First, I want to say that it's really important
for those of us in health care
to be able to talk to people whose primary mission
is advocacy for patients,
and I think that is just so important to keep us centered,
because that's the reason
that I personally went into anesthesiology
and health care in the first place, became a doctor.
And I think that's true of people who are nurses, respiratory therapists,
all of us who-- physical therapists, nurses' aides--
whatever reason people go into health care,
it's to help patients.
And there's so much complexity to it right now,
that it's great to have an organization that is so focused on that.
So that is fantastic.
And I've personally gotten to see some of the work that you all have done
when I was there in 2018.
One of the things I love is this--
everybody's wondering what's coming next in health care
and what's going on with COVID,
and I really like this quotation from Yogi Berra,
"It's tough to make predictions,
especially when we're talking about the future."
I feel like that pretty much sets up where we are
because we're always wrong in what we say.
Just my background, in terms of who I am and my connection--
many of you are in New York, but not all of you, I think.
I was actually in New York volunteering at one of the hospitals
through Serve New York in April
as a clinician, as an anesthesiologist,
and it was-- for people who are familiar with it at NYU--
in the ICU as a critical care physician,
I worked and--
don't worry, there's no--
I blurred out any patient-sensitive information there,
but I just wanted to show how much equipment there is,
how much technology,
and this will be a brief part of this--
I will get to handwashing and hand hygiene, don't worry.
So, what I learned was there were a lot of challenges
that even I didn't know.
I've been working in the space for two--
I'm in my second decade of working in patient safety,
and I've been working for more than 20 years in anesthesia,
and I realized there were a lot of challenges.
We had volume at 400% capacity for ICU beds compared to normal,
we had really sick patients, we didn't know how to treat them,
we didn't know what would work,
we were running out of equipment, running out of staff,
the equipment that we had was often borrowed from different places,
people had volunteered it,
so we had different machines than normal.
So in addition to people who weren't used to working with each other,
we had unusual equipment.
All of a sudden, people used to working in cath labs or oncology,
they suddenly were ICU nurses,
which may not need cancer nurses.
So that may not seem like a big deal but--
and you had anesthesiologists from Michigan being ICU doctors.
So it may not seem like a big deal
to people who don't have a technical background in it
but it's like having the helicopter pilot become the 747 pilot or vice versa.
Everything has its own familiarity that you're trained on
and you really know well.
The protocols were changing every day.
But the biggest thing is this bottom one
that there were no families in the building,
and that was to prevent the pandemic from infecting the families
and making it even worse.
But why do I say that?
I say that because it was something I didn't anticipate,
which is the toll that took on all of us as caregivers, as providers.
I'm talking about the doctors, the nurses,
the respiratory therapists, the nurses' aides.
the reception staff.
Every single person just found it so hard not to see any families
because you had to provide clinical care for people,
which we were used to,
but you had to be their emotional support too
when they were isolated from their family,
and you saw how hard that was and how much that impacted
and really impaired their healing, the overall healing of them.
So, that's a little bit of background
that even in this incredibly difficult disease
with so much complexity and a lot of technical things,
that that really was the hardest thing for all of us.
And so we can really see the importance of what you all do
to focus on the patients,
and being sure that they're really upfront.
I just want to tell you of a typical patient safety event
that we might hear about.
It's a lot of words but don't worry, I'll summarize it.
A patient safety event, for those who--
again, I don't know the familiarity of everybody
so I apologize if I repeat things,
but I like to make sure that we all have a level setting
and that I'm not using too much jargon or technical terms
because I always think that's just a way for us to hide
from what we're really saying.
A patient safety event is like when something bad happens
that threatens the safety of someone in the healthcare system
and it really shouldn't have happened.
So that's how we think of it.
It's something that shouldn't happen that happens.
There's a 47-year-old teacher who goes for a mammogram,
just the annual mammogram.
And the radiologist sees an area that isn't right,
but a lot of times, these areas that aren't right are okay.
For people who are familiar with mammograms,
most of the time, sometimes they get just a second read,
another radiologist looks at it and they say everything's fine.
Sometimes though, it does require a biopsy.
Sometimes it requires another mammogram
maybe in six months or three months.
There are a number of-- an ultrasound--
there are many different things that you could do,
but it doesn't always mean that it's a bad thing.
But it does require some follow-up
in this case.
So, there were some office changes in the patient's doctor,
their regular doctor.
PCP is primary care doctor, like the primary care physician.
And that doctor should have told the patient,
"Hey, you've got to follow up on this."
But because of some changes in staff that they were going through,
they missed that notification
from the radiologist that sent over the note.
And they weren't on the same electronic medical record,
because they would've been able to see it all.
But sometimes the primary doctor
is not on the same one as the people who do the mammograms,
and that's what happened there.
The patient was told at the end of her mammogram
that the radiologist would tell her if anything was an issue
so she just assumed everything was fine when she didn't hear anything.
And there's a little technical detail
of how they make the follow-up calls in that radiology practice.
There was like a printed list where the radiologist
whose job it was that week would have to call
the small percentage of patients that needed follow-up,
maybe another mammogram, maybe another study, maybe come back in.
But this patient was on page two and the printer ran out of paper,
so they only got page one.
So it was kind of a lot of things. We kind of talk about it
in terms of all the holes in the Swiss cheese lining up,
is how we think of it.
Just a series of mistakes really,
each one of which wouldn't have been a problem,
but when they all happened, it was a problem.
So, a year later, in a visit with her regular doctor,
the doctor realized that she should have followed up.
And then she got a follow-up
and turned out she had stage three cancer,
which means that it involves the lymph nodes,
so it's a more advanced cancer than perhaps she would have had,
and certainly, it was not the intended treatment.
So, this is something that we see
which involves technology.
But really, what we see is
when we look at the root cause of patient safety events--
so what that means is when we have an event like this,
of course, at the local level,
the organization needs to care for the patient,
that's the primary thing to do, apologize, be transparent about it,
that's what they should do.
But they also need to understand why it happened.
And I went through some of the things.
But some of it is the way the technology was
and the way that people there were interacting with it.
Some of it is what's called Safety Culture
which is the ability of the team to really speak up.
So, why would that be important?
Because maybe they knew that there were problems
with their technology,
and nobody there really said anything
because they knew they wouldn't be listened to.
Surprisingly, that's a big problem in health care.
The physical environment, the kind of printer they had,
the fact that the radiologist and the primary care doctor
weren't working together.
Communication was a problem, you heard that.
And staffing, they had changes in staffing,
turnover in their staffing in the primary care doctor's office.
All of these things, each one of which,
if they happened on their own,
might not have led to this serious problem.
When you put them together, they lead to a serious problem.
So, that's a background for what I do in patient safety, is I look at--
and what we do at the Joint Commission
is we work with organizations when they have a serious safety problem.
We might hear about it from a patient,
a family member, a staff member, a visitor,
somebody might tell us,
and then we'll work with them to understand what the problem is
and how to solve it,
and try to really understand the root cause
or the fundamental causes, they can make fundamental changes.
When we speak of infection prevention--
so, when we think of infection prevention,
the most common types of infections that we get is something called sepsis,
which is a bloodstream infection.
You may not have heard of it but it's actually the leading killer
in hospitals from infection.
It can come from almost anywhere,
but eventually, once you get serious bacteria in your blood,
it can be a really bad thing.
People can get urinary tract infections.
Many of us have had urinary tract infections
or family members have,
and usually they're not serious.
So, I don't want to scare people to death, but sometimes they are very serious.
Pneumonia is another one that is in the same category.
You can have pneumonia and be treated as an outpatient,
but you can also get very sick from pneumonia, as we see with COVID.
The last common source of infection,
cause of infections in hospitals and healthcare settings,
are what's called Surgical Site Infections or wound infections.
And that is, surprisingly, a big problem,
that we do more surgery in this country than any other country,
and that's not just total, but that's per capita
or per person, if you will.
An average American has more surgery done,
is more likely to have a procedure than anywhere else.
So, the fact that we have an infection problem
impacts us tremendously, it costs a lot of money,
adds hospital days, and kills people.
So, these are all very serious things that can happen.
I'm going to show you a quick video in a second
of the importance of these.
But these all have a common solution.
Every one of these things, which all sound technical and serious,
and we've spent millions of dollars--
billions of dollars, actually, looking into these,
if we wash our hands better as doctors, nurses,
family members, even patients,
we will have a reduced incidence of these.
And that was a great introduction from [Maya] on Semmelweis,
and it's so important and really humbling to hear
that as physicians, as doctors,
we cause a lot of these infections and we need to be aware of that,
and humbled by that.
The thing that I wanted to call out in that
that's such a common misconception,
not just of staff, but of patients and families,
is that wearing gloves is no substitute for hand hygiene.
So, a lot of people don't realize that,
they think that if they've got gloves on, they're good.
And a lot of times, the gloves become contaminated,
and you're really just transferring germs from here to there.
It's really key that people understand that gloves are not a substitute,
they're a barrier protection for the person wearing them,
but they're not any substitute for hand hygiene.
One of the things that organizations--
every organization, whether you're talking about a doctor's office,
or a nursing care facility, or a home healthcare agency--
suffers from this lack of clarity around hand hygiene.
Why do I say that?
It should be really simple.
It should be, basically, always before and after entering a patient room.
It shouldn't be like if you're going to touch something and so on,
because that can change in any setting.
It should be really clear.
Why should it be really clear?
Because it's really easy to hold yourself accountable
and your colleagues accountable to something clear.
If the standard is every single time,
always before and after you go in a patient's room,
you foam in with an alcohol-based prep
or you use soap and water for at least 20 seconds,
then it's really clear what you should do.
And if I miss an opportunity for hand hygiene,
somebody can coach me on it.
If we say, "Oh well, we only have to do it if we touch somebody
or if we're doing something patient care-related,"
then it becomes really complicated to figure out,
"Well, was I really intending to do something patient care-related?"
And essentially, coaching, and also holding people accountable
becomes very, very difficult.
50% of providers, at least, fail to perform hand hygiene
on a regular basis as they're expected to,
which is a huge problem.
And the saying is,
and this has been repeated by people
who've looked at the data,
that if hand hygiene were a drug,
it would be the most powerful drug we have in health care
to prevent death and illness.
So, it's a great focus on hand hygiene.
When we talk about infection prevention,
I know this is repetitive, but what can you do
as somebody working in the healthcare space
or as a family member?
You can wash your hands,
you can ask the staff to wash their hands.
What are some other things you can do once we get beyond hand hygiene?
Because I talked about a lot of kinds of infections
that have more causes than just hand hygiene.
One of the things you can do,
I mentioned about how we do a lot of stuff to people in health care in America,
we do a lot of surgery,
we do a lot of procedures,
we put a lot of IVs in people,
we put a lot of tubes in people for various reasons.
The quicker you can get those out of yourself or your family member,
the better off you are.
Of course, they're sometimes necessary, not questioning that.
But there's been groundbreaking work
that seems perhaps really simple,
where they have some checklists that they've come up with,
and one of the things they do
is they ask every single day about every patient,
"Do they need all these things in them?"
Because just asking that question
and empowering the staff, the nursing staff,
everybody on the team to say, "Hey, do we really need this IV?
Do we really need this fancy line in patients?"
is really important because, as fancy as a lot of these things are,
they cause infections when they sit there.
That includes bladder catheters, things like that.
Now, do not ask for antibiotics when they're not needed.
Why do I say that?
We have a huge problem.
Again, in the U.S. we prescribe more antibiotics than anyone in the world.
It's a big problem.
So, overtreatment causes its own illness
that causes all sorts of problems by disrupting our own normal bacteria.
And that might sound like, "Well, who cares about that?"
but that makes people really sick.
It causes also a problem called drug resistance
or antimicrobial resistance where the antibiotics no longer work.
And that's not just for someone else,
but that can be for you when you get a subsequent infection.
So, most of the time, when we get sick, we don't need antibiotics.
There's only certain situations we do and it won't even help if we get them.
But if you're actually prescribed antibiotics
and you really do need them,
you shouldn't just stop taking them once you feel better.
That's also something that can cause illness.
Now, this is something that-- I started off with a radiology case,
and this is a CAT scan--
it doesn't really matter if you haven't read a CAT scan before--
but what's interesting about this
is they asked Harvard radiologists to read this many years ago in a study,
about 15 years ago, 10 to 15 years ago,
and the same finding would be true now.
They looked at it and they said,
"Say all the things that are abnormal in it."
So, people looked here and here
and here, and so on,
and what they didn't see was this guy here that's a gorilla.
And I don't know if you can see it,
but on my view, it looks pretty clear like you got a little...
(man laughing)
And you can google it,
it's called the invisible gorilla if you do,
and there's a great video that lasts for a little while.
So, I didn't want to show two videos the last little while,
but it really is impressive and this--
(man) [inaudible]
So, most, two-thirds of the Harvard radiologists
did not see that gorilla and they were looking really closely,
they were finding all these tiny little things
and they were asked to say all the things that are abnormal with it,
but they couldn't find a gorilla that is way bigger than any normal--
no cancer or anything else is almost ever that big.
It's huge.
And nothing's that clear, but they're not looking for it.
And that's called inattentional blindness,
and it doesn't, in a way, matter what we call it,
but it's just like you might think,
which is if we're not looking for something, we won't see it.
So, if we're not looking for doctors not washing their hands,
we might not even notice it.
If we're not looking for people
thinking that gloves are as good as handwashing,
we might not see it.
So, it really matters what we're looking for
and being aware of this.
So, it's really great work that you all are doing
by making people aware of that.
And that's the same for us as clinicians.
So, if anybody ever came to me and said,
"Hey, are you aware that you didn't wash your hands?"
it's not that I tried to go in and not wash my hands,
it's that I was preoccupied or thinking about
"Well, what am I going to do for this patient?"
or I have another patient going for surgery later,
I'm thinking about something else.
So, it's not usually that I'm making a conscious choice
to just disregard what I'm supposed to do,
and that's true for lots of us.
As doctors, and nurses, and nurses' aides,
and patient care sitters,
we're all very busy because we have a lot going on
and we can be distracted,
and then we will just miss a really obvious opportunity
that's right in front of us.
Common source of error is infection in the operating room,
and this is one of those patient safety events that we had.
So, when we sterilize instruments, we clean them before surgery.
That's done by a really important group of people who are some of the--
they often work in the basements of facilities
and they have very rigorous processes
to clean the instruments to make sure they're safe for use,
and they have to go through these sterilizers
that heat up the instruments and put them under pressure,
and use cleaning solutions,
and they have to be basically certified or stamped as okay.
So, when they have these black tiger stripes
like you can see on one of them,
then they're ready or sterile.
Before they go in the sterilizer,
so there's surgical instruments in these blue packs--
it's two separate sets of instruments--
the other blue pack hasn't gone into the sterilizer yet.
After they come out of the sterilizer,
there's a little bit of moisture,
so they have to sit there because that can cause infections too,
even though they technically don't have bacteria,
but the moisture itself can pick up bacteria from the air,
so you'll need to let it dry afterwards.
Why do I say that?
What happened in this case is,
they left these together on the same rack,
so the ones that were supposed to go into the sterilizer
were right next to the ones that had been sterilized,
so one of them is ready to go to the OR because they're clean and sterile,
the other one needs to go into the sterilizer.
And what happened?
Well, sure enough--
this is just another way of looking on the inside of the pack.
When you open it, you have a sterile indicator
and one that's not changed.
So, there were two surgical drills-- I'll just go back--
that were in these packs
and one of them was sterile and one of them wasn't.
Unfortunately, the unsterile drill went to the OR,
because somebody from the OR came to pick up the sterile pack
because they didn't have it in the OR and they needed another one.
The first one, the battery didn't work on it or it jammed,
so they needed another one.
So, they came up and they were kind of rushing
because the patient's under anesthesia,
and they asked the people from sterile processing
to give them the sterile pack and unfortunately,
they grabbed the unsterile one.
If you look at these two things together,
it's easy to tell the difference between black stripes and yellow stripes.
But if you imagine somebody who's really busy
thinking that there's patient down there in the OR
and a whole team of surgeons and anesthesia and nurses waiting,
you can imagine that somebody might just look at the blue and grab it.
And that's what happened and then it got into the OR.
I won't go through-- in the interest of time,
I want to make sure that you guys
can really get a chance to ask as many questions as you want--
but what we do at the Joint Commission and other organizations,
we would expect them to do a root cause analysis on this
and understand all the factors that led to it,
not just that they were mixing sterile and unsterile,
and that the way that everything was crammed into sterile processing--
CPD means sterile processing--
and unfortunately, the patient was exposed to an unsterile drill,
which is a very dangerous thing for that patient.
At the Joint Commission, we work on a Speak Up campaign
and this is small, I understand, but we have it online,
if you just google "Speak Up To Prevent Infection."
The number one thing is clean your hands.
Soap and water is just fine
and alcohol-based rubs work just fine too.
You need to--
We require organizations to monitor their own caregivers,
but the more patients and families
can remind caregivers to clean their hands,
the better off they are.
When I personally have a family member go in the hospital,
I try to make sure that somebody is there looking out for them.
I think that's so important.
Keep away from others when you're sick.
I think we're all learning that now.
Stay home if possible.
A lot of us have got in the habit,
over the years, of going to work when we were sick,
and we know now, during COVID, how dangerous that is.
If you're coughing or sneezing,
wearing a mask is a great idea and distancing is a great idea.
Again, during COVID,
some of this has become very clear to us.
When you go to visit a patient in the hospital,
you need to always clean your hands
before and after entering the patient room.
And the other thing is that
in some organizations people have,
depending on what-- it's called precautions--
depending on what illness the patient has,
you might have to put on, even outside of COVID,
a mask, gloves, or gown.
And really, asking the nurses, asking at the nurses' station
before you go in the patient room
if it's okay to do so based on infection control is important.
And then, getting shots to avoid disease.
Appropriate vaccinations not just for yourself,
but to avoid transmitting diseases.
I have just one more video that--
in health care we try to be as clear as possible with communication,
and this, I think, is a funny example of how sometimes
the more we insist on being clear, it's not always clear.
♪ (music from video) ♪
(speaking in foreign language)
Alright. So, anyway, I thought that'd be an amusing interlude
and it's pretty relevant,
even though I think that's a Greek commercial,
it's pretty relevant to the U.S. where a grandma has a gun in her purse.
And then they have the bankers,
when they say "Only those doing the robbery,"
the bankers all have to get up and leave.
So, I thought that was pretty good.
But anyway.
So, what are the most common errors
or harms that we see overall?
So, not just infection-related.
Certainly, infection-related is one of the main ones,
but since you all are advocating for patients,
I really want to mention medication, getting medications right.
Eileen said that I should make sure that I didn't call it--
just to say reconciliation because not everybody knows what that is,
but it's making sure that when I--
that I get the right prescriptions for me,
that I get the right medication,
so, I don't get someone else's list and I don't get an old list of my own.
It becomes complicated but you can imagine--
and this has happened--
if there are two people named Ed Pollak, that might seem far-fetched,
but at any time in a given healthcare facility or given pharmacy,
there are often multiple patients with the same name.
Famous case that we--
well, actually, we're not allowed to repeat names,
but you can just imagine more common names than Ed Pollak
that would be redundant,
meaning there are more than one patient
in a given pharmacy network that have that name,
so they can easily dispense their medications
when you go for a refill.
So, always check to make sure that you're verifying it
against your own prescriptions
and that you are engaged with that.
We talked about diagnostic errors,
I mentioned that earlier, that was the first case that we did.
Surgical and procedural errors, I mentioned that.
Hospital-acquired infections, and falls.
That's really all I have as far as prepared material.
I will stop sharing my screen
and put my video back on,
and be happy to answer any and all questions that you have.