Chasing Zero: Winning the War on Healthcare Harm



most of us think of hospitals as cathedrals of healing and hope and we stand in awe of the doctors and nurses who work in them as the architects of miracles but even the best hospitals can be dangerous places with unknown hazards that can cause catastrophic harm they are the battlefield of a war with an invisible enemy that never sleeps failing support systems that can't keep up I'm Dennis Quaid I found out about healthcare harm because it happened to my family since 1999 we've known that more than 100,000 Americans die every year because of health care harm that's the equivalent of more than 10 jumbo jet airliners crashing every single week in that number doubles if you include infections that patients get from hospitals the sheer number of deaths is shocking however what's even more shocking is that it is possible to bring this number to almost zero so why isn't it happening you will meet just a few of the leaders who are making it happen they call it chasing zero and they are preventing the enemy from shattering other families lives the way it almost shattered mine our twins were born the healthy and happy yeah we just got them home one if they had a staph infection they'd go back into the hospital they were overdosed twice with a thousand times the amount of heparin that they should have received our little twins were the victims of preventable harm they came very very close to dying you know I've been in the hospital in my life I had never given a thought to my own safety about being there you always trust the doctors and the nurses and and they knew what they were doing and they never made mistakes but this is preventable error it's a wake-up call for my wife and I to try to do as much as we could to me to try to make sure this doesn't happen to other families well the twins were in the hospital and they had made it it made me feel that they had survived for a reason that that first offer really thank God that they had pulled through and but they'd survived for a reason that they were maybe going to change the world in a little way that might wind up saving more lives I was looking for a way to help prevent harm to other families and children when I met dr. Charles Denham the leader of T MIT a medical research organization in patient safety he introduced me to the heroes in the movement and I have found a role I can play I've joined the army of those who are chasing zero harm together near the group of leaders in hospitals who you can ask to step up tell you what I'm excited about I'm excited to be working with people like you chuck because you've taught me quite a lot we are so grateful to have somebody that's a voice thank you fear is a major barrier to action but the great ones like the Mayo Clinic are ever vigilant and humble champions of high performance they are just one of the chasing zero role models I'll never forget the day that we learned of quite accident that Jill came over me I asked myself could this happen at the Mayo Clinic the answer was yes the collaborative empowering culture of Mayo allows nurses to redesign their workflow they adopt safe practices and even allow their cleaning staff to get involved they develop their own new cleaning checklist of high contact services to prevent infections using culture methods from other industries if we can help them not to get more infection real not just cleaning homes will saving lives this is a Pyxis medication dispensing unit it's another system safety net we have to protect patients from the frailties of competent human beings our nurses enter the identification number and the patient name to make sure that the right medication is take it out of the Pyxis unit and the pharmacist put the medication in only after they bar-coded it to make sure it is the right medication for the right patient in the right cells despite the efforts of places like the Mayo Clinic Healthcare harm still occurs in many hospitals sue Sheridan is a great example of someone who has turned her family's tragedy into triumph by putting aside her anger and resentment moving forward to make things better in 1995 my son Cal was born a healthy baby normal delivery when we were home he started to change before our eyes and eventually Cal was readmitted into the hospital it was discovered that his jaundice was I'm over the nurses terms off the charts one of the highest I'd ever seen at the hospital they treated cows jaundice with traditional treatment with photo therapy however on the second day that he was there after about 24 hours Cal started arching backwards there are classic signs of the onset of brain damage from jaundice Cal now has a condition called connector Asst it is brain damage from jaundice and he has significant cerebral palsy he's hearing impaired he speech impaired very bright very woody but his lifelong challenges were totally preventable we just finished a survey we surveyed over a thousand hospitals across the country and when you look at the bottom performing the worst performing hospitals in America not a single board chair from any of those hospitals not one thought they were below average and these are hospitals that are at the very bottom of performance there they are they have terrible quality and yet most thought they were better than average a few thought they were about average but not a single one thought they were they were below average and it's a level of denial and a lack of knowledge about their own performance that I think is shocking business performance guru Jim Collins has documented how even the mighty fall in his recent bestseller the principles are frightening ly applicable to hospitals how do institutions fall how do they go from great performance to good to mediocre to bad and maybe even irrelevant we're gone all we found is that it is actually a little bit like a stage disease that there's that you go through the early stages of the disease still looking healthy on the outside you can be more easily deny that you're sick because you look healthy now if you look inside you might not look so healthy but you look from the outside and you can still say see we're still doing well if our healthcare leaders can get through their denial about their failing systems it becomes a David and Goliath story Goliath is fear fear of shame fear of malpractice and fear of cost to win the war on harm we must activate the inner David in our hospital leaders they will find that Goliath is not as big as they think he is the weapons against healthcare harm our leadership safe practices and technology great leaders take risk they confront their fear to drive adoption of best practices and they invest in technologies that make it easier to be safe has this been done before do we have role models absolutely many agreed that the Institute for healthcare improvements 100,000 lives campaign led by dr. Don Berwick ignited the passions of America's health care leaders to save lives and put us on a path to zero harm don't take me back to when you stepped up to the podium and announced the hundred thousand lives campaign were you scared what was it like we knew we were going out on thin ice and I was scared I stood in front of 5,000 people at I chose annual national forum on quality improvement in health care and I was gonna lay out this challenge here's the number 100,000 and here's the time June 14 2006 9 a.m. I really didn't know what the reactions would be denial anger silence of course what happened was just the opposite we got more involvement and more enthusiasm and more buoyancy in the pursuit of health care improvement and I had experienced in my entire career what was it like to realize that the hundred thousand lives campaign then was achieved the goal was met the biggest surprise in the hundred thousand lives campaign and the five million lies campaign that followed it was the reservoir the the immense reservoir of goodwill go commitment courage intention in the healthcare workforce doctors nurses technicians pharmacist managers all over the nation eventually all over the world really wanting to make Care safer and better not angry that we were challenging them to do it but grateful that we would we would put a stake in the ground and that we would say let's go do this back that that energy it still AHS me many of the main elements to the 100,000 lives campaign have become key National Quality forum safe practices a leaders blueprint to chasing zero the safe practices are a road map there's no need for every hospital to reinvent the wheel these are practices that have been proven there's a strong evidence base they can be implemented in every single hospital immediately leading organizations such as the Mayo Clinic Cleveland Clinic Vanderbilt Catholic Healthcare Partners and Brigham and Women's Hospital are working with T MIT to validate the financial business case for adoption of the safe practices so that leaders will greenlight investment in safety for boards and administrators I think the green light approach will help them justify the hard decisions that need to be made about investing in changes that are going to tangibly improve safety we have some great action lists for leaders like the National Quality forum safe practices that is we know what to inline so far we're approaching that as a matter of volunteerism we're saying please do this we know it works saves lives reduces injuries ultimately we're gonna have to mature I think to the point where a safe practice that's well known is no longer an optional matter you have to be safe because we know how to do it we owe it to our patients it's an honor really to be a part of authoring and EQs safe practices what I really appreciate is that they're involving patients because patients are a part of the health care team but often unused 1im sauce and so it's it's it's really great that that are involving patients in the process mr. Cueto to understand what happened to your twins you had on the screen picture of the two vials I do have them right here they look very very much alike the one that was 1,000 times more was the one that was administered to your children is that right yes sir and once but twice over an eight-hour period not once but twice yes how could this have happened well the answer became very clear to us after talking with the doctors and nurses and doing a little bit of research on our own the ten units of heparin 10,000 unit of heparin are deadly similar in their labeling in size the 10,000 unit label is dark blue and the 10 unit bottle is light blue and if the bottles are slightly rotated which they often are when they're stored they are virtually indistinguishable now since this breast of a tragedy my wife and I have found out that such errors are unfortunately all too common since our accident the labeling on the vials has dramatically changed our twins Zoey Grace and t-bone Quaid are already protecting other kids and saving lives while my wife Kimberly and I have been on this journey we've had the privilege of learning about many other families who have gone through similar tragedies Raks me I always had a smile and he just didn't leave he loved life he was premium time in the dedication he'd spent hours at the stairs I'm daddy throws and pucks at me dad you know and I think the difference between a an athlete and a professional athlete is as their heart and their dedication and I think braixen could have been one to take it real far now let's go back to the beginning Braxton needed the surgery for sleep apnea was Braxton worried he always put on a tough face but yeah he was he was concerned he was very worried what did you tell him that he was gonna be okay and it wasn't true we brought Rex home from the hospital and everything seemed fine you know he wasn't complaining much of pain you know he was resting and watched TV and we sat with him watching cartoons and about 4 o'clock he said daddy I'm hurting so I gave him his pain medicine and everything seemed all right he fell asleep it seemed normal to me and he woke up at 7:30 and he said daddy said you know um my chest hurt you know it up I'll never forget that you know in seven just comforted him and I asked him Rex her are you alright are you in pain do you need something for pain and he said no damn fine that's the last time I saw him alive we went months and months without any answers from the medical examiner and you know all we wanted to know was what happened to our son the rels went for four months without answers and then they were forced to seek legal help the system failed them 13 months after Braxton's death all they had was an autopsy report sent in the mail when I went to get the medical records I was given two or three pages and I was told that they don't keep anesthesia records and nursing notes and it just didn't seem right to me so I talked to some experts and was given some advice on how to get the complete set of medical records which I did you know it really erodes your trust and it makes you fearful you know you think that you would have answers right away when something adverse happens to your loved one it's been 13 months and we still don't have all the answers and so you don't have closure no closure at all you know a lot of times I think that lawyers get involved in hospitals lawyers get involved and the focus seems to be on risk management um after an accident occurs and not to say that they weren't doing everything that they could to right the situation but it's as as a as a human being I feel felt that last thing I want to do do was focus on legal issues and somebody's liability you know the last thing we wanted was to hire an attorney just to get the answers that we should have had all along the NQF say practices states that hospitals and caregivers should reach out to families after an adverse event without any type of communication it makes us feel that you know Braxton didn't mean anything to anybody but us and you know you just can't you have to communicate you know it's it's the most important thing there is it's understandable that a hospital reacts the way that they do because it is a business there is liability involved yes and it has they have to protect themselves and protect that entity but what happens in the end is that one of times the problem winds up not getting fixed because a lot of things get swept under the carpet they don't want people to talk they don't want the nurses to talk they don't want the staff to really talk so the investigation into what happened is stifled for sooo preventable harm struck her family not once but twice shortly after Cal's injury my husband Pat had a pain at the base of the skull and his cervical spine they removed actually a tumor from the base of the skull set it to pathology the surgeon came out when my husband was in the operating room and he shared with me that it was a benign tumor and six months later my husband was in pain again we've got another MRI and it was discovered that Pat had masked the size of the surgeon's fist the final pathology report from his initial surgery indicated that Pat had cancer this misplaced path report was yet another error that shattered the future for the Sheridan family ending Pat's life prematurely we to this day still don't know what happened to it it appears that it got filed in my husband's charge without anybody seeing it except for the pathologist Pat underwent five more surgeries they basically removed his spine he became disabled so I had a son using a walker and a husband using a walker but after about a year and a half of treatment Pat's cancer came back explosively and he woke up paralyzed one day from his waist down and they they shared with us that he had about ten days to live Pat had always told me that if he was gonna die from his cancer he wanted to die with family and friends and a bunch of really good wine and he after a long long pause said I want to go to Disney World said I want to watch my kids and my family have the time of the lives and so after I collected myself I picked up the phone I called Disney World and within four days 53 of us flew to Disney they put the kids in parades they sent up Minnie Mickey Pluto it was truly a celebration on the third day cat died at Disney World one of the biggest barriers to getting to safe care all the time everywhere is fear we're trained if we make mistakes not to come forward that this is something to hide and feel badly about and sometimes people are punished when they acknowledge mistakes a very powerful lesson gets learned immediately when that happens generally and I put ourselves at the nurses shoes I'm sure that no one wanted to harm our kids but it's human errors a part of the system it should not be criminalized all it's going to do is alienate the very people that we're trying to bring in to help think make things better I wanted to work as a nurse and with babies since I was a little girl in 1990 I graduated from nursing school I had four little babies up until about four years ago and this happened my life was full of babies on the 4th of July I worked double shift and we were busy and it was almost 1:00 a.m. before I was able to kind of wind down and leave and I lived a long way from the hospital and I decided I was too tired to drive home and I needed to be back in a few hours to do the day shift I was scheduled for and so I laid down in a patient room on a patient bed and tried to sleep and got up um to start the next day and at 9 o'clock I'm not the patient she was just a very young 16 year old girl and she was so scared the plan was that they were going to break her water and um start some pitocin and she was going to deliver her baby Julie followed nursing unit guidelines designed to improve readiness of patients for anesthesiologists to give an epidural injection she adhered to the checklist of guidelines and prepared the anesthetic medication at the same time that she had antibiotic medication ready to go a number of systems flaws contributed to Julie's absolutely predictable human error so I got her IV her antibiotic and her epidural they both bags had ends that received IV tubing I had her antibiotic in my hand I knew that but I didn't have around my otic in my hand I had a rapid dural medication in my hand and after it started running I heard a sound and turned to her bed and she was already arresting people came to remain mediately many many many people dozens of people who are familiar with both of those medications that we used everyone saw that hanging there in fact I said I just hung this antibiotic and I think she's reacting to the penicillin and then someone cleaning the room found the bag you brought it to me and they were crying he put it in my hands and it didn't make sense for a while I kept okay and then it just Julie administered the wrong medication fatigue identical medical tubing connectors similar IV fluid bags in a sub-optimal barcode process I'll spell death for the young mother the hospital fired Julie she was criminally indicted as a single mother of four and with no resources to defend herself she had to plead a misdemeanor to avoid prison what happened to her led to the development of the new National Quality forum safe practice called care of the caregiver well the Joey Tao story is really a tragedy because she was hung out to dry for making a mistake which was clearly caused by a whole host of very bad systems she was truly the second victim in two ways she was the victim of bad systems as well as being emotionally a second victim she was devastated by her error as anyone would be but in addition she was the person who was the victim of these bad systems and the lesson I think is not just that hospitals need to be responsible for their systems and fixing which is clearly what they need to do but there's a second lesson here and that is Julie Tao was fired she was indicted she lost her license because she was presumed to be incompetent there's no evidence that she was incompetent no evidence was ever produced that she was incompetent Eric crop is a hospital pharmacist convicted of involuntary manslaughter after a two-year-old girl received a fatal injection of saline solution more than 20 times the intended concentration a pharmacy technician working under Eric on a very busy day accidentally mixed the clear saline solution incorrectly by signing off on her work eric sealed his fate I was your coach agent wish you good I wish I could change places with Emily Gerry I wish I was one of dads uptight it is just the way because I didn't have anybody there for me either it hurts well I think the criminalization is a terrible thing because both the examples that I know they've unfortunately only been a few but in every case there were obvious explanations for why the mistake happened and those explanations all have to do with the systems they were working in when we now have a safe practice around care of the caregiver which define good ways to deal with the people involved at the providing end of care and they need help they need healing they need support and you need them sometimes the the best knowledge you could ever get that will allow you to redesign the care system for which you are responsible will come from the very people who have been trapped in a spider web of cause and effect that's led to the injury three years after the death of Julie's patient the hospital published an independent study revealing that multiple systems issues contributed to setting up Julie's error an honest mistake anyone could have made never shrugging her accountability for causing a death Julie has moved on as a tea MIT patient safety fellow to help save other lives hello is this portland general hi could I get your patient safety department she is helping measure life saved and dollars invested in safety from the impact of video stories now being used in thousands of hospitals deployed by T MIT one of the many video stories is about a little girl named Josie King I would like to share my story with you I do this with the hope that what I'm about to tell you will make a difference in how you care for your patients and how strongly committed you and your hospital are to patient safety Josie was admitted after suffering first and second-degree burns from climbing into a hot bath Josie's death was not the fault of one doctor or one nurse it was the result of a total breakdown in the system the power of stories is incredible in story power the secret weapon our article targeting health care leaders we share some of the secrets of the power of connecting the head to the heart to prompt action in it we present the preliminary results of this Josie King story and its impact on 2,000 hospitals it revealed that the majority of users have seen lives saved and money invested as a direct result of viewing it we can control Hospital errors and we can save the lives of other potential victims other helpless children well the battle is is one of the life at a time I think that's what the battle is one mistake at a time one were the life at a time in the war it's really the end result of the war would be taking medical errors down to zero so you need three things you have to start with engaged leaders then practices that work then if you implement the practices with great technologies that make it easier to be safe you have the winning combination in the war on the fin of alarm here lies the sweet spot of high-performance and safe care many hospitals are getting extraordinary results from ordinary things they already have today my biggest lesson that has been to empower the staff we spent two months listening to 250 people in this organization about what we could do to make it better we came up with a list of 72 recommendations 71 of those came from the staff that's what we're implementing and that's why things are getting better Harry hello hi this is Amanda she's gonna be your nurse this evening an example of staff led innovations is share rounds developed at the Mayo Clinic in Rochester Minnesota which helps nurses include patients in the process of passing on information during shift change making the patient and family part of their own safety net it's really hard to understand how your day is going to go without visualizing the patient we used to give report right out at the nurse's station or in the back room the nurse would sometimes write report or tell you in person but you can't really assess a person or be prepared for your day until you actually see the patient in person so they kept the IV fluids going he said L are going at 150 the first thing we do is we can get an overall picture of how the patient is doing so they'll write prescriptions for you on the data we can see that he's doing well as pain is under control and maybe address any needs right away I'll be leaving now but Amanda's gonna take great care of you tonight this way before I leave the patient is comfortable with who his next nurses I feel more involved makes me feel reassured that the nurse coming on knows exactly what's going on with me and know they are in coordination I can ask questions as well and um if this something that I'm concerned about or I'm thinking about I can bring it up because the nurse is going off knows perhaps something that we discussed earlier and and then it sort of reminds all of us to pass it on to the nurse that's coming on no problem have a good evening she'll take good care of you all right I'll see you guys in a little bit okay I definitely think that this could be done at any Hospital good morning miss hon hi this is Casey she's gonna be your nurse this morning from 7:00 to 3:00 just by changing the routine a little bit and that might be a bit of an adjustment it actually is just that simple it's just bringing it in to the patient I don't just think it should be done I think it needs to be done I mean it provides for the safest way to care for the patient another great cost-free initiative is the IHI open school which puts healthcare students into the safety game literally thousands are joining the action check a box save a life that's a program devised by medical students and nursing students and pharmacy students who realize that students when they're in training and hospitals can introduce the surgical checklist as sort of change agents at from the inside they calculated the medical students calculated that a medical student during their surgical clerkship when they're learning surgery is involved in enough operations that if you do the math if they could get the checklist used and all the operations that are involved in one life would be saved check a box save up Denis are you surprised that we're just starting to use checklist and healthcare and having impact you're an experienced pilot you know the value of a checklist I can't believe it stay the truth that it's not there it's it's how much does this cost right exactly it's the most important piece of equipment really on the airport we're taking the World Health Organization checklist and we're combining it with the regulatory requirements so that we can use it in every operating room in America checklists help make things simple predictable standardized they enhance communication just like they do in airplanes okay we were just going through the checklist right you were calling it out we got the beacon and I set off what does it checklist say on on so we missed that we missed something checklist yeah and that's that's why checklists are important but they always have to be backed up by humans exactly yeah it's human error good point right we're using checklists in our operating rooms so that we can make sure that we don't miss an element of care that we provide safe care and that we do it the same way every time I feel like we haven't even touched what checklists could do for us in medicine is that a fair statement or is that unfair no it's absolutely a fair statement Chuck health care is grossly under standardized mean checklist are a tool to help us do our work but they standardized processes in healthcare we have a very autonomous culture that is grossly under standardized we got to make sure we have a checklist and ensure it's done on every patient every day all the time you know what I see when I come down is we're functioning much more as a team in the operating rooms not and I think that's huge if something's not working quite right it can be reported and acted upon before the next case yeah the checklist has been a real way of getting to that I think one of the biggest patient safety things we've certainly seen in the ORS in my lifetime I guess my fantastic avionics master yeah masters on emergency lights emergency lights on beacon beacon on technologies make it easier to be safe once you've engaged leaders and staff open to improve their own practices they deliver great impact currently there's just a handful of hospitals within the nation that have the barcode technology they did have this technology in place I do believe that it would save more lives I'm just going to double check here the software matches the barcode on the medication to the barcode profiled for the patient but does that safety check of the five rights the right medication the right dose the right time the right patient and the right route it does not do the critical thinking for the nurse however it does ensure that those five things are matching for the medication and for the patient before we had the smart pump we had a pump that looked similar but did not have a drug library we'd go on the information we have on paper essentially as far as how to give a medication now that we have the smart pump we're still responsible for knowing how to give these drugs to follow the policy and procedure however this is a double check for us we're able to program the pumps to know this is the way to safely give this medication this is the rate this is how fast you want to run it we're gonna use the bar coding system to scan your medication scan your patient once you get all your checks and that everything matched up you're then ready to hang your bed at the end of the day this is what double checks your work and covers you as a nurse when you're hanging medications one of the interesting things is that using chlorhexidine with alcohol prep has shown that in type ii wounds which are the more common types of abdominal surgery and lung surgery that that prep reduced the rate of infections by 40 percent when we looked at our individual patients we found that if we could reduce one infection of this type that we would say somewhere between two and four thousand dollars per event so if we could reduce surgical site infections in ten patients using this it would have paid for the entire conversion to a new prep for the entire institution this really has been shown with evidence in a well-designed way what exactly we can achieve as far as surgical site infections so where is the rationale for not doing it the computer prescriber order entry or CPOE allows doctors and other caregivers to automatically check for accurate dosage allergies and drug interactions when prescribing medications for their patients without CPOE this is a manual paper process with no safety net the sophisticated technology however may not always be implemented well it can be less effective or even cause unintended harm a real breakthrough developed by leading experts is the CPOE flight simulator that allows hospitals to verify their performance before they use it on real patients you and I've had the wonderful privilege to work together with doctors like dr. David Classen and others on the CPOE flight simulator just a printed in layman's terms what is it and what's the value the flight simulator basically lets hospitals get a sense of how good the the checks for problems are around medications when a doctor is ordering a medication and what we did was to develop a set of orders that for medications that have harmed patients and look to see how often the computer would warn about those those errors there's no question that simulation is the future of medical care I think it's the future in everything from surgical operations to the use of sophisticated devices to actually making sure that the computerized order entry system works as we expected it to you can't know until you check it and better to know ahead of time than to find out that our expectations didn't come about for everything from surgical operations to teamwork in emergencies to the use of very sophisticated devices to the use of computers effectively simulation and practice and rehearsal and getting it right in the laboratory so to speak will definitely be the way we move forward this is going to be transformative in terms of getting to safer care one of the most powerful innovations in healthcare are automated infection identification and mitigation systems called Em's for short they are being used to identify and prevent the impact of infections using computer systems I manage the office of healthcare quality really the mission of this office is to strengthen the nation's health system and to promote quality care within this country we're targeting a variety of areas the reduction prevention and hopefully elimination of healthcare associated infections is a prime focus as is medication error and coordination of care in this country is zero the number is it rhetoric or reality can the reality meet the rhetoric absolutely it's reality and we are focusing on total elimination when I received my medical training hospital acquired infections were considered inevitable but in the decades since that period of time we now recognize that they are largely preventable in our goal is complete elimination Pat died at forty five years old in 2002 with a four year old daughter and a seven year old son you know he had a sense of humor till the very end honestly and he said ed Brown he said you know whatever you do you know you'll be successful he said but whatever you do he said don't you give up on patient safety and he went on to say you know don't kick some butt so I started speaking up about what happened to my family and calling for change and he had unique opportunities to testify at one of the testimonies I met the w-h-o and soon after they invited me to join them and lead a program of patients from all over the world just like me that had experienced tragedy in health care yet who wanted to contribute in a really productive positive way in effect it was a call to action by patients to the health care system to partner with the health care system to work with the health care system this is the exciting part this is the part that inspires and ignites people and for those of us here that have lost family members or children this is the piece that gives us hope you know that the w-h-o says to us patients you're important in your voice your collective wisdom is important to the WHL that's that's a powerful thing for us to hear our future in health care to create safer more effective healthcare depends on partnerships with patients and their families we need patients and families and consumers who are not yet patients or family members to become advocates in the ownership of their own health their own healthcare and to hold us accountable when braixen passed away it was pretty tough for a lot of the kids and it still is tough for some of them we wanted to run a tournament that kind of exemplified what we felt he was all about than that sportsmanship kids that understand that they're out there to compete and they're going to play against you hard but you're still kids and you're still out there playing a kids game having fun right in here right in there the backstory hasn't finished but I think there's a chance for a happy ending that we and hospitals could have a working relationship that no one would have to feel the pain that we've gone through 14 years after Cal's birth Hospital and sue Sheridan agreed to join forces and put the past behind them to save future patients lives this may lead to them becoming a national role model the harm that our family experienced was of course unintentional what we really struggled with was what happened after the harm occurred and the wall of silence and the isolation that we felt it was very much like a hit and run we expect the truth and a sincere attempt to make every effort that will never happen again to another family when we had the opportunity to connect for me was actually relatively easy because I didn't have a lot of history but I was representing the hospital and I know that it it's a difficult time but it was also an awareness that it is time to move forward we've come a long way in health care from where safety events were considered a cost of doing business that transition from a cost of doing business to it's no longer an acceptable option the challenge that we're facing now is fully understanding how do we get to that point where none will occur or the overriding sense was it's the right thing to do and it's an opportunity to see what we can create together I am absolutely convinced that we can make a huge difference so I'm thankful I'm excited I look forward to a relationship over challenged each other learn from each other that we're going to create a model that others are going to want a copy from Boise Idaho Pat would say right on he'd see right on brown it is true that when there's profound grief the best medicine for grief is doing something productive but something bad happens in life and kind of have a choice you can shrivel up and disappear in life or you can come out fighting like hell I think we're ready to ski what do you think I don't know if it's strength per se but given what my family's witnessed and experienced I don't see any other route for me you can come out challenging life I thank God I'm hopeful you know without hope it would be a pretty missable life chasing zero is the quest to ensure that accidental death and harm like what happened to my kids are a thing of the past zero is within our reach if we have leadership the right practices in place and we leverage innovative technology visionary CEOs that are willing to adopt new principles of management and leadership and deploy them quickly are going to be successful they will be the innovators they're the pioneers but more than that they will have the feeling of pride and accomplishment in what they've done for their own organization I want everybody to remember the essential purpose of why people go into health care it's because they care about people they care about health status they care about saving lives if the future looks like the past will achieve nothing the past 10 or 12 years we've written a great deal about safety and we've done very little about it the future has to be roll-up-your-sleeves let's get going those who to supply to the hospital and medical industry need to make certain that they not only have safe products and devices but they're used as safely as possible those who use these things must be certain that they're used only to achieve the best possible clinical outcome we can achieve those of us who pay for this care must assure all those families who are paying premiums that we're using those dollars as wisely as possible to lead to the best possible outcomes in the safest possible environment we're really bringing the forces the energy the resources that we need into this really really important sphere that mail is the time there is enough knowledge there's enough energy we have enough money in the system currently to do what we need to do what we don't have enough is action we should do everything we can so that people can reach their full potential for health that's what chasing the zero is all about and that's why it's such a inspirational aspirational and realistic goal I get asked a lot by normal consumers of care what they can do to make their care safer I generally advise them take someone with you make sure that you're not alone in your care system but I think I'm more and more thinking that the answers speak up we have standards we know like the National Quality forum safe practices we know what standards hospitals should be adopting as a consumer of care ask your Hospital ask them if they're using the kinds of standards that we know can make your care safer so the National Quality forum safe practices are a tremendous opportunity for all leaders now to unleash their full potential to improve patient safety and health care quality and it's time to act now I have found the role that I can play and it is to partner with the best experts and drive awareness of what we can do if we act now the Quaid Foundation has merged into T MIT to apply the power of stories to bring consumers and leaders together our mission is to save lives save money and bring value to the communities we serve facts figures and statistics reach the head but nothing happens unless we reach the heart through stories of real people that put the hands to work join us in this war on preventable harm zero is the number now is the time you

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