
SAFE AND COMFORTABLE WITHIN

1343
00:39:41,177 --> 00:39:41,610
THEIR TEAMS?

1344
00:39:41,610 --> 00:39:45,581
AND THEN FINALLY, WITH HUMAN

1345
00:39:45,581 --> 00:39:46,415
FACTORS AND INFLUENCES, THOSE

1346
00:39:46,415 --> 00:39:48,784
IMPLICIT BIASES IT IS ABOUT RACE

1347
00:39:48,784 --> 00:39:51,220
AND ETHNICITY OR LANGUAGE OR

1348
00:39:51,220 --> 00:39:53,689
SUBSTANCE ABUSE, MENTAL HEALTH

1349
00:39:53,689 --> 00:39:53,923
ISSUES.

1350
00:39:53,923 --> 00:39:57,393
SO WE'RE STARTING TO LOOK AT HOW

1351
00:39:57,393 --> 00:39:58,794
EQUITY ISSUES HAVE A PLAY IN

1352
00:39:58,794 --> 00:40:02,898
THE -- CAUSE OF SAFETY EVENT,

1353
00:40:02,898 --> 00:40:03,799
BUT ALSO MAYBE HOW WE'RE

1354
00:40:03,799 --> 00:40:05,234
RESPONDING AS WELL.

1355
00:40:05,234 --> 00:40:05,434
OKAY.

1356
00:40:05,434 --> 00:40:08,404
WE HAVE TAKEN A LOOK BACK AT

1357
00:40:08,404 --> 00:40:08,871
WHEN AN EVENT OCCURS.

1358
00:40:08,871 --> 00:40:10,372
WE KNOW A LITTLE BIT ABOUT THE

1359
00:40:10,372 --> 00:40:13,509
SCIENCE BEHIND HOW TO KEEP THEM

1360
00:40:13,509 --> 00:40:14,810
FROM HAPPENING IN THE FUTURE.

1361
00:40:14,810 --> 00:40:19,081
BUT WE WANT TO GO IN HEALTHCARE

1362
00:40:19,081 --> 00:40:20,149
IS REALLY NOT HAVING ANY HARM AT

1363
00:40:20,149 --> 00:40:20,316
ALL.

1364
00:40:20,316 --> 00:40:22,651
WHICH MEANS WE HAVE TO START

1365
00:40:22,651 --> 00:40:23,819
LOOKING FOR RISKS BEFORE IT EVEN

1366
00:40:23,819 --> 00:40:25,020
HAPPENS.

1367
00:40:25,020 --> 00:40:26,288
WHICH WE DON'T HAVE TIME IN OUR

1368
00:40:26,288 --> 00:40:28,390
LIVES TO LOOK INTO BAD THINGS

1369
00:40:28,390 --> 00:40:30,126
THAT HAPPEN, BUT WE NEED TO

1370
00:40:30,126 --> 00:40:34,029
START CARVING OUT TIME TO DO

1371
00:40:34,029 --> 00:40:34,697
THIS PROACTIVE AND PERSPECTIVE

1372
00:40:34,697 --> 00:40:35,264
RISK ASSESSMENT.

1373
00:40:35,264 --> 00:40:37,533
SO, THIS IS A FRAMEWORK THAT WE

1374
00:40:37,533 --> 00:40:38,501
USE.

1375
00:40:38,501 --> 00:40:41,937
IT'S SORT OF A CONTINUUM OF

1376
00:40:41,937 --> 00:40:43,606
REACTIVE TO PROACTIVE.

1377
00:40:43,606 --> 00:40:45,307
WE LIVE IN THIS, FOR HEALTHCARE

1378
00:40:45,307 --> 00:40:47,376
IN GENERAL, FOR THE MOST PART,

1379
00:40:47,376 --> 00:40:49,612
LIVE IN SORT OF TERTIARY AREA,

1380
00:40:49,612 --> 00:40:51,747
ON THE RIGHT-HAND SIDE.

1381
00:40:51,747 --> 00:40:52,081
VERY REACTIVE.

1382
00:40:52,081 --> 00:40:53,215
WE HAVE GOTTEN GOOD AT

1383
00:40:53,215 --> 00:40:53,983
IDENTIFYING EVENTS.

1384
00:40:53,983 --> 00:40:56,852
WE HAVE GOTTEN PRETTY GOOD AT

1385
00:40:56,852 --> 00:40:57,753
ANALYZING EVENTS.

1386
00:40:57,753 --> 00:40:58,487
AND WE'RE PRETTY GOOD AT

1387
00:40:58,487 --> 00:40:59,822
DEVELOPING SOLUTIONS.

1388
00:40:59,822 --> 00:41:01,490
NOT AS GOOD AS SHARING THE

1389
00:41:01,490 --> 00:41:03,092
SOLUTIONS AND WHAT WE DID TO FIX

1390
00:41:03,092 --> 00:41:03,492
THINGS.

1391
00:41:03,492 --> 00:41:04,493
BUT WE'RE PRETTY COMFORTABLE

1392
00:41:04,493 --> 00:41:05,127
THERE.

1393
00:41:05,127 --> 00:41:07,663
BUT THINGS ARE STILL HAPPENING.

1394
00:41:07,663 --> 00:41:08,631
HARM IS STILL HAPPENING.

1395
00:41:08,631 --> 00:41:09,632
THE DATA SHOWS US THAT.

1396
00:41:09,632 --> 00:41:13,435
SO WHAT WE WANT TO DO IS MOVE

1397
00:41:13,435 --> 00:41:14,904
FURTHER TO THE LEFT HERE AND

1398
00:41:14,904 --> 00:41:16,238
BECOME MORE AND MORE PROACTIVE.

1399
00:41:16,238 --> 00:41:18,073
WE'RE GETTING GOOD AT

1400
00:41:18,073 --> 00:41:19,675
IDENTIFYING PROBLEMS AND

1401
00:41:19,675 --> 00:41:20,209
MITIGATING EXISTING RISKS.

1402
00:41:20,209 --> 00:41:25,681
WE KNOW THIS IS GOING TO HAPPEN,

1403
00:41:25,681 --> 00:41:27,683
LET'S PUT IN PLACE A STOPPING

1404
00:41:27,683 --> 00:41:28,651
THIS FROM HAPPENING, BUT WE WANT

1405
00:41:28,651 --> 00:41:30,553
TO DESIGN SAFETY INTO NEW

1406
00:41:30,553 --> 00:41:30,820
PROCESSES.

1407
00:41:30,820 --> 00:41:32,221
SO THE MINUTE WE DECIDE WE HAVE

1408
00:41:32,221 --> 00:41:33,956
AN IDEA ABOUT A NEW PROCESS WE

1409
00:41:33,956 --> 00:41:36,492
WANT TO PUT IN OR BUILDING WE

1410
00:41:36,492 --> 00:41:38,060
WANT TO BUILD, WE IMMEDIATELY

1411
00:41:38,060 --> 00:41:40,162
START DESIGNING SAFETY INTO IT

1412
00:41:40,162 --> 00:41:41,096
AND IDENTIFYING RISKS BEFORE

1413
00:41:41,096 --> 00:41:41,697
SOMETHING HAPPENS.

1414
00:41:41,697 --> 00:41:42,932
WE'RE GOING TO TALK A LITTLE BIT

1415
00:41:42,932 --> 00:41:44,500
ABOUT HOW YOU DO THAT.

1416
00:41:44,500 --> 00:41:46,368
YOU CAN DO THIS -- RISKS

1417
00:41:46,368 --> 00:41:47,736
ASSOCIATED WITH CLINICAL CARE,

1418
00:41:47,736 --> 00:41:49,638
BUT WE ALSO DO IT WITH RISKS

1419
00:41:49,638 --> 00:41:51,006
ASSOCIATED WITH CLINICAL

1420
00:41:51,006 --> 00:41:51,874
RESEARCH.

1421
00:41:51,874 --> 00:41:54,076
AND THESE ARE COUPLE EXAMPLES OF

1422
00:41:54,076 --> 00:41:56,478
WHERE WE USED A PROACTIVE RISK

1423
00:41:56,478 --> 00:41:59,081
ASSESSMENT OR ANOTHER NAME IS A

1424
00:41:59,081 --> 00:42:00,115
FAILURE MODES AND EFFECTS

1425
00:42:00,115 --> 00:42:02,718
ANALYSIS TO LOOK FOR RISKS IN

1426
00:42:02,718 --> 00:42:06,188
NEW PROCEDURES, IN THIS CASE, A

1427
00:42:06,188 --> 00:42:06,956
COUPLE OF PROTOCOLS, BEFORE THEY

1428
00:42:06,956 --> 00:42:10,092
WERE EVER LAUNCHED.

1429
00:42:10,092 --> 00:42:12,862
YOU CAN SEE TARA THERE IN HER

1430
00:42:12,862 --> 00:42:13,629
GRAB, EBOLA GARB.

1431
00:42:13,629 --> 00:42:15,798
DID A LOT OF WORK WITH HES

1432
00:42:15,798 --> 00:42:17,867
TRYING TO FIGURE OUT WHERE BAD

1433
00:42:17,867 --> 00:42:20,236
THINGS CAN HAPPEN, WITH MICHELLE

1434
00:42:20,236 --> 00:42:21,337
EVANS, WHERE BAD THINGS CAN

1435
00:42:21,337 --> 00:42:23,272
HAPPEN BRINGS THE PATIENTS INTO

1436
00:42:23,272 --> 00:42:25,808
THE REALLY COMPLEX ENVIRONMENT.

1437
00:42:25,808 --> 00:42:27,910
WE INTRODUCED A PROTOCOL.

1438
00:42:27,910 --> 00:42:30,579
WHERE WERE CREWS HEPATIC

1439
00:42:30,579 --> 00:42:31,547
INFUSIONS ARTERIAL PUMPS.

1440
00:42:31,547 --> 00:42:32,781
THEY WITHER NOT USED HERE

1441
00:42:32,781 --> 00:42:33,382
BEFORE.

1442
00:42:33,382 --> 00:42:35,150
AND WE ARE THE CLINICAL CENTER.

1443
00:42:35,150 --> 00:42:36,986
WE CAN PRETTY MUCH DO ANYTHING.

1444
00:42:36,986 --> 00:42:38,554
IT IS GOOD TO TAKE A PAUSE, WE

1445
00:42:38,554 --> 00:42:40,723
FOUND A COUPLE OF THINGS WE

1446
00:42:40,723 --> 00:42:42,625
COULD PROBABLY IMPROVE ON.

1447
00:42:42,625 --> 00:42:45,461
AND DID WORK AROUND NIMH AROUND

1448
00:42:45,461 --> 00:42:46,595
THE NEUROBIOLOGY OF SUICIDE.

1449
00:42:46,595 --> 00:42:48,364
THIS TOOL IS REALLY, REALLY

1450
00:42:48,364 --> 00:42:50,099
USEFUL IN THE CONTEXT OF

1451
00:42:50,099 --> 00:42:50,966
CLINICAL RESEARCH.

1452
00:42:50,966 --> 00:42:53,869
SO A PROACTIVE RISK ASSESSMENT

1453
00:42:53,869 --> 00:42:54,436
OR FMEA.

1454
00:42:54,436 --> 00:42:56,238
IS A SYSTEMATIC ANALYSIS OF A

1455
00:42:56,238 --> 00:42:57,573
PROCESS IN ORDER TO IDENTIFY ALL

1456
00:42:57,573 --> 00:42:59,141
OF THE BAD THINGS THAT CAN

1457
00:42:59,141 --> 00:43:00,309
HAPPEN WITH IT.

1458
00:43:00,309 --> 00:43:02,645
ARE SO IF YOU HAVE A LITTLE BIT

1459
00:43:02,645 --> 00:43:05,347
OF INNER EEYORE, YOU KNOW THE

1460
00:43:05,347 --> 00:43:06,315
CHARACTER IN WINNIE THE POOH

1461
00:43:06,315 --> 00:43:07,850
THAT THINKS THE WORLD IS ALL

1462
00:43:07,850 --> 00:43:09,285
GRAY AND THE GLASS HALF FULL,

1463
00:43:09,285 --> 00:43:10,920
YOU GET TO SIGN, YOUR JOB IS TO

1464
00:43:10,920 --> 00:43:13,522
COME IN AND TELL ALL OF YOUR

1465
00:43:13,522 --> 00:43:14,390
COLLEAGUES HOW BAD THEIR IDEA

1466
00:43:14,390 --> 00:43:15,591
WAS SO WE CAN FIND ALL OF THE

1467
00:43:15,591 --> 00:43:17,359
THINGS WE NEED TO FIX BEFORE IT

1468
00:43:17,359 --> 00:43:17,826
GOES LIVE.

1469
00:43:17,826 --> 00:43:20,029
THE REASON YOU WANT TO DO THAT.

1470
00:43:20,029 --> 00:43:22,531
YOU HAVE THE LUXURY OF THEN

1471
00:43:22,531 --> 00:43:24,333
ELIMINATING OR MINIMIZING THAT

1472
00:43:24,333 --> 00:43:25,868
RISK OR IF THAT RISK IS STILL

1473
00:43:25,868 --> 00:43:27,703
GOING TO BE THERE, AND SOMETIMES

1474
00:43:27,703 --> 00:43:30,072
WE HAVE TO ACCEPT THE RISK,

1475
00:43:30,072 --> 00:43:30,973
CERTAINLY IN THIS ENVIRONMENT,

1476
00:43:30,973 --> 00:43:32,508
WE'RE DOING PROOF OF PRINCIPLE

1477
00:43:32,508 --> 00:43:34,476
STUDIES, YOU ACCEPT A LOT OF

1478
00:43:34,476 --> 00:43:35,878
RISK, BUT YOU NEED TO BUILD

1479
00:43:35,878 --> 00:43:36,812
RESILIENCY INTO IT.

1480
00:43:36,812 --> 00:43:38,480
IF THERE IS A RISK OUT THERE,

1481
00:43:38,480 --> 00:43:40,783
WHAT ARE WE GOING TO DO IF THAT

1482
00:43:40,783 --> 00:43:43,686
HAPPENS, AND IDENTIFY IT EARLIER

1483
00:43:43,686 --> 00:43:44,987
BEFORE IT BECOMES CATASTROPHIC.

1484
00:43:44,987 --> 00:43:46,755
THESE ARE COME EXAMPLES OF WHERE

1485
00:43:46,755 --> 00:43:47,589
WE USED THIS PROACTIVE PAUSE AT

1486
00:43:47,589 --> 00:43:48,924
MEDSTAR HEALTH IN THE LAST YEAR

1487
00:43:48,924 --> 00:43:50,592
AND A HALF OR SO.

1488
00:43:50,592 --> 00:43:52,695
AGAIN, THE GOAL IS JUST TO FIND

1489
00:43:52,695 --> 00:43:53,929
BAD THINGS THAT HAPPEN BEFORE

1490
00:43:53,929 --> 00:43:56,031
THEY ACTUALLY HAPPEN.

1491
00:43:56,031 --> 00:43:57,232
SO EVERYTHING FROM LOOKING AT

1492
00:43:57,232 --> 00:44:00,002
NEW TELEMETRY AND RESPIRATORY

1493
00:44:00,002 --> 00:44:01,937
MONITORING EQUIPMENT TO OUR

1494
00:44:01,937 --> 00:44:03,305
HELICOPTER GUYS AND LADIES AND

1495
00:44:03,305 --> 00:44:06,976
MEN, AND WANTED TO USE, PUT MORE

1496
00:44:06,976 --> 00:44:08,410
ECMO AND BYPASS EQUIPMENTS ONTO

1497
00:44:08,410 --> 00:44:10,012
A SMALLER HELICOPTER.

1498
00:44:10,012 --> 00:44:11,847
AND WE REALIZED THAT IF THEY DID

1499
00:44:11,847 --> 00:44:13,282
THAT, NOBODY WOULD BE ABLE TO

1500
00:44:13,282 --> 00:44:14,850
GET TO THE PATIENT.

1501
00:44:14,850 --> 00:44:17,586
THEY TRASHED THAT IDEAS AND

1502
00:44:17,586 --> 00:44:18,120
STARTED AGAIN.

1503
00:44:18,120 --> 00:44:18,988
VIRTUAL NURSING.

1504
00:44:18,988 --> 00:44:21,123
I DON'T KNOW IF THE NURSING

1505
00:44:21,123 --> 00:44:22,825
DEPARTMENT IS THINKING ABOUT

1506
00:44:22,825 --> 00:44:23,492
VIRTUAL NURSING.

1507
00:44:23,492 --> 00:44:24,393
THAT RAISED MY BLOOD PRESSURE A

1508
00:44:24,393 --> 00:44:24,560
LOT.

1509
00:44:24,560 --> 00:44:27,763
WE ARE LOOKING INTO THAT.

1510
00:44:27,763 --> 00:44:29,932
WE HAVE AN IMRI, MRI IN THE

1511
00:44:29,932 --> 00:44:32,835
NEW -- OPERATING ROOMS IN THE

1512
00:44:32,835 --> 00:44:35,237
STANDING PAVILION.

1513
00:44:35,237 --> 00:44:37,439
AND HAVING GONE, HAVING BEEN

1514
00:44:37,439 --> 00:44:38,307
INVOLVED IN PUTTING THAT MRI IN

1515
00:44:38,307 --> 00:44:39,975
THIS SPACE, WHEN THEY STARTED TO

1516
00:44:39,975 --> 00:44:42,177
TALK ABOUT IT I GOT VERY

1517
00:44:42,177 --> 00:44:42,478
INTERESTED.

1518
00:44:42,478 --> 00:44:45,180
AND SO WE DID A PRESCRIPTIVE

1519
00:44:45,180 --> 00:44:45,714
RISK ASSESSMENT THERE.

1520
00:44:45,714 --> 00:44:47,349
AND THEY HAD DONE A PRETTY,

1521
00:44:47,349 --> 00:44:49,952
REALLY GOOD JOB OF SORT OF

1522
00:44:49,952 --> 00:44:53,956
DESIGNING THE MRI STUFF AROUND,

1523
00:44:53,956 --> 00:44:56,492
THE MRI PROCESSES, BUT THE STUFF

1524
00:44:56,492 --> 00:44:58,293
AROUND IT, THE SCHEDULING, WHAT

1525
00:44:58,293 --> 00:44:59,361
OTHER PEOPLE'S ROLES ARE, THEY

1526
00:44:59,361 --> 00:45:01,697
DIDN'T PAY A LOT OF ATTENTION TO

1527
00:45:01,697 --> 00:45:02,231
THAT.

1528
00:45:02,231 --> 00:45:03,132
WE FOUND WHAT THEY COULD FINISH

1529
00:45:03,132 --> 00:45:04,967
SO THEY DIDN'T RUN INTO

1530
00:45:04,967 --> 00:45:05,234
PROBLEMS.

1531
00:45:05,234 --> 00:45:05,934
REALLY USEFUL TOOL.

1532
00:45:05,934 --> 00:45:07,569
SO JUST WANT TO TAKE YOU THROUGH

1533
00:45:07,569 --> 00:45:08,804
HOW TO DO IT.

1534
00:45:08,804 --> 00:45:10,472
AGAIN, THIS DOESN'T HAVE TO BE

1535
00:45:10,472 --> 00:45:12,141
REAL FORMALISM YOU CAN DO THIS

1536
00:45:12,141 --> 00:45:14,610
ON A PATIENT CARE UNIT SITTING

1537
00:45:14,610 --> 00:45:15,844
IN YOUR LAB JUST THINKING ABOUT

1538
00:45:15,844 --> 00:45:17,746
A NEW PROCESS YOU WANT TO

1539
00:45:17,746 --> 00:45:17,980
DESIGN.

1540
00:45:17,980 --> 00:45:21,383
FIRST OUT LINE THE STEPS OF THE

1541
00:45:21,383 --> 00:45:21,950
PROCESS, SO EVERYBODY AGREES

1542
00:45:21,950 --> 00:45:23,485
WHAT IS GOING TO HAP.

1543
00:45:23,485 --> 00:45:23,619
.

1544
00:45:23,619 --> 00:45:28,157
NOW IS THE TIME TO BRING OUT THE

1545
00:45:28,157 --> 00:45:37,299
INNER EAR OR --  OR -- EEYORE.

1546
00:45:37,299 --> 00:45:38,734
AND WHICH ARE THE RISKIEST TO

1547
00:45:38,734 --> 00:45:39,068
FIX.

1548
00:45:39,068 --> 00:45:42,838
SOME PEOPLE USE A HAZARD SCORE.

1549
00:45:42,838 --> 00:45:43,605
WE USE A PROCESS CALLED MY THREE

1550
00:45:43,605 --> 00:45:44,506
BIGGEST WORRIES.

1551
00:45:44,506 --> 00:45:46,175
WE HAVE PEOPLE LOOK AT ALL OF

1552
00:45:46,175 --> 00:45:47,409
THE FAILURE MOLDS AND PICK OUT

1553
00:45:47,409 --> 00:45:49,244
THE ONES THEY ARE WORRIED ABOUT,

1554
00:45:49,244 --> 00:45:50,679
AND THOSE WE FOCUS ON.

1555
00:45:50,679 --> 00:45:51,914
THE PEOPLE IN THE ROOM ARE THE

1556
00:45:51,914 --> 00:45:53,382
PEOPLE THAT DO IT EVERY DAY.

1557
00:45:53,382 --> 00:45:57,252
IT WOULD BE VERY DIFFERENT IT WE

1558
00:45:57,252 --> 00:45:58,587
HAD PROGRAM DIRECTORS, CEO, THE

1559
00:45:58,587 --> 00:45:59,388
HEAD OF NIH SITTING IN A ROOM

1560
00:45:59,388 --> 00:46:01,824
TRYING TO FIGURE OUT HOW TO DO A

1561
00:46:01,824 --> 00:46:02,925
NURSE PROCEDURE.

1562
00:46:02,925 --> 00:46:06,161
BUT WHEN YOU HAVE BEDSIDE NURSES

1563
00:46:06,161 --> 00:46:07,262
THERE, YOU FEEL CONFIDENT WHERE

1564
00:46:07,262 --> 00:46:08,097
THE BAD THINGS LIE.

1565
00:46:08,097 --> 00:46:10,099
I WANT TO TAKE YOU THROUGH.

1566
00:46:10,099 --> 00:46:11,834
THIS IS WORK YOUR SAFETY

1567
00:46:11,834 --> 00:46:13,602
SPECIALIST IN THIS BUILDING

1568
00:46:13,602 --> 00:46:16,672
WORKED ON SEVERAL YEARS AGO.

1569
00:46:16,672 --> 00:46:18,774
A NIMH STUDY, YOU WILL SEE A

1570
00:46:18,774 --> 00:46:20,476
THEME.

1571
00:46:20,476 --> 00:46:22,044
NIMH HAS BEEN A GOOD PARTNER

1572
00:46:22,044 --> 00:46:23,512
AROUND PATIENT SAFETY IN THIS

1573
00:46:23,512 --> 00:46:23,712
WORLD.

1574
00:46:23,712 --> 00:46:27,316
THIS IS A STUDY LOOKING AT

1575
00:46:27,316 --> 00:46:30,219
DOPAMINE ON SELF-CONTROL AND

1576
00:46:30,219 --> 00:46:30,853
IMPULSIVENESS.

1577
00:46:30,853 --> 00:46:32,955
TO THERE ARE PEOPLE ENGAGED IN

1578
00:46:32,955 --> 00:46:33,388
SUBSTANCE ABUSED.

1579
00:46:33,388 --> 00:46:34,656
THEY LIVED IN BALTIMORE CITY.

1580
00:46:34,656 --> 00:46:36,558
AND MANY OF THEM LIVED IN A

1581
00:46:36,558 --> 00:46:38,994
SHELTER, AND LIKELY TO LIVE IN A

1582
00:46:38,994 --> 00:46:40,829
SHELTER OR ABOUT HOWSED.

1583
00:46:40,829 --> 00:46:42,764
AND THE PROTOCOL REQUIREMENTS

1584
00:46:42,764 --> 00:46:44,166
WERE INTERESTED, THEY NEEDED TO

1585
00:46:44,166 --> 00:46:44,933
GET HERE EARLY.

1586
00:46:44,933 --> 00:46:46,835
PET SCANNING AT THE TIME OF THIS

1587
00:46:46,835 --> 00:46:48,604
WAS VERY DIFFICULT TO GET.

1588
00:46:48,604 --> 00:46:51,073
YOU HAD A VERY NARROW WINDOW OF

1589
00:46:51,073 --> 00:46:53,175
GETTING THAT PATIENT HERE, DRUG

1590
00:46:53,175 --> 00:46:55,544
TESTED, THE PET SCAN, GIVING

1591
00:46:55,544 --> 00:46:56,311
THEM INFUSION, AND MRI.

1592
00:46:56,311 --> 00:46:58,614
SO TIGHTLY COUPLED IF YOU MISSED

1593
00:46:58,614 --> 00:47:00,415
IT BY 15 MINUTES YOU BLEW THE

1594
00:47:00,415 --> 00:47:00,983
WHOLE DAY.

1595
00:47:00,983 --> 00:47:03,085
THAT SCANNING SLIDE.

1596
00:47:03,085 --> 00:47:05,087
SO IT JUST -- SWEEP ELEMENTARY

1597
00:47:05,087 --> 00:47:06,855
SCREAMED RISK TO US.

1598
00:47:06,855 --> 00:47:07,756
BETWEEN THE PATIENT POPULATION,

1599
00:47:07,756 --> 00:47:10,859
THE TIGHT COUPLING AND THE

1600
00:47:10,859 --> 00:47:12,594
IMAGING REQUIREMENTS.

1601
00:47:12,594 --> 00:47:13,795
WE DID AGFMEA.

1602
00:47:13,795 --> 00:47:15,764
REALLY GOOD PARTNERS ON THE

1603
00:47:15,764 --> 00:47:17,666
RESEARCH SIDE AND CLINICAL SIDE.

1604
00:47:17,666 --> 00:47:20,502
WE FLOWCHARTED OUT THE PROCESS.

1605
00:47:20,502 --> 00:47:21,703
BASIC, HIGH LEVEL, GET TO THE

1606
00:47:21,703 --> 00:47:24,573
CLINICAL CENTER, GO TO THE

1607
00:47:24,573 --> 00:47:26,842
CLINICAL, GET THE MED, THE PET

1608
00:47:26,842 --> 00:47:27,643
SCAN, THE IMAGING.

1609
00:47:27,643 --> 00:47:29,678
SO LOOKING AT THREE OF THOSE

1610
00:47:29,678 --> 00:47:30,546
PROCESS STEPS ABOUT WHAT COULD

1611
00:47:30,546 --> 00:47:31,680
GO WRONG.

1612
00:47:31,680 --> 00:47:33,782
SO ARRIVING THAT CLINICAL

1613
00:47:33,782 --> 00:47:34,016
CENTER.

1614
00:47:34,016 --> 00:47:35,584
WE'RE GETTING PEOPLE WHO HAVE

1615
00:47:35,584 --> 00:47:39,688
CHALLENGES JUST ON A DAY-TO-DAY

1616
00:47:39,688 --> 00:47:40,722
BASIS LIVING, READY AT 6:00 IN

1617
00:47:40,722 --> 00:47:42,991
THE MORNING TO GET TO A TAXI TO

1618
00:47:42,991 --> 00:47:45,494
TAKE THEM TO THE CLINICAL CENTER

1619
00:47:45,494 --> 00:47:46,328
AND GET THROUGH SECURITY.

1620
00:47:46,328 --> 00:47:49,131
JUST THAT IN ITSELF IS DANCING.

1621
00:47:49,131 --> 00:47:51,333
THEN YOU ADD IN THINGS LIKE TAXI

1622
00:47:51,333 --> 00:47:51,533
DELAY.

1623
00:47:51,533 --> 00:47:53,535
THIS IS BEFORE UBER WAS A BIG

1624
00:47:53,535 --> 00:47:54,469
THING.

1625
00:47:54,469 --> 00:47:55,404
AND THEN TRAFFIC DECAYS.

1626
00:47:55,404 --> 00:47:57,706
AGAIN, IT DOESN'T SEEM ON THE

1627
00:47:57,706 --> 00:47:59,575
SURFACE THAT'S A TERRIBLY BAD

1628
00:47:59,575 --> 00:48:00,776
THING, BUT IT BLOWS THAT WHOLE

1629
00:48:00,776 --> 00:48:02,811
VISIT IF THEY ARE LATE.

1630
00:48:02,811 --> 00:48:03,712
AND THEN MEDICATION

1631
00:48:03,712 --> 00:48:04,546
ADMINISTRATION.

1632
00:48:04,546 --> 00:48:06,815
YOU KNOW, IT IS TIME IN THE PAST

1633
00:48:06,815 --> 00:48:07,482
WHERE THERE WERE, YOU KNOW,

1634
00:48:07,482 --> 00:48:09,117
PHARMACY WAS GOING THROUGH

1635
00:48:09,117 --> 00:48:09,551
CHANGES.

1636
00:48:09,551 --> 00:48:10,919
SO, MEDICATION DELAYS AND THINGS

1637
00:48:10,919 --> 00:48:13,222
LIKE THAT WERE NOT UNCOMMON.

1638
00:48:13,222 --> 00:48:14,856
AND SO, MAKING SURE THAT WE GOT

1639
00:48:14,856 --> 00:48:17,559
MEDICATIONS UP TO THAT SPACE AT

1640
00:48:17,559 --> 00:48:19,328
VERY EARLY HOURS, LIKE 7:00 IN

1641
00:48:19,328 --> 00:48:20,696
THE MORNING WAS CHALLENGING.

1642
00:48:20,696 --> 00:48:21,763
SIMPLY BECAUSE OF STAFFING.

1643
00:48:21,763 --> 00:48:22,364
NOT ANYBODY'S FAULTS.

1644
00:48:22,364 --> 00:48:25,100
IT WAS JUST HOW THE SYSTEM WAS

1645
00:48:25,100 --> 00:48:25,634
DESIGNED AT THE TIME.

1646
00:48:25,634 --> 00:48:28,337
MAKING SURE THAT WE HAVE THE

1647
00:48:28,337 --> 00:48:29,404
RIGHT EQUIPMENT.

1648
00:48:29,404 --> 00:48:31,240
SOMETIMES THE EQUIPMENT WENT

1649
00:48:31,240 --> 00:48:31,473
MISSING.

1650
00:48:31,473 --> 00:48:32,641
ALONG THINGS, BUT A NURSE AND

1651
00:48:32,641 --> 00:48:34,176
GET THERE AT 7:00 IN THE MORNING

1652
00:48:34,176 --> 00:48:35,711
AND SOMEONE HAS TAKEN YOUR

1653
00:48:35,711 --> 00:48:38,180
MONITORING EQUIPMENT AND YOU

1654
00:48:38,180 --> 00:48:40,115
HAVE TO FIND IT AND GOT THIS

1655
00:48:40,115 --> 00:48:40,749
TIGHT COUPLING IT THROWS AVENUE

1656
00:48:40,749 --> 00:48:42,384
INTO CHAOS.

1657
00:48:42,384 --> 00:48:45,153
AND THE PET SCAN, TRASHERSE WAS

1658
00:48:45,153 --> 00:48:45,787
HARD TO GET AT SOMETIMES, AND

1659
00:48:45,787 --> 00:48:47,889
WHAT IF THERE WAS A CLINICAL

1660
00:48:47,889 --> 00:48:48,156
EMERGENCY.

1661
00:48:48,156 --> 00:48:49,224
HAVE YOU EVER THOUGHT ABOUT

1662
00:48:49,224 --> 00:48:52,027
HAVING TO MANAGE, YOU KNOW, AND

1663
00:48:52,027 --> 00:48:52,728
PRACTICE AND DRILLED AN

1664
00:48:52,728 --> 00:48:54,096
EMERGENCY IN THE PET SCANNING

1665
00:48:54,096 --> 00:48:54,296
AREA?

1666
00:48:54,296 --> 00:48:55,597
SO, THOSE WERE ALL THINGS THAT

1667
00:48:55,597 --> 00:48:57,566
WERE CONSIDERED.

1668
00:48:57,566 --> 00:48:59,101
AND THEN, JUST -- SOLUTIONS WERE

1669
00:48:59,101 --> 00:49:01,003
DEVELOPED BASED ON EACH OF THESE

1670
00:49:01,003 --> 00:49:02,638
FAILURE MOLDS TO TRY TO REDUCE

1671
00:49:02,638 --> 00:49:03,338
THE RISKS.

1672
00:49:03,338 --> 00:49:05,240
SOME OF THE THINGS WE'RE

1673
00:49:05,240 --> 00:49:06,908
IMPLEMENTED AND WORKED REALLY

1674
00:49:06,908 --> 00:49:07,109
WELL.

1675
00:49:07,109 --> 00:49:09,011
ORALLY THINGS THE TEAM CHOOSE

1676
00:49:09,011 --> 00:49:10,045
NOT TO IMPLEMENT.

1677
00:49:10,045 --> 00:49:11,346
WE IDENTIFIED THAT THEY PROBABLY

1678
00:49:11,346 --> 00:49:13,348
NEEDED TO IMPLEMENT IT BECAUSE

1679
00:49:13,348 --> 00:49:13,982
DELAYS OCCURRED.

1680
00:49:13,982 --> 00:49:16,218
JUST AN EXAMPLE ABOUT HOW YOU

1681
00:49:16,218 --> 00:49:18,153
CAN APPLY THIS TO A CLINICAL

1682
00:49:18,153 --> 00:49:18,987
RESEARCH PROTOCOL AND ANY ONE OF

1683
00:49:18,987 --> 00:49:20,555
THE OTHER CLINICAL AREAS THAT I

1684
00:49:20,555 --> 00:49:22,791
MENTIONED TO YOU BEFORE.

1685
00:49:22,791 --> 00:49:24,760
SO JUST -- WE SPEND A LOT OF

1686
00:49:24,760 --> 00:49:26,461
TIME TALKING ABOUT DOING

1687
00:49:26,461 --> 00:49:27,129
REACTIVE WORK.

1688
00:49:27,129 --> 00:49:29,765
AND RCAs AND LOOKING AT

1689
00:49:29,765 --> 00:49:29,998
EVENTS.

1690
00:49:29,998 --> 00:49:31,600
I REALLY ENCOURAGE YOU, WE'RE ON

1691
00:49:31,600 --> 00:49:33,302
THIS JOURNEY, TOO, AT MEDSTAR

1692
00:49:33,302 --> 00:49:34,803
HEALTH, TO REALLY THINK

1693
00:49:34,803 --> 00:49:36,004
PROACTIVELY ABOUT THINGS,

1694
00:49:36,004 --> 00:49:36,872
BECAUSE IT WILL MAKE OUR

1695
00:49:36,872 --> 00:49:37,839
PATIENTS SAFER.

1696
00:49:37,839 --> 00:49:40,409
SO A COUPLE OF KEY TAKEAWAYS.

1697
00:49:40,409 --> 00:49:42,444
GROUND YOUR WORK IN SAFETY

1698
00:49:42,444 --> 00:49:43,045
SCIENCE.

1699
00:49:43,045 --> 00:49:43,712
AND HUMAN FACTORS.

1700
00:49:43,712 --> 00:49:45,747
IT'S REALLY A LIFE CHANGER.

1701
00:49:45,747 --> 00:49:46,114
A GAME-CHANGER.

1702
00:49:46,114 --> 00:49:48,083
ALL OF THE SUDDEN YOU ARE DRIVEN

1703
00:49:48,083 --> 00:49:49,318
BY SCIENCE, THERE IS NO PLACE

1704
00:49:49,318 --> 00:49:52,321
BETTER THAN THIS TO BE DRIVEN BY

1705
00:49:52,321 --> 00:49:53,455
SCIENCE.

1706
00:49:53,455 --> 00:49:55,524
SPEAK UP, REPORT HAZARDS AND

1707
00:49:55,524 --> 00:49:55,757
HARM.

1708
00:49:55,757 --> 00:49:58,193
REPORT HAZARDS AND HARM, REPORT

1709
00:49:58,193 --> 00:50:00,395
HAZARDS BECAUSE YOU GOT TO KNOW

1710
00:50:00,395 --> 00:50:01,863
THE NEAR MISSES.

1711
00:50:01,863 --> 00:50:03,765
USE THAT SYSTEM'S LENS TO ALWAYS

1712
00:50:03,765 --> 00:50:04,166
ASK WHY.

1713
00:50:04,166 --> 00:50:06,868
AND REALLY LEAN INTO THE

1714
00:50:06,868 --> 00:50:07,903
CONTRIBUTOR FACTORS.

1715
00:50:07,903 --> 00:50:09,771
NANOT JUST IN THE CONTEXT OF A

1716
00:50:09,771 --> 00:50:10,706
ROOT CAUSE ANALYSIS, BUT

1717
00:50:10,706 --> 00:50:12,274
UNDERSTANDING WHAT IS GOING ON

1718
00:50:12,274 --> 00:50:14,743
WITH SOMETHING GOING ON THERE IN

1719
00:50:14,743 --> 00:50:15,477
YOUR LAB OR IN YOUR, ON YOUR

1720
00:50:15,477 --> 00:50:16,912
PATIENT CARE UNIT.

1721
00:50:16,912 --> 00:50:20,282
AND BE ALSO BE ON THE LOOK OUT

1722
00:50:20,282 --> 00:50:21,516
FOR RISKS AND POTENTIAL RISKS

1723
00:50:21,516 --> 00:50:23,752
THAT ARE OUT THERE.

1724
00:50:23,752 --> 00:50:24,519
AND I'LL LEAVE YOU WITH YOUR

1725
00:50:24,519 --> 00:50:25,420
WEEKEND READING LIST.

1726
00:50:25,420 --> 00:50:27,222
THIS IS SORT OF WHAT YOU CAN

1727
00:50:27,222 --> 00:50:29,658
LOOK AT TO LEARN MORE ABOUT THE

1728
00:50:29,658 --> 00:50:30,759
WORK THAT, THE INFORMATION THAT

1729
00:50:30,759 --> 00:50:32,694
I TALKED ABOUT.

1730
00:50:32,694 --> 00:50:35,330
BUT MOSTLY, I WANT TO THANK YOU

1731
00:50:35,330 --> 00:50:36,131
ALLLER FOR INVITING ME.

1732
00:50:36,131 --> 00:50:37,265
THIS IS A REALLY SPECIAL

1733
00:50:37,265 --> 00:50:39,234
EXPERIENCE, IT IS SO GOOD TO SEE

1734
00:50:39,234 --> 00:50:39,501
EVERYBODY.

1735
00:50:39,501 --> 00:50:40,569
AND JUST AWESOME.

1736
00:50:40,569 --> 00:50:51,113
I'M HAPPY TO TAKE ANY QUESTIONS.

1737
00:50:59,821 --> 00:51:01,289
[ APPLAUSE ]

1738
00:51:01,289 --> 00:51:05,627
OH, YEAH.

1739
00:51:05,627 --> 00:51:08,597
>> HI, LAURA LEELER HOW
ARE YOU.

1740
00:51:08,597 --> 00:51:09,498
>> ONE VERY NICE
PRESENTATION.

1741
00:51:09,498 --> 00:51:11,733
I REALLY THINK THAT EMPHASIZING

1742
00:51:11,733 --> 00:51:12,901
THE PROACTIVE IS THE WAY TO GO

1743
00:51:12,901 --> 00:51:15,404
BECAUSE ONE OF MY CONCERNS IS

1744
00:51:15,404 --> 00:51:17,072
WITH THIS REACTIVE MODE WE'RE

1745
00:51:17,072 --> 00:51:19,674
IN, THERE'S A LOT OF HEAT AND

1746
00:51:19,674 --> 00:51:23,678
MOTION THAT'S BEING MISTAKEN FOR

1747
00:51:23,678 --> 00:51:25,814
ACTUAL CORRECTION OF THE ACTUAL

1748
00:51:25,814 --> 00:51:27,048
PROBLEMS.

1749
00:51:27,048 --> 00:51:29,618
YOU KNOW, THERE'S -- A HUGE

1750
00:51:29,618 --> 00:51:32,354
CHURN AND PEOPLE WHO ARE NUMBER

1751
00:51:32,354 --> 00:51:34,122
VOLVED IN THAT CHURN IN REACTING

1752
00:51:34,122 --> 00:51:37,058
TO ALL OF THESE THINGS, THERE'S

1753
00:51:37,058 --> 00:51:37,726
OFTEN AN UNDERSTANDING, BUT

1754
00:51:37,726 --> 00:51:39,394
ITY NOT A COMMITMENT TO

1755
00:51:39,394 --> 00:51:40,529
PUTTING IN THE PROPER

1756
00:51:40,529 --> 00:51:43,565
ENGINEERING CONTROLS AND SO

1757
00:51:43,565 --> 00:51:44,466
FORTH WHICH ACTUALLY TAKE A LOT,

1758
00:51:44,466 --> 00:51:46,134
TAKE A LOT OF RESOURCES.

1759
00:51:46,134 --> 00:51:48,570
EVERYONE'S TRYING TO FIX THINGS

1760
00:51:48,570 --> 00:51:50,739
WITH THE RESOURCES THEY HAVE.

1761
00:51:50,739 --> 00:51:52,140
AND THE UNDERSTANDING THAT THEY

1762
00:51:52,140 --> 00:51:52,340
HAVE.

1763
00:51:52,340 --> 00:51:53,942
SO THE PEOPLE WHO ARE ANALYZING

1764
00:51:53,942 --> 00:51:55,277
IT, YOU KNOW, WHEN YOU DO

1765
00:51:55,277 --> 00:51:56,845
MENTION, IT IS IMPORTANT TO HAVE

1766
00:51:56,845 --> 00:51:57,446
THE NURSES WHO ARE ON THE THE

1767
00:51:57,446 --> 00:51:58,313
FLOOR IN THAT ROOM.

1768
00:51:58,313 --> 00:52:00,916
BUT I CAN TELL YOU, YOU ASK A

1769
00:52:00,916 --> 00:52:02,884
BUNCH OF SAY RADIOLOGISTS WHAT

1770
00:52:02,884 --> 00:52:06,021
THEY WANT IN A PAC SYSTEM THEY

1771
00:52:06,021 --> 00:52:06,822
DON'T ACTUALLY KNOW.

1772
00:52:06,822 --> 00:52:08,490
THEY KNOW WHAT THEY'VE DONE AND

1773
00:52:08,490 --> 00:52:10,358
WHAT MAKES THEM EFFICIENT, BUT

1774
00:52:10,358 --> 00:52:11,927
IF SOMEONE, YOU KNOW, BREAKS

1775
00:52:11,927 --> 00:52:14,529
OUT-OF-THE-BOX TO MAKE IT MUCH

1776
00:52:14,529 --> 00:52:15,564
EASIER, THEY'RE NOT NECESSARILY

1777
00:52:15,564 --> 00:52:16,631
TO PEOPLE WHO IMAGINE THAT.

1778
00:52:16,631 --> 00:52:21,403
I'M SURE IF YOU ASKED A BUNCH OF

1779
00:52:21,403 --> 00:52:23,705
RADIOLOGIST 50 YEARS AGO TO GET

1780
00:52:23,705 --> 00:52:25,941
RID OF FILM, NO IT NEVER WOULD

1781
00:52:25,941 --> 00:52:27,409
HAVE HAPPENED.

1782
00:52:27,409 --> 00:52:29,644
THE ONLY HAPPENED, THERE WAS NO

1783
00:52:29,644 --> 00:52:30,378
STUDIES, THIS IS NOT FROM

1784
00:52:30,378 --> 00:52:31,213
SCIENTIFIC RESEARCH, THAT SAYS

1785
00:52:31,213 --> 00:52:33,849
IT IS BETTER TO DO THIS.

1786
00:52:33,849 --> 00:52:35,484
SO HOW YOU APPLY THESE

1787
00:52:35,484 --> 00:52:37,953
TECHNOLOGIES, BUT I THINK IT IS

1788
00:52:37,953 --> 00:52:38,954
REALLY IMPORTANT TO GET THERE.

1789
00:52:38,954 --> 00:52:42,624
AND THE -- AND THE COMMITMENT

1790
00:52:42,624 --> 00:52:44,993
TO -- TO DO THESE PROACTIVE

1791
00:52:44,993 --> 00:52:47,162
THINGS, BECAUSE, I CAN THINK

1792
00:52:47,162 --> 00:52:49,865
OF -- IT'S HARD TO KNOW.

1793
00:52:49,865 --> 00:52:50,365
SO WHERE'S THE FEEDBACK.

1794
00:52:50,365 --> 00:52:52,200
YOU FIXU  SOMETHING, NO ONE KNOS

1795
00:52:52,200 --> 00:52:53,768
YOU FIXED IT BECAUSE IT IS

1796
00:52:53,768 --> 00:52:54,269
FIXED.

1797
00:52:54,269 --> 00:52:56,004
YOU DON'T GET CREDIT FOR IT.

1798
00:52:56,004 --> 00:52:57,739
NO ONE KNOWS.

1799
00:52:57,739 --> 00:52:59,508
IT IS REALLY HARD TO GET THAT TO

1800
00:52:59,508 --> 00:52:59,708
WORK.

1801
00:52:59,708 --> 00:53:01,610
SO I'M JUST THROWING THINGS OUT,

1802
00:53:01,610 --> 00:53:04,980
BUT HOW WE GET FROM THE REACTIVE

1803
00:53:04,980 --> 00:53:06,781
PRO ACTIVE, I THINK IT IS REAL

1804
00:53:06,781 --> 00:53:07,048
CHALLENGE.

1805
00:53:07,048 --> 00:53:10,252
>> LAURA:  YEAH, IT'S
REALLY

1806
00:53:10,252 --> 00:53:10,452
HARD.

1807
00:53:10,452 --> 00:53:11,920
WE ARE NOT ANYWHERE NEAR IT YET.

1808
00:53:11,920 --> 00:53:13,922
FOR, EXACTLY WHAT YOU SAID IT IS

1809
00:53:13,922 --> 00:53:16,424
LIKE WE FIXED IT, NOTHING

1810
00:53:16,424 --> 00:53:16,691
HAPPENED.

1811
00:53:16,691 --> 00:53:17,392
SO THEREFORE, WE WERE RIGHT ALL

1812
00:53:17,392 --> 00:53:19,861
ALONG SORT OF THING.

1813
00:53:19,861 --> 00:53:23,632
SO, I THINK IT STARTS WITH

1814
00:53:23,632 --> 00:53:24,199
LEADERSHIP, CULTURE REALLY

1815
00:53:24,199 --> 00:53:25,367
EMBRACING PROACTIVE AND STARTING

1816
00:53:25,367 --> 00:53:26,835
TO TALK ABOUT IT AND HELPING

1817
00:53:26,835 --> 00:53:27,435
PEOPLE UNDERSTAND WHAT IT IS.

1818
00:53:27,435 --> 00:53:30,205
THEN JUST DO A COUPLE OF GOOD

1819
00:53:30,205 --> 00:53:30,472
EXAMPLES.

1820
00:53:30,472 --> 00:53:31,640
SO, THIS IS BEFORE I WANT TO

1821
00:53:31,640 --> 00:53:34,242
MEDSTAR HEALTH, THEY WERE HAVING

1822
00:53:34,242 --> 00:53:35,210
A BUNCH OF PROBLEMS WITH CORD

1823
00:53:35,210 --> 00:53:36,578
CUP APPROXIMATIONS.

1824
00:53:36,578 --> 00:53:38,713
PATIENTS WERE COMING INTO THE ED

1825
00:53:38,713 --> 00:53:39,414
AND IT WAS MISSED.

1826
00:53:39,414 --> 00:53:43,051
FOR 30 YEARS I WAS SHELTERED

1827
00:53:43,051 --> 00:53:45,053
FROM FRO S WORLD OF THESE

1828
00:53:45,053 --> 00:53:45,787
CATASTROPHIC EFFERVENTS THAT

1829
00:53:45,787 --> 00:53:46,821
HAPPEN AND ALSO FROM THE WORLD

1830
00:53:46,821 --> 00:53:48,890
THAT CLAIMS COME IN THAT YOU PAY

1831
00:53:48,890 --> 00:53:49,958
APPROPRIATELY, BECAUSE WE HARMED

1832
00:53:49,958 --> 00:53:52,093
SOMEBODY, BUT THEY HAVE A REAL,

1833
00:53:52,093 --> 00:53:54,396
MEDSTAR HEALTH HAVE VERY

1834
00:53:54,396 --> 00:53:57,832
FINANCIALLY STABLE, BUT IT HAS

1835
00:53:57,832 --> 00:53:59,234
AN IMPACT ON WHAT YOU CAN DO.

1836
00:53:59,234 --> 00:54:00,902
MEDSTAR HEALTH IS VERY, VERY

1837
00:54:00,902 --> 00:54:03,038
PROACTIVE IN TRYING TO ADDRESS

1838
00:54:03,038 --> 00:54:03,838
THOSE SORTS OF THINGS.

1839
00:54:03,838 --> 00:54:04,873
SO CORD COMPRESSION.

1840
00:54:04,873 --> 00:54:07,075
SO, A BUNCH OF CASES.

1841
00:54:07,075 --> 00:54:08,877
INSTEAD OF JUST LOOKING AT THE

1842
00:54:08,877 --> 00:54:10,579
CASES THAT HAPPENED,EY HTH

1843
00:54:10,579 --> 00:54:11,546
STARTED TO DO, THEY WENT BACK

1844
00:54:11,546 --> 00:54:14,049
AND LOOKED AT ALL OF THE CASES

1845
00:54:14,049 --> 00:54:15,750
THAT WERE CORD COMPRESSION

1846
00:54:15,750 --> 00:54:16,651
CASES, BUT NEVER ENID UP BEING A

1847
00:54:16,651 --> 00:54:19,321
BAD EVENT, THEY CAME IN AND GOT

1848
00:54:19,321 --> 00:54:20,255
TREATED IMMEDIATELY.

1849
00:54:20,255 --> 00:54:22,057
THEY LOOKED AT THOSE AND FIGURED

1850
00:54:22,057 --> 00:54:25,093
OUT WHAT HAPPENED, WHO WAS DOING

1851
00:54:25,093 --> 00:54:25,527
IT WELL.

1852
00:54:25,527 --> 00:54:26,561
WERE, WHAT WERE THEY DOING WELL

1853
00:54:26,561 --> 00:54:28,229
THAT THE OTHER PEOPLE WEREN'T.

1854
00:54:28,229 --> 00:54:30,532
IT HAD TO DO WITH AVAILABILITY

1855
00:54:30,532 --> 00:54:32,334
OF RESOURCES IN TERMS OF IMAGING

1856
00:54:32,334 --> 00:54:33,134
AND COMMUNICATION.

1857
00:54:33,134 --> 00:54:35,804
SO, YOU KNOW, YOU JUST, IT IS

1858
00:54:35,804 --> 00:54:36,504
JUST A DIFFERENT MIND-SET.

1859
00:54:36,504 --> 00:54:38,506
WE HAVE GOTTEN GOOD AT LOOKING

1860
00:54:38,506 --> 00:54:39,007
AT EVENTS.

1861
00:54:39,007 --> 00:54:40,642
BUT MAN, IT TAKES LOT MORE WORK.

1862
00:54:40,642 --> 00:54:42,243
SO IT IS LOT MORE WORK TO GO AND

1863
00:54:42,243 --> 00:54:44,746
LOOK AT 50 CASES OF THINGS THAT

1864
00:54:44,746 --> 00:54:46,147
WENT WELL THEN THREE CASES THAT

1865
00:54:46,147 --> 00:54:46,448
WENT POORLY.

1866
00:54:46,448 --> 00:54:46,815
SO YEAH.

1867
00:54:46,815 --> 00:54:52,921
IT IS JUST A CULTURE CHANGE.

1868
00:54:52,921 --> 00:54:53,722
>> HI, LAURA.

1869
00:54:53,722 --> 00:54:55,256
FIRST OF ALL, THANK YOU,NK BUT I

1870
00:54:55,256 --> 00:54:56,358
WANTED TO ASK IF YOU CAN COMMENT

1871
00:54:56,358 --> 00:54:59,961
ON THE FACT THAT THIS IS A GRAND

1872
00:54:59,961 --> 00:55:01,763
ROUND FOR THE GRADUATE MEDICAL

1873
00:55:01,763 --> 00:55:03,231
EDUCATION PROGRAMS.

1874
00:55:03,231 --> 00:55:05,300
ARE WE REALLY DON'T ALWAYS THINK

1875
00:55:05,300 --> 00:55:06,368
ABOUT WHERE TRAINEES, PHYSICIAN

1876
00:55:06,368 --> 00:55:07,702
TRAINEES IN PARTICULAR, FIT INTO

1877
00:55:07,702 --> 00:55:10,505
THE SYSTEM AND WHETHER THEY

1878
00:55:10,505 --> 00:55:12,340
UTILIZE THESE REPORTING SYSTEMS

1879
00:55:12,340 --> 00:55:13,742
AND WHAT'S YOUR ADVICE IS AND

1880
00:55:13,742 --> 00:55:15,510
HOW YOU CAN HELP US ENCOURAGE

1881
00:55:15,510 --> 00:55:18,580
THAT MORE AMONG THE PHYSICIANS

1882
00:55:18,580 --> 00:55:18,780
HERE.

1883
00:55:18,780 --> 00:55:20,181
>> LAURA:  THANKS.

1884
00:55:20,181 --> 00:55:21,182
THAT IS REALLY TRUE.

1885
00:55:21,182 --> 00:55:22,283
REPORTING SHOULD HAPPEN ACROSS

1886
00:55:22,283 --> 00:55:22,617
THE BOARD.

1887
00:55:22,617 --> 00:55:24,686
FIRST OF ALL THEY NEED TO KNOW,

1888
00:55:24,686 --> 00:55:26,254
FIRST OF ALL IT HAS TO BE

1889
00:55:26,254 --> 00:55:27,255
MODELED WITH THE LEADERSHIP THAT

1890
00:55:27,255 --> 00:55:28,323
REPORTING IS IMPORTANT.

1891
00:55:28,323 --> 00:55:29,924
SO STARTING THAT THE LOCAL

1892
00:55:29,924 --> 00:55:30,125
LEVEL.

1893
00:55:30,125 --> 00:55:32,060
THEY HAVE TO KNOW HOW TO REPORT.

1894
00:55:32,060 --> 00:55:32,861
AND THEY NEED TO KNOW SORT OF

1895
00:55:32,861 --> 00:55:33,695
WHAT TO REPORT.

1896
00:55:33,695 --> 00:55:35,764
SO THAT NEEDS TO BE DONE AT THE

1897
00:55:35,764 --> 00:55:36,097
PROGRAM LEVEL.

1898
00:55:36,097 --> 00:55:38,299
NEEDS TO BE MODELED.

1899
00:55:38,299 --> 00:55:39,934
AND IF PEOPLE PUT REPORTS IN

1900
00:55:39,934 --> 00:55:43,304
THEY SHOULD TALK ABOUT IT AT

1901
00:55:43,304 --> 00:55:44,272
THEIR HUDDLES OR MEETINGS.

1902
00:55:44,272 --> 00:55:46,107
AT THE ORGANIZATIONAL LEVEL,

1903
00:55:46,107 --> 00:55:47,842
THIS HAPPENS ACROSS HEALTHCARE.

1904
00:55:47,842 --> 00:55:49,844
WE FOR NOT REALLY GOOD AT

1905
00:55:49,844 --> 00:55:50,545
FEEDING BACK WHAT WE DID.

1906
00:55:50,545 --> 00:55:52,914
SO FOLKS THAT ARE SAFETY LEADERS

1907
00:55:52,914 --> 00:55:54,549
NEED TO FIGURE OUT WAYS TO GET

1908
00:55:54,549 --> 00:55:58,219
THE INFORMATION THAT PEOPLE HAVE

1909
00:55:58,219 --> 00:55:59,354
TAKEN PRECIOUS MOMENTS OF THEIR

1910
00:55:59,354 --> 00:56:00,755
TIME TO TELL US ABOUT, HOW DO

1911
00:56:00,755 --> 00:56:01,456
YOU FEED THAT BACK.

1912
00:56:01,456 --> 00:56:02,824
THAT IS REALLY ONE OF THE KEY

1913
00:56:02,824 --> 00:56:05,627
WAYS TO GET IT TO CHANGE.

1914
00:56:05,627 --> 00:56:08,263
BUT I THINK JUST ENCOURAGING

1915
00:56:08,263 --> 00:56:09,931
FOLKS TO ENTER THINGS.

1916
00:56:09,931 --> 00:56:11,700
YOU HAVE TO HAVE THAT

1917
00:56:11,700 --> 00:56:13,068
PSYCHOLOGICAL SAFETY.

1918
00:56:13,068 --> 00:56:14,269
WE STILL SEE INSTANCES WHERE

1919
00:56:14,269 --> 00:56:16,438
PEOPLE ARE NOT PUTTING THINGS IN

1920
00:56:16,438 --> 00:56:18,306
BECAUSE MAYBE THEY ARE NOT BEING

1921
00:56:18,306 --> 00:56:19,374
ENCOURAGED TO DO IT.

1922
00:56:19,374 --> 00:56:21,342
OR THERE IS A NONPUNITIVE

1923
00:56:21,342 --> 00:56:21,609
RESPONSE.

1924
00:56:21,609 --> 00:56:25,013
THAT'S ACROSS HEALTHCARE IN GEN.

1925
00:56:25,013 --> 00:56:27,816
SO YEP.

1926
00:56:27,816 --> 00:56:29,818
>> I WAS WONDERING TO WHAT

1927
00:56:29,818 --> 00:56:31,953
EXTENT YOU HAVE SEEN PEOPLE USE

1928
00:56:31,953 --> 00:56:34,189
OR YOU SEEN IF THERE MIGHT BE

1929
00:56:34,189 --> 00:56:36,825
ANY POTENTIAL FOR USING MORE

1930
00:56:36,825 --> 00:56:41,096
TOOLS OF PROCESS ENGINEERING

1931
00:56:41,096 --> 00:56:43,198
LIKE MARKOV CHAIN MODELING OR

1932
00:56:43,198 --> 00:56:44,866
COMPLEXITY SCIENCE, LIKE AGENT

1933
00:56:44,866 --> 00:56:46,968
BASED MODELING TO SORT OF

1934
00:56:46,968 --> 00:56:50,271
UNDERSTAND PATIENTW AND, YOU

1935
00:56:50,271 --> 00:56:52,073
KNOW, ANTICIPATE PROBLEMS BEFORE

1936
00:56:52,073 --> 00:56:53,808
THEY ARISE AND MOVE LIKE, YOU

1937
00:56:53,808 --> 00:56:55,310
KNOW, THE HEURISTICS REALLY

1938
00:56:55,310 --> 00:56:56,711
IMPORTANT, BUT SORT OF HOW YOU

1939
00:56:56,711 --> 00:56:58,613
MIGHT INTERFACE WITH THAT.

1940
00:56:58,613 --> 00:57:00,281
>> LAURA:  YEAH.

1941
00:57:00,281 --> 00:57:01,449
SO I WILL PROBABLY JUST NOT

1942
00:57:01,449 --> 00:57:02,417
ANSWER A LOT, BECAUSE I KNOW

1943
00:57:02,417 --> 00:57:04,252
ABOUT ENOUGH TO KEEP, TO GET

1944
00:57:04,252 --> 00:57:06,087
MYSELF IN TROUBLE BY ANSWERING

1945
00:57:06,087 --> 00:57:06,554
YOUR QUESTION.

1946
00:57:06,554 --> 00:57:07,989
I AM VERY FORTUNATE TO WORK IN

1947
00:57:07,989 --> 00:57:10,091
AN ORGANIZATION THAT HAS A WHOLE

1948
00:57:10,091 --> 00:57:11,960
CENTER ON HUMAN FACTORS

1949
00:57:11,960 --> 00:57:12,260
ENGINEERING.

1950
00:57:12,260 --> 00:57:13,161
AND THEY HAVE A HUGE GROUP THAT

1951
00:57:13,161 --> 00:57:15,764
ARE LOOKING AT THAT.

1952
00:57:15,764 --> 00:57:16,664
BUT I THINK THOSE ARE ALL PARTS

1953
00:57:16,664 --> 00:57:19,367
OF THE SCIENCE THAT WE NEED TO

1954
00:57:19,367 --> 00:57:20,802
BE PUTTING IN PLACE.

1955
00:57:20,802 --> 00:57:23,371
IT IS JUST THAT WE NEED --

1956
00:57:23,371 --> 00:57:24,773
HEALTHCARE TO FIND SPACE AND

1957
00:57:24,773 --> 00:57:25,406
MONEY TO DO THAT.

1958
00:57:25,406 --> 00:57:26,941
THAT'S REALLY THE PROBLEM.

1959
00:57:26,941 --> 00:57:27,375
SO YES.

1960
00:57:27,375 --> 00:57:28,710
THERE ALL IMPORTANT.

1961
00:57:28,710 --> 00:57:31,146
AND THEY ALL NEED TO BE DONE.

1962
00:57:31,146 --> 00:57:33,114
BUT HEALTHCARE IS OPERATING IN A

1963
00:57:33,114 --> 00:57:34,682
1% MARGE RECALL GENERALLY, THERE

1964
00:57:34,682 --> 00:57:37,118
IS NOT A LOT OF ROOM OUT IN THE

1965
00:57:37,118 --> 00:57:38,686
REAL WORLD TO BE ABLE TO USE

1966
00:57:38,686 --> 00:57:39,587
THOSE THINGS RIGHT NOW.

1967
00:57:39,587 --> 00:57:42,190
YES, THAT'S WHERE WE WANT TO GO.

1968
00:57:42,190 --> 00:57:44,425
AND HOPEFULLY, SOMEDAY WE WILL

1969
00:57:44,425 --> 00:57:44,692
GET THERE.

1970
00:57:44,692 --> 00:57:47,529
>> THANK YOU FOR SUCH A

1971
00:57:47,529 --> 00:57:48,696
WONDSCUSSION TODAY.

1972
00:57:48,696 --> 00:57:51,900
REGARDING OUR TOPIC ON THE

1973
00:57:51,900 --> 00:57:53,601
SHIFTING THE SAFETY FROM

1974
00:57:53,601 --> 00:57:54,702
REACTIVE TO PROACTIVE, I THINK

1975
00:57:54,702 --> 00:57:56,971
ONE OF THE KEY FACTORS THAT YOU

1976
00:57:56,971 --> 00:58:01,009
WERE JUST DISCUSSING IS THIS

1977
00:58:01,009 --> 00:58:01,943
CONCEPT OF PSYCHOLOGICAL SAFETY.

1978
00:58:01,943 --> 00:58:07,916
AS THE LEADER OF A CLINICAL

1979
00:58:07,916 --> 00:58:10,919
TEAM, WHAT'S THE -- BEST INITIAL

1980
00:58:10,919 --> 00:58:15,356
APPROACH TO ADDRESSING

1981
00:58:15,356 --> 00:58:15,824
PSYCHOLOGICAL SAFETY?

1982
00:58:15,824 --> 00:58:17,458
IS THERE A GOLD STANDARD?

1983
00:58:17,458 --> 00:58:19,294
IS THIS TRAINING SEMINAR?

1984
00:58:19,294 --> 00:58:20,461
AN OPEN DISCUSSION?

1985
00:58:20,461 --> 00:58:22,897
OR IS THIS A SYSTEMATIC THING?

1986
00:58:22,897 --> 00:58:24,032
CULTURAL WITHIN THE HOSPITAL?

1987
00:58:24,032 --> 00:58:25,066
WHAT'S THE BEST WAY TO ADDRESS

1988
00:58:25,066 --> 00:58:26,267
IT?

1989
00:58:26,267 --> 00:58:28,469
>> LAURA:  ALL OF THE
ABOVE.

1990
00:58:28,469 --> 00:58:29,270
THIS IS A WHOLE, THIS IS ANOTHER

1991
00:58:29,270 --> 00:58:31,840
HOUR LONG TALK THAT I CAN GIVE

1992
00:58:31,840 --> 00:58:32,006
YOU.

1993
00:58:32,006 --> 00:58:34,776
SO IT, IT STARTS -- IT JUST

1994
00:58:34,776 --> 00:58:38,446
STARTS WITH THE LEADER BEING

1995
00:58:38,446 --> 00:58:39,147
OPEN LEADER.

1996
00:58:39,147 --> 00:58:41,249
WANTING TO KNOW WHAT IS GOING

1997
00:58:41,249 --> 00:58:41,883
ON.

1998
00:58:41,883 --> 00:58:43,284
ASKING PEOPLE'S OPINION,

1999
00:58:43,284 --> 00:58:43,952
ENGAGING PEOPLE, MAKING SURE

2000
00:58:43,952 --> 00:58:45,486
THAT PEOPLE FEEL COMFORTABLE

2001
00:58:45,486 --> 00:58:46,855
BRINGING THEIR IDEAS IF SOMEONE

2002
00:58:46,855 --> 00:58:50,458
COMES TO YOU WITH AN IDEA, TALK

2003
00:58:50,458 --> 00:58:53,094
TO THEM ABOUT IT IF IT IS AN

2004
00:58:53,094 --> 00:58:55,363
IDEA THEY CAN'T USE OR RESOURCE

2005
00:58:55,363 --> 00:58:56,097
IT, TELL THEM WHY.

2006
00:58:56,097 --> 00:58:58,299
MAKING SURE THAT EVERYBODY FEELS

2007
00:58:58,299 --> 00:58:58,600
COMFORTABLE.

2008
00:58:58,600 --> 00:58:59,267
THERE IS NO SORT OF

2009
00:58:59,267 --> 00:59:00,735
MICROAGGRESSIONS WITHIN THE

2010
00:59:00,735 --> 00:59:01,603
GROUP.

2011
00:59:01,603 --> 00:59:06,107
IT IS A BIG LEADERSHIP

2012
00:59:06,107 --> 00:59:06,941
MANAGEMENT -- CHALLENGE BECAUSE

2013
00:59:06,941 --> 00:59:09,911
YOU HAVE TO BE OUT THERE

2014
00:59:09,911 --> 00:59:10,378
CONSTANTLY, CONSTANTLY

2015
00:59:10,378 --> 00:59:10,845
CULTIVATING.

2016
00:59:10,845 --> 00:59:12,313
SO THERE IS TRAINING AROUND IT.

2017
00:59:12,313 --> 00:59:16,050
BUT IT HONESTLY, IT IS MOSTLY

2018
00:59:16,050 --> 00:59:16,584
LEADERSHIP MODELING.

2019
00:59:16,584 --> 00:59:19,687
WE DO TRAINING WITH OUR LEADERS

2020
00:59:19,687 --> 00:59:20,321
AROUND PSYCHOLOGICAL SAFETY AND

2021
00:59:20,321 --> 00:59:22,490
HOW TO GET THERE, WHAT IT IS,

2022
00:59:22,490 --> 00:59:23,024
WHAT IT ISN'T.

2023
00:59:23,024 --> 00:59:25,860
WE GOT, I CAN SEND THAT TO

2024
00:59:25,860 --> 00:59:26,628
JOYCE, I'VE GOT JUST A

2025
00:59:26,628 --> 00:59:27,862
POWERPOINT SLIDE THAT HAS EIGHT

2026
00:59:27,862 --> 00:59:29,898
THINGS THAT YOU CAN DO AS A

2027
00:59:29,898 --> 00:59:30,131
LEADER.

2028
00:59:30,131 --> 00:59:31,499
ONE OR ALL EIGHT OF THEM EVERY

2029
00:59:31,499 --> 00:59:33,868
DAY TO START TO BUILD THAT

2030
00:59:33,868 --> 00:59:34,335
PSYCHOLOGICAL SAFETY.

2031
00:59:34,335 --> 00:59:35,603
I THINK ONE THING THAT HAS

2032
00:59:35,603 --> 00:59:37,472
HELPED US TALKING T ABOUT

2033
00:59:37,472 --> 00:59:39,440
THE CONCEPT OF PSYCHOLOGICAL

2034
00:59:39,440 --> 00:59:39,908
SAFETYONCE

2035
00:59:39,908 --> 00:59:44,679
 YOU START TO SOCIALIZE IT,

2036
00:59:44,679 --> 00:59:45,280
THEN PEOPLE START TO EXPECT IT

2037
00:59:45,280 --> 00:59:47,348
AND HOLD YOU AS A TEAM LEADER

2038
00:59:47,348 --> 00:59:48,850
ACCOUNTABLE FOR IT.

2039
00:59:48,850 --> 00:59:50,285
BUT JUST MAKING SURE THAT

2040
00:59:50,285 --> 00:59:51,119
EVERYBODY IS INCLUDED IN WHAT'S

2041
00:59:51,119 --> 00:59:51,586
GOING ON.

2042
00:59:51,586 --> 00:59:53,588
AND THAT PEOPLE DON'T GET SHAPED

2043
00:59:53,588 --> 00:59:55,056
AND BLAMED AND BULLIED.

2044
00:59:55,056 --> 00:59:58,626
IT IS REALLY PRETTY BASIC STUFF,

2045
00:59:58,626 --> 00:59:59,594
BUT SO ESSENTIAL.

2046
00:59:59,594 --> 01:00:02,330
I'M HAPPY TO TALKABOUT

2047
01:00:02,330 --> 01:00:03,431
IT ANY TIME, I'M PASSIONATE

2048
01:00:03,431 --> 01:00:04,666
ABOUT THAT TOPIC IN PARTICULAR.

2049
01:00:04,666 --> 01:00:05,033
>> THANK YOU.

2050
01:00:05,033 --> 01:00:15,033
>> LAURA:  THANK YOU.