Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now, your host, Dr. Sergio Zanotti.
Speaker: It has been almost 25 years since the publication of the Institute of Medicine report entitled To Error is Human, Building a Safer Health System.
Speaker: This landmark report stated that medical errors cause between 44,000 and 98,000 deaths every year in American hospitals, and over 1 million injuries to patients.
Speaker: This publication marked an inflection point in the recognition of the perils and prevalence of medical errors in hospitals.
Speaker: In today's episode of the podcast, we will discuss medical errors.
Speaker: Where do we stand today and what can we do to continue to make care for our patients safer?
Speaker: Our guest is Dr. Nitin Puri.
Speaker: Dr. Puri is a critical care physician.
Speaker: He's a division head for critical care medicine and the co-director for the Center for Critical Care Medicine at Cooper University Health System in Camden, New Jersey.
Speaker: He's an associate professor of medicine at Cooper Medical School of Rowan University.
Speaker: Dr. Puri is a recognized clinician, educator, and researcher with a special interest in medical education, medical errors, point of care ultrasound, and mechanical support.
Speaker: Nitin, welcome back to the podcast.
Speaker: Sergio, thank you for inviting me back.
Speaker: Well, we had a conversation on the same topic almost five years ago as we were talking.
Speaker: A lot has happened since.
Speaker: But I think a good place to start would be if you could tell us why do you think this is an important topic for clinicians at the bedside?
Speaker: Well, I think all of us make errors.
Speaker: And how do we deal with them?
Speaker: psychologically and how do we, how do our patients handle it and how can we help our patients get through that process and help ourselves get through that process.
Speaker: One of the things that I always appreciate, Nitin, is that the sign of intelligence really is our ability to change our mind and to learn new things, right?
Speaker: And we talked about this back in 2018.
Speaker: So my next question is, since we last talked about medical errors, what is one thing that you have changed your mind about or learned about this topic?
Speaker: Yeah, that's a great question.
Speaker: So since the last time we spoke, there was a global pandemic.
Speaker: And, you know, fear and panic had gripped our subspecialty pretty substantially.
Speaker: And that definitely led to errors.
Speaker: And it also made me think and reflect at that time, what can I do as a bedside clinician to create an environment where we can talk about those errors openly and
Speaker: And it was actually a book you had recommended to me, the Amy Edmondson's book.
Speaker: I know she's been a guest on your podcast.
Speaker: And, you know, I think creating psychological safety in the critical care environment is one of the fundamental tenets of what we do to recognize that failure is common and
Speaker: And how we respond to it is more important than failure occurring.
Speaker: Perfect.
Speaker: And I do believe it.
Speaker: We'll talk a little bit about it.
Speaker: that psychological safety is a concept that obviously not only applies to dealing with failure and medical errors, but also applies to being a high-performing ICU.
Speaker: And I would also say that between 2018 and today, that is a word that has become a much more frequent part of my lexicon than it was before.
Speaker: As some people who might be listening know, I was your fellowship program director many, many years ago.
Speaker: And I don't think that I ever mentioned that word during your critical care and pulmonary fellowship training at all.
Speaker: Yeah, no, no, no.
Speaker: I actually don't remember seeing you much during my training.
Speaker: Well, that's an indictment on you.
Speaker: I was always there.
Speaker: So as we move along with the topic, I think it's always good to start by aligning expectations and making sure everybody's on the same page.
Speaker: So why don't we start with some definitions?
Speaker: I think a lot of times people are talking about different things, but using the same terminology, maybe with a different fully understanding.
Speaker: So what is a medical error?
Speaker: Yeah, that is, I think, definitely most important.
Speaker: You know, defining what is happening is very, very important.
Speaker: So a medical error is any error that occurs in the delivery of medical care, whether harmful or trivial.
Speaker: And I think it's worth pausing there and emphasizing that a medical error does not require...
Speaker: to cause harm to be considered a medical error, correct?
Speaker: Yeah, that is correct.
Speaker: And I think that that's very important because there are further definitions, which, you know, I think we'll talk about.
Speaker: And, you know, medical errors that cause harm, you know, go into the next category, serious medical error.
Speaker: So that's a medical error that causes harm.
Speaker: or it has substantial potential to cause harm.
Speaker: And that's very different than a medical error.
Speaker: But addressing errors, thinking about them, reflecting upon them, hopefully will prevent a serious medical error.
Speaker: Correct.
Speaker: And I think that's what I was trying to also articulate is that when we think of medical errors, we should really be focused on process of delivery of care.
Speaker: as opposed to the outcome.
Speaker: And I think this is true for so many decision making approaches is that we think of the outcome too much, but outcomes are important obviously, but ultimately the only way we can learn is by focusing on the process.
Speaker: Because if I'm lucky, I might have a good outcome or I might follow the right process and have a bad outcome for other reasons.
Speaker: And I wouldn't be able to learn if I wasn't focusing on was the process done correctly.
Speaker: Yeah, I think that that's actually really interesting because one of the.
Speaker: medical errors since the errors human report came out in 2001 that's improved substantially in the United States is the decrease in stints of hospital acquired infections.
Speaker: And there's two pathways that are going in hospital acquired infections in the field of critical care.
Speaker: One pathway is we focus on
Speaker: having a quality process to prevent hospital-acquired infections.
Speaker: And if we do have hospital-acquired infections, we try to understand why they occurred and, you know, think about them.
Speaker: And another pathway is, it's even led to, you know, definition changes, you know, for ventilators.
Speaker: Pneumonia is gaining the system or, you know, drawing less cultures.
Speaker: And, you know,
Speaker: That is the wrong way to address an error or a problem.
Speaker: What you want to do is improve the quality of the system, even if you go through
Speaker: a tough moment because that will produce the quality outcomes and that's the type of place you want to be delivering care.
Speaker: Absolutely.
Speaker: So I think it's really about focusing on how do we improve our process in order to be more likely to deliver safe care.
Speaker: So the next definition I think that often is thrown around or category is an adverse event.
Speaker: How would you define that?
Speaker: Yeah, so adverse events...
Speaker: is any injury that occurs due to medical management, and it can be broken up into a non-preventable adverse event or a preventable adverse event.
Speaker: And a non-preventable adverse event is caused by medical care without any apparent error.
Speaker: So an example would be somebody is on a heparin drip, they're anticoagulated for whatever reason, and then they have an intracranial hemorrhage.
Speaker: You know, if they were supposed to be on the apron drip, the dosing was correct.
Speaker: At least to our knowledge, it's unclear to us why the bleed occurred.
Speaker: That would be a non-preventable adverse event.
Speaker: Well, a preventable adverse event would be, you know, the bolus was too high and that caused the bleed or the dosing was too high and that caused the bleed.
Speaker: I think it's important because there obviously are known risks with many of the treatments that we implement in the ICU.
Speaker: And people have multiple comorbidities.
Speaker: And every treatment has a risk, right?
Speaker: And sometimes these are non-preventable.
Speaker: And understanding that and understanding that maybe the process was the right process in that patient is important because if we were to change it just for the outcome, we could actually put more patients at danger.
Speaker: Now, we talked about the relationship of process to outcome and how sometimes you might have no harm in the patient, but it's still a medical error.
Speaker: What's a near miss?
Speaker: Yeah, so a near miss is an error in care that has substantial potential to cause harm, but does not.
Speaker: either because it's intercepted or because it unexpectedly causes no harm despite reaching the patient.
Speaker: So a near miss is luck.
Speaker: And luck cannot be your strategy.
Speaker: And those should be treated as sentinel events and dissected and understanding the root cause of why they occurred to try to prevent something like that occurring again.
Speaker: And I guess in some circumstances, a good process could create a near miss if you intercept it before it reaches the patient.
Speaker: Is that correct?
Speaker: That is correct.
Speaker: A good process would allow you to catch.
Speaker: Now, it wouldn't necessarily, hopefully it's not a near miss to get that close, but, you know, let's say, you know,
Speaker: At our facility or our colleagues, before we do a procedure, we call a timeout.
Speaker: So it's clear to us that when we're putting a central line, we're putting it on the side we want to, and we've consented the patient's family.
Speaker: So we're not getting ourselves into a situation where, you know, the horrific stories of doing surgery on the wrong of the limb or something like that.
Speaker: Perfect.
Speaker: So now that we've defined some of the key elements of what a medical error is, what's in your midst, what's preventable, what's not preventable, let's talk a little bit about the scope of the problem, Nitin.
Speaker: And I did mention in the intro the Institute of Medicine to Error's Human Report, which was based on one of the landmark original studies on medical errors, which was the Harvard Medical Practice Study.
Speaker: They quoted...
Speaker: up to maybe 100,000 deaths in hospitals and a million injuries back 25 years ago.
Speaker: What do we know today?
Speaker: Is our medical errors a leading cause of death?
Speaker: What does the recent literature suggest in terms of what has happened or not happened over the last 25 years?
Speaker: Yeah, I think it's important to digest the literature and understand that
Speaker: medical errors and how we understand the magnitude of them is epidemiological based work.
Speaker: So you go back and analyze records and then you extrapolate going forward.
Speaker: There was a very...
Speaker: controversial, but also thoughtful piece that was put out that looked analyzed records from North Carolina in 2013, and I think the study came out in 2017, that said approximately 250,000 people died of medical errors in the United States.
Speaker: every year that would have put medical errors as the third leading cause of death in the United States.
Speaker: And then the study went on to say, which is important, but as a clinician who does fill out death certificates, they say, and likely the number's even higher than that because medical error is not even put on death certificates where we can directly attribute death or harm due to a medical error.
Speaker: So I guess what I would say is that the –
Speaker: The magnitude of the problem is difficult to quantify, but if you were to look granular at studies that have come out since the Harvard Medical Practice Study in the early 90s, including more studies by that same group at other places like in Utah and Colorado, there are a lot of medical errors which occur, and there is significant potential for harm, and I think anyone who practices knows it's an issue.
Speaker: And that we still have a tremendous, we still have a lot of opportunity to improve our care.
Speaker: And I think an important point, like you mentioned in the study that I think was in BMJ by Macri that reported it might be the third cause of death in the United States, that every report that's been published recognizes that because of limitations due to the methodology, we're probably not
Speaker: undercounting medical serious medical errors.
Speaker: Furthermore, a lot of medical errors are recognized because people report them.
Speaker: And we know that reporting is also something that probably could be a lot better.
Speaker: And we'll talk about that a little bit later.
Speaker: So in summary, it really seems like it is a real problem.
Speaker: And like you said, it happens probably every day in hospitals around the country, right?
Speaker: Yeah, I mean, I don't think we can even say every day.
Speaker: I think, you know,
Speaker: I think a good article to talk about would be that recent New England Journal of Medicine article.
Speaker: It's, I mean, one out of four admissions seems a pretty reasonable number to cite for medical errors.
Speaker: And you want to mention a little bit about, so this was recently re-evaluated, and we'll link all these articles in the show notes in a study that was, I think the original group was also from the
Speaker: from, from Harvard and the medical practice study to kind of a continuation, any, any comments from what we learned from that, the safety of inpatient healthcare?
Speaker: Yeah.
Speaker: So that's a really important study.
Speaker: Um, and although it's not specifically focused on critical care medicine, it is inpatient practice.
Speaker: And, um,
Speaker: You know, one out of four patients had medical errors.
Speaker: It was seven hospitals of varying sizes.
Speaker: Actually, if I'm not right, maybe it was 11 hospitals of varying sizes.
Speaker: And I think two hospitals greater than 700 beds all the way down to hospitals less than 200 beds.
Speaker: And I think they sampled something like 2,800 records, nine nurses reviewing the records, then adjudicated by eight physicians.
Speaker: This group has been doing this methodology for now, you know, 20, 30 years.
Speaker: So I think they have a very clean way of looking at medical errors, and they're continuing trying to refine it.
Speaker: And, you know, 7% of errors with serious errors
Speaker: harm and 0.2% leading to, I think, death.
Speaker: So 0.2% of 2,800 is not a significant number, but if you think about the number of people who are hospitalized in the United States, then that number starts to grow substantially of the number of people who've possibly been harmed.
Speaker: So that study was very, very insightful and well done.
Speaker: And the other thing I recall that I think is important for our discussion today as well is that you mentioned that one in four patients, so 25% of admissions, are associated with a medical error during their hospital stay.
Speaker: And of those, again, one out of four of those errors or 25% of those were preventable.
Speaker: So that's really, I think, where we should really focus on as clinicians is, okay, let's make sure that we...
Speaker: do everything we can to avoid preventable errors, right?
Speaker: And then we can try to figure out, okay, what else can we do to improve the delivery of care to prevent adverse events and other things or minimize them?
Speaker: 100%.
Speaker: I think that there are some simple strategies to address preventable errors.
Speaker: And one of the simplest is communication, clear, direct communication, making sure that those you're communicating with understand what you're saying.
Speaker: You can follow through on their plan and they can follow through on your plan to care for patients.
Speaker: That goes along with a clean and effective sign out and a multitude of things.
Speaker: So before we dive into more interventions that we could do to move the needle in the right direction, let's dissect a little bit more the types of failure and the most common types of medical errors that we see in the hospital.
Speaker: I believe, Nitin, that unfortunately critical care and medicine in general
Speaker: have a very bad relationship with failure, right?
Speaker: We have been brought up and educated and really just judging failure is always bad.
Speaker: And it's led to, I think, a lot of blame throughout health care.
Speaker: which is not a very effective way of creating psychological safety or of learning.
Speaker: But the reality is when you really look at failure, there's a lot to be learned from failure.
Speaker: Not all failures are bad and not all failures are blameworthy.
Speaker: So when you think of failures of mistake, how would you classify them?
Speaker: Yeah, that's a good point.
Speaker: So, you know, I think there's three ways that I like the way Amy Edmondson had quantified them.
Speaker: I described them preventable, complex, and intelligent.
Speaker: Preventable error is a deviation from a process.
Speaker: You know, I decided, you know,
Speaker: I trained in the era of using ultrasound to place a central line.
Speaker: I have now decided to put the central line without the ultrasound because, you know, I didn't want to wait.
Speaker: And so I placed the line and I caused a pneumothorax.
Speaker: That was a deviation of practice.
Speaker: And that's a preventable error.
Speaker: A complex error is a system failure.
Speaker: I think a common and important complex error is the workaround, which is, you know, I go to pull Versed because a patient needs a
Speaker: an MRI and they have anxiety.
Speaker: And when I go to pull Versed, I instead pulled Vecaronium.
Speaker: And that's a pretty important case that happened in the past year with a nurse in
Speaker: Tennessee.
Speaker: And the reason that she was pulling medications like that without safety checks was it was a workaround.
Speaker: The medication dispensary machine was not working appropriately for the care that needed to be provided.
Speaker: And so everyone knew that you just bypass the safety system and that had become a normal workaround.
Speaker: So that is a system failure.
Speaker: And then intelligent failure is the failure that we, I think the researcher themselves may be a bit frustrated with, but I think we celebrate a medicine.
Speaker: And it's also, you know, a bit of frustration in medicine that negative trials aren't published, but that's when a clinical trial is negative, but it provides insight into what
Speaker: You know, medications that are being used and why they're being used.
Speaker: And, you know, we had a lot of success with that with COVID, the adaptive clinical trials, you know, saying, OK, no, Plavik doesn't work for a COVID patient, but, you know, modern anticoagulation works for patients not in the ICU.
Speaker: And those were adaptive clinical trials and help inform our practice and help people along the way.
Speaker: I think it's important to emphasize this because we can't always categorize failure as a bad thing.
Speaker: I believe that we should definitely try to prevent preventable failures, right?
Speaker: Like if we have a protocol, we should follow the protocol.
Speaker: There's a reason for that.
Speaker: And deviations from that,
Speaker: require accountability.
Speaker: And those would be the ones that are maybe blameworthy, because I think it's also important to investigate why was the protocol broken?
Speaker: And there's a lot of other reasons that we may talk later.
Speaker: Complex, I think you talked about the workaround, but also in our world, complex failures can also relate to just the severity of
Speaker: interactions between organ failures and the therapies we're doing and the complexity of critical illness and multi-organ failure.
Speaker: And perhaps despite everything that we do, the patient dies and that's seen as a failure, but it was really due to the complexity of the situation or the system.
Speaker: And with intelligent failure, I think that another example that comes to mind that I think is very important that goes outside the context of clinical trials is when we are trying to improve delivery of care and we do a small pilot, right?
Speaker: We say, well, maybe if we did things this way, it would be better.
Speaker: We do a pilot and we realize that, no, actually things are worse.
Speaker: And we stopped there before we have made a big change for everybody.
Speaker: Right.
Speaker: And that is also, I think, an intelligent failure.
Speaker: And those should be celebrated.
Speaker: I agree with you, Nitin.
Speaker: I think they should be celebrated because they are giving us insight into improving care.
Speaker: And I think we need more of that, obviously, at the bedside and in the ICU.
Speaker: Now, the next thing I wanted to ask you about, Nitin, was the types of medical errors that are commonly described or the most common medical errors that we see in the hospital setting.
Speaker: Yeah, almost uniformly in most studies, medication errors are the first medical error that is cited.
Speaker: You know, delivery of medication, wrong dose, wrong patient.
Speaker: And so medication error, and now with medication shortages, it's become even more complex.
Speaker: Yeah.
Speaker: So medication errors really are as number one.
Speaker: Then after that, procedural, surgery procedural related errors.
Speaker: Although there's been some disagreement about that.
Speaker: You know, I think...
Speaker: around surgery itself, perioperative during the surgery, post-surgery, but some of the conversation has not necessarily been during the surgical event, but post-surgical and therapy that's being provided has not been what is advised.
Speaker: And then...
Speaker: You know, patient care errors, you know, something we, I think, as intensivists many times are at the bedside and we're familiar with, whether it's diagnostic, you know, not basically recognizing clinically deterioration and what needs to happen and intervene.
Speaker: And then, you know, the classic hospital-acquired infection would be...
Speaker: Something that is actually easily quantifiable, and a lot of work has gone on to that since Terris Human came out in 2001, and there's been substantial improvement in that realm.
Speaker: I think mainly because it's been able to be quantified and attacked.
Speaker: And I guess another category that maybe not in our world, but in our ED colleagues world is very important is diagnostic errors, right?
Speaker: Where somebody comes in with a bad headache, they do a CAT scan, it's negative, but they didn't narrow it to the LP and then they have a massive secondary subacnoid bleed or something along those lines, or somebody gets sent home with chest pain and they actually had an acute MI.
Speaker: So these are all, I think, like you said, important errors.
Speaker: Now,
Speaker: One of the things that I understand, and I want to hear your comments, is you did mention that with hospital-acquired infections, just the fact that we talk about it all the time, I think, has made us much more aware, and it's been demonstrated.
Speaker: I mean, obviously, Peter Pronovost and others have done, I mean, landmark work on demonstrating that abiding to a process that is evidence-based can decrease the incidence of infections dramatically, right?
Speaker: So...
Speaker: There are processes in place.
Speaker: Some of these may have been abandoned or worked around during COVID, but there's a lot of opportunity to bring those back.
Speaker: But the other thing that I wanted to ask you about is we always complain about the EMR.
Speaker: Yet my understanding, Nitin, is that the literature is clear.
Speaker: Computer physician order entry, which is part of the EMR, and EMR in general have improved health.
Speaker: safety for patients and have decreased errors dramatically.
Speaker: Is that the way you read the literature as well?
Speaker: Yeah, that's actually, if you think about the original Harvard medical practice study, there's been substantial improvement
Speaker: in care delivery and electronic medical records have played a role in that.
Speaker: There are, you know, have been unintended consequences, you know, the copy and paste function.
Speaker: And I think that leads to a different type of medical error.
Speaker: And that was probably different from what we saw in the pre-EMR.
Speaker: But EMR has definitely improved care delivery.
Speaker: And I don't think...
Speaker: be curious to see if anyone had other thoughts on that.
Speaker: Perfect.
Speaker: Now, what are some of the common causes of medical errors?
Speaker: Now, we talked about, before we started recording, obviously, that we're going to try to focus on what individual clinicians can do and talk a little bit about system solutions.
Speaker: But when people have looked at medical errors in general, there seems to be some themes that are recurrent.
Speaker: Could you talk about some of those common causes?
Speaker: Yeah, you know, I definitely hit on the first one is communication.
Speaker: So I think that clear and direct communication is really a huge important point in medicine.
Speaker: And we don't, unfortunately,
Speaker: spend enough time, I think, teaching that at the bedside when people are coming up.
Speaker: So I really emphasize that.
Speaker: And then communication between yourself and the nursing staff, yourself and your colleagues.
Speaker: So I think that that's definitely a big one.
Speaker: But that's not the only one.
Speaker: There are definitely a lot of concerns about inadequate information that flows between people.
Speaker: There's
Speaker: You know, patient-related issues is like, you know, you don't have appropriate identification, you don't get consent, you know.
Speaker: And, you know, something that comes up all the time in our world, and especially during COVID, is, you know, are we appropriately staffed?
Speaker: You know, we see appropriate staffing ratios, people, you know, care has improved.
Speaker: But that's not most of the time what I've seen as the...
Speaker: as the cause.
Speaker: And then technical failures, which are common.
Speaker: We use a lot of technology in our world and have devices failed and how do we handle those devices.
Speaker: but I think, again, I keep on going back to communication because I think communication goes back to inadequate information flow.
Speaker: Um, and so I'm very particular about picking up the phone and speaking to people and making sure that I understand what they are saying and that they understand what I'm thinking.
Speaker: And, um,
Speaker: And even if there's a moment of frustration, I try to, because I recognize that'll hamper the flow of information, try to make sure that the patient's at the center of the conversation and that the frustrations can be dealt with later.
Speaker: And I think with regards to communication, one of my favorite quotes, I think it's from Bernard Shaw, is that the biggest problem with communication is the illusion that it has occurred, right?
Speaker: And a lot of times people only measure the effectiveness of their communication based on what they said.
Speaker: And if it wasn't understood, like you said, or if it was misunderstood, it definitely will lead to an error.
Speaker: So making sure that we're verifying, that we're providing the right information, but they're also verifying that there's clear understanding of what we're trying to communicate.
Speaker: And it's very interesting that a lot of the things that you mentioned, Nitin, have all been addressed.
Speaker: And I wouldn't say solved, but they have all been addressed and worked upon by people
Speaker: aviation, right?
Speaker: So, communication through checklist and for process procedures that make sure that everybody's clear, technology failures and redundant systems.
Speaker: These are all things that adequate hours of work and staffing.
Speaker: There's all things that our aviation partners have been working on for many years and that I believe there's still opportunity for us to do a little bit better.
Speaker: Yeah, no, no, I agree 100%.
Speaker: And I think that we, you know, patients are very complex.
Speaker: There's a multiple patients that we're taking care of.
Speaker: And, you know, has information been adequately given to us to be able to care for the patients?
Speaker: And are we in the psychological space to receive that information and, um, move on it going forward?
Speaker: And that's the utility of the checklist.
Speaker: Some very, very important things are, um, you know, moved out of the way.
Speaker: And so you can focus on, uh, you know, perhaps a new problem at hand.
Speaker: I, uh, have a lot of respect for, uh, the safety that's gone on in the aviation industry and, um,
Speaker: I also think that other professions where you have to make split-second decisions, whether it's firefighters or the police, and then having to look back on that, decisions can be very difficult and brutal.
Speaker: And I think that we fall into that category at times.
Speaker: Now, I have to ask you before we move on as a cause of medical errors, because it's something that especially post-COVID, but even pre-COVID has been a topic that is prevalent in health care and in critical care.
Speaker: Does burnout lead to increased medical errors?
Speaker: Yeah, that's a great, great question.
Speaker: Burnout is such a vague topic.
Speaker: Yeah.
Speaker: And it's a catch-all phrase that it's hard for me to directly attribute it to it.
Speaker: What I can tell you is if you've made a medical error, that will lead you to burning out.
Speaker: I think the causation, that's pretty clean.
Speaker: That'll lead to that.
Speaker: But as somebody who is, you know, burnout leads you to being disengaged,
Speaker: And then that, you know, you will definitely have more of a chance of creating medical error.
Speaker: If you work in a space that doesn't have psychological safety and that makes you burn out, that will lead to medical error.
Speaker: But burnout itself, I have not seen anything directly.
Speaker: Well, I think that's a perfect lead way to our next topic, which is really how does the individual clinician listening to us understand?
Speaker: improve their role in making care safer.
Speaker: And before we go into what people should do, since you mentioned it, maybe we should talk first about the effects on the clinician who made the error, right?
Speaker: So we always obviously are very concerned with when we have a severe medical error, a serious medical error on the implication it has on the patient and their family.
Speaker: but there's also something described as second victims.
Speaker: Can you talk a little bit about that, Nitin?
Speaker: Yeah.
Speaker: This is a really important and big topic for us as intensivists.
Speaker: You know, when you make an error, you know, you need to disclose to the family and, you know,
Speaker: being supported to be able to disclose and be in a supportive environment is very important too but even after you're disclosed you yourself feel awful and you may be beating yourself up and really taking a lot of uh you know psychological blows that may be internal or from others people whispering in the hallways like oh yeah do you see what happened to him you know or and
Speaker: it's very very important to recognize there is a second victim when a medical error occurs you know something uh possibly bad may have happened to a patient or but there's also another human on the back side who committed the error and you know most physicians or most healthcare practitioners got into this to care for others and be you know look out for others and when you've caused
Speaker: harm or inadvertent harm to somebody, the toll on you can be tremendous.
Speaker: So that's, you know, the second victim.
Speaker: And, you know, to link back into the burnout, you know, that, if you are not able to engage that moment as a colleague or as a clinician in a manner where you can, I don't know if you'll ever be able to make it something positive, but make it a moment of growth and resilience because, you know,
Speaker: You were trying the best you could.
Speaker: You were being thoughtful.
Speaker: You made a mistake or the system was inappropriate.
Speaker: Then that will lead people to not want to practice medicine, not just critical care.
Speaker: For sure.
Speaker: And I think, Nathan, like you mentioned, right, recognizing also the impact it has on the individual clinician should make us more empathetic towards our colleagues and to be more supportive and less blaming and more asking how we can improve the system and understand what really happened.
Speaker: And one of the topics you mentioned at the beginning, the case of the nurse in Tennessee, and I think that, correct me if I'm wrong, but that went to, I think, a criminal court and obviously resulted in, I think, a significant harm on the nurse, but
Speaker: except for people who do it, I mean, with a criminal intent, I don't think any healthcare worker goes to the hospital thinking that they want to harm another patient, right?
Speaker: That's not what we went into healthcare.
Speaker: So I think that maybe depenalizing some of these medical errors and really trying to find ways of improving the system and giving people the tools and knowledge that they need to provide the best possible care is really the way to go.
Speaker: So what would you recommend,
Speaker: for the individual clinician as step one in improving patient safety and how we deal with medical errors?
Speaker: It's funny, but to err is human, right?
Speaker: That's the 2001 report.
Speaker: We all make mistakes.
Speaker: We make them every day.
Speaker: And to embrace that an error is the starting point
Speaker: in a conversation, not the end of a conversation, and to expand, you know, to dissect that error, open it up, and be allowed to think about it and see why it occurred is very, very important.
Speaker: So the individual clinician, if I was to make one point, I would say is that be kind to yourself, that voice in your head.
Speaker: Don't be angry with yourself.
Speaker: And if you have a colleague who makes an error, be empathetic because the next time it could be you and be supportive.
Speaker: And, you know, with the family, sometimes the families are very, very angry at times.
Speaker: They're going to be angry.
Speaker: This is their loved one.
Speaker: You know, we're happy.
Speaker: You know, we're a very specialized group of medicine and expect us to be perfect.
Speaker: You know, the patients are so sick, so if an error is made, it could be catastrophic.
Speaker: If it's a small one, but allowing them to have the space to be frustrated and being able to put it in context is important.
Speaker: So resilience is what I would say is understand everything.
Speaker: how to build resilience in your own life and, um, what is it that, um, you need to, uh, build up that, uh, so you have that psychological, uh, uh, ability to handle mistakes.
Speaker: And what about, um, you did mention the families and, uh, any suggestions, uh, or tips on how to best disclose medical errors to patients and families?
Speaker: Yeah.
Speaker: Um,
Speaker: I definitely have a couple of suggestions.
Speaker: So I think that after error has been made, it's important to try to deal with the outcomes of the error.
Speaker: And medically, if you are not in the psychological space to be able to do that, if you have a colleague or somebody who can help you out in that moment, lean on them and be transparent with them.
Speaker: Say, listen, I'm just not, I don't have the headspace right now to deal with this.
Speaker: And I just need to take a break.
Speaker: You know, the ability to express yourself open and honest to another colleague so the patient can still receive care.
Speaker: But, you know, after that point is,
Speaker: being honest with the families without self-flagellation.
Speaker: There, for good reason, is some historical distrust of medical providers in this country.
Speaker: So I try to be as transparent as possible.
Speaker: But I think when I was a younger clinician, I would just be like, I did it.
Speaker: I made a horrible mistake.
Speaker: I'm sorry, I'm sorry, I'm sorry.
Speaker: And that's okay, but that's you...
Speaker: venting to the family or You know looking for the family to comfort you in a dark moment and that that's what you know don't need to do you need to Be professional and say listen.
Speaker: I made a mistake and
Speaker: or a mistake was made that possibly led to harm or did lead to harm, I want to tell you that I acknowledge it.
Speaker: And as an institution, we acknowledge it.
Speaker: We're not trying to hide anything.
Speaker: It will be as transparent with you as possible.
Speaker: It is fascinating now that in most of America,
Speaker: The patients and the patient's families have access to the medical record.
Speaker: So at times people will come and approach me and say, I don't understand why this is said.
Speaker: Can you help us understand?
Speaker: So having a very open relationship with families is important.
Speaker: And I think that what I'm hearing here, Nitin, is that be very clear and concise with non-medical jargon.
Speaker: What happened?
Speaker: What is the implication for the patient?
Speaker: And I think also very important to list the steps that we're taking to remediate or make things better, right?
Speaker: And the follow-up that they'll have.
Speaker: So being just, like you said, clear and really thinking about providing the right information in a compassionate way.
Speaker: But
Speaker: like you said, and being very precise with what you're saying.
Speaker: Yeah.
Speaker: And, and, uh, you know, disclosing, apologizing, I think are important.
Speaker: I think any clinician thinks about the medical legal ramifications, but at that moment, what you need to do is just be, um, transparent and truthful and whatever may come may come.
Speaker: Uh, but, uh,
Speaker: We all took the Hippocratic Oath.
Speaker: Our duty is to protect.
Speaker: And this is common, right?
Speaker: I mean, the Harvard Medical Practice Study from, I think earlier this year, it was in January.
Speaker: It's one out of four patients.
Speaker: This is not a rare occurrence.
Speaker: So...
Speaker: I think that we as a practice or as clinicians need to understand that it's common and we make mistakes and be transparent about it.
Speaker: I also think that I like what you said about medical jargon.
Speaker: Sometimes we will go into our heads and use a lot of medical words, but explaining in language that the patients can understand is important.
Speaker: Some would argue that at a fifth grade level probably is where you should target if you're explaining something like this.
Speaker: And I believe that also the other comment I want to make, Nathan, you mentioned the medical legal.
Speaker: I think the literature that's available is quite clear that transparent and timely communication will decrease the likelihood that you will be involved in legal problems.
Speaker: It doesn't obviously print 100%, but I think it definitely will decrease.
Speaker: And actually...
Speaker: University of Michigan has had a program that they're self-insured and they have a very robust and a very active process of disclosing medical errors in the hospital.
Speaker: And since they went that route, they have noticed that their legal issues have decreased significantly.
Speaker: So I
Speaker: I think that silence is probably much more likely to lead to malpractice issues.
Speaker: And like you said, I mean, we took an oath and we should always be very, very straightforward and clear with people on what's going on with their loved ones.
Speaker: Yeah, we, um, uh, the hospital on that, um, Cooper, um, health system, uh, we have a, uh,
Speaker: A standardized note for disclosure, and then you're supposed to notify your chief of service if a disclosure has been made.
Speaker: And then there's a process you follow, which is on the back of the badges, an extra card that I give to my faculty, advanced practice providers and fellows.
Speaker: because what you want is in that moment of panic, you want to have a playbook that can be followed and be transparent.
Speaker: Michigan, they've published literature on what they've done, and Cooper is similarly self-insured and follows a similar playbook.
Speaker: And it's, you know, as institutionally, I like being in an institution like that.
Speaker: Excellent.
Speaker: Well, we talked a little bit about some of the important aspects for the clinician, including being kind to yourself and recognizing that clinicians are also victims of medical errors, especially when they happen, I mean, to themselves and how to deal with that.
Speaker: We talked about the importance of being kind to others and being more curious about medical errors with the intention of learning from them.
Speaker: And we talked about disclosing medical errors to patients and families.
Speaker: You're a leader of a critical care division, of a critical care center.
Speaker: As a leader, what are things that you're focusing on to try to improve safety for our patients and decrease medical errors?
Speaker: Yeah, one of the advances that I've seen over my career is the system for reporting errors and for errors –
Speaker: than to be thought about in a global manner.
Speaker: Like there's a process around it.
Speaker: So at my institution, it's called the EARS system.
Speaker: I think it's important to, if you are not in a place that you're able to report errors in a standardized fashion and those errors can be queried and be thought about, then to speak up and say, listen, I've heard that other institutions do this.
Speaker: How can we gain access to
Speaker: an anonymous way to report errors and I also would like to know the outcomes of those conversations.
Speaker: I think also as a leader, a true leader facilitates conversations or things that quote-unquote a leader may not want to necessarily hear and
Speaker: you know, if the dirty laundry is aired, um, it allows, uh, conversations on how to improve practice.
Speaker: Cause you know, patients are at the center of the conversation.
Speaker: Um, and then, um,
Speaker: I think there's important to know the difference between as a leader, and also this is very important for a bedside clinician, the difference between speaking up about a problem, being thoughtful, and complaining.
Speaker: And that if you are speaking about a problem and you've shifted over more to...
Speaker: Just complaining that, you know, the concept of psychological safety allows you to speak up, but it doesn't necessarily protect your right to speak, but it doesn't necessarily protect your right to, you know, speak illy of others or cycle into a negative spiral.
Speaker: So as a leader to promote open and honest discourse, but also for your colleagues to know that if you're going to go into an unproductive cycle, that as a leader, you probably stop that.
Speaker: But the worst thing you can have is have a meeting, an important meeting, and no one speaks because that's a sign that people don't feel safe to speak or
Speaker: When they speak up, it's useless.
Speaker: And if that's what's happening at you or your institution, you need to re-engage to see why you're not hearing other people's voices in the room.
Speaker: Absolutely.
Speaker: And I think that another important aspect of this is that you did mention that we all are part of the problem.
Speaker: Every clinician will commit medical errors.
Speaker: So I believe that short of just complaining, they should be part of the solution, right?
Speaker: And this is something that actively should engage everybody in trying to make care better.
Speaker: And that is part of being in a high-performing critical care team that requires psychological safety as its first ingredient.
Speaker: But I agree, I mean, that at the end of the day, we can't solve things unless we're working together as a team in the ICU.
Speaker: Nitin, this is obviously a super important topic.
Speaker: I appreciate you taking the time to talk with us about it.
Speaker: We'll have links to the articles you mentioned, to some other resources.
Speaker: You've been on the podcast before, so you know that we like to close with a couple of questions that are unrelated to the clinical topic, but that kind of tap into your wisdom.
Speaker: Would that be okay?
Speaker: Yeah, yeah.
Speaker: No, no, no.
Speaker: My wisdom is on short supply, but I'll do my best.
Speaker: So the first question relates to books.
Speaker: Are there any books or book that has influenced you significantly recently that you have gifted to others recently?
Speaker: You know, I would say that I enjoy fiction and literature.
Speaker: So,
Speaker: I really enjoyed reading Pachinko, and I think it became like an HBO teleseries or something like that.
Speaker: But just the history of basically, you know, Southeast Asia during World War II.
Speaker: And I've gifted that book to a couple people because it's just an amazing read.
Speaker: But it's also...
Speaker: insightful way to understand that part of the world is part of the world that I'm not from.
Speaker: Excellent.
Speaker: Second question.
Speaker: What do you believe to be true in medicine or life that most other people don't believe, or at least don't act like they believe?
Speaker: Um, I don't know if everyone embraces this, but I, it's, it's something that, uh, I sort of live my life by that, uh, uh,
Speaker: problems or opportunities like you know if i have a problem or there's failure at you know my immediate reaction is like oh my god this is terrible and then i take a step back and be like well you know how do i turn this around to make it an opportunity and um you know career-wise that's uh
Speaker: We had patients with ARDS.
Speaker: We were transferring out of the hospital for ECMO, and I said, you know, this is an opportunity to build an ECMO program.
Speaker: How do I do that?
Speaker: And it has been – it's really been a useful tool for me.
Speaker: And I think that also, obviously, very, very applicable to what we're talking about today.
Speaker: Any medical error, any failure is an opportunity to learn how we can do things better for more patients.
Speaker: And I think that that humility, that growth mindset is something that we all need as clinicians, but also as leaders.
Speaker: And the last question would be, what would you want every intensivist and APP that's listening to us today to know?
Speaker: Could be a quote, a fact, or just a thought.
Speaker: I would want them to know that you are my friend and a very thoughtful person.
Speaker: And it's been a tremendous honor and opportunity to know you and listen to you as the years have gone on.
Speaker: Well, thank you very much.
Speaker: Same here.
Speaker: I really always enjoy spending time with you, whether it be on the podcast or in person.
Speaker: Appreciate you sharing such an important topic with us today and looking forward to having you back.
Speaker: I appreciate it.
Speaker: Sergio, you take care.
Speaker: Take care.
Speaker: Thank you.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
