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Provider Stories","2025-11-18T19:04:33.812Z","2025-12-18T18:28:47.341Z","2025-12-18T18:28:47.467Z",113881390448419,"5f3dab6a-c8fb-450d-97d6-957200cf07e0",{"new":277,"seo":278,"_uid":281,"hero":282,"type":179,"topics":299,"content":300,"audience":2558,"duration":16,"regional":2559,"component":2560},false,{"title":270,"plugin":279,"description":280},"seo_metatags","Read stories from healthcare providers about patient safety.","8365a3a6-95bb-41d3-ad9e-77fc12b7d58c",[283],{"_uid":284,"file":285,"image":286,"title":270,"format":16,"component":290,"description":291,"key_learning":16,"prerequisite":16},"3c642d75-be6d-4fac-b626-8dfe6bb74a85",[],{"id":287,"filename":288,"fieldtype":289},108534901744414,"https://a-ca.storyblok.com/f/850807391887861/670x450/0df79330c2/header-2-visual.png","asset","hero-resource",{"type":12,"content":292},[293],{"type":15,"attrs":294,"content":295},{"textAlign":53},[296],{"text":297,"type":298},"This is a collection of stories from healthcare providers.","text",[91,84,76],[301,587,893,1203,1420,1676,2040,2304],{"_uid":302,"title":303,"video_id":304,"component":305,"transcript":306,"video_type":368,"description":369,"video_title":303,"video_description":383},"f5df979c-5600-4751-8f8e-ea1a4968926e","Tragedy leads Dr. Doug Cochrane on mission to improve patient safety","1QGSne7E3_w","video-transcript",{"type":12,"content":307},[308,313,318,323,328,333,338,343,348,353,358,363],{"type":15,"attrs":309,"content":310},{"textAlign":53},[311],{"text":312,"type":298},"[0:00:10] I'm Doug Cochrane and I am the current chair of the BC Patient Safety and Quality Council in the province of British Columbia. I also serve the Minister as the patient safety and quality officer for the province. In addition, though, I have a clinical role in I do pediatric neurosurgery at BC Children's Hospital. And I must say that over the course of my life, it's been that combination of activities that have been pretty important to me. One has a sense of balance and a sense of combination of efforts that come from treating patients directly and from trying to help make the system better. ",{"type":15,"attrs":314,"content":315},{"textAlign":53},[316],{"text":317,"type":298},"[0:00:51] It was a number of years ago as a young neurosurgeon at BC Children's Hospital when we had a tragic event related to the administration of a medication into the spinal fluid, the fluid that normally surrounds the brain and spinal cord. It was being given to try and counter a cancer that the patient had, but the wrong medication was given in the wrong place. And as a consequence of that, despite the efforts that many of us made to try and wash out the medicine and dilute it, it had a profound effect on how the nervous system worked. And as a consequence of that, the child died. It was just a profound event to have a patient succumb as a result of the best-intended treatments, but where those treatments had failed that patient. And as an organization, the Children's Hospital at that time went through great, great deliberations. We had a courageous CEO who, at that time, Linda Cranston came forward and described what had happened to this child in a very public way. And I think it was the first time that we as an organization had taken a responsibility for the consequences of our actions where those outcomes had been tragic. ",{"type":15,"attrs":319,"content":320},{"textAlign":53},[321],{"text":322,"type":298},"[0:02:15] As an organization, we had no idea that there was a possibility of creating this kind of injury. We thought our systems were foolproof. We thought that we had systems that were resilient and rigorous, and we had people in whom we had absolute and continue to have absolute committed trust. And yet, the system failed the patient. The system failed the organization. The system failed those individuals who were treating that patient. ",{"type":15,"attrs":324,"content":325},{"textAlign":53},[326],{"text":327,"type":298},"[0:02:45] For me, it took me from the enthusiastic trainee who I guess had – well, I'll be really honest – the arrogance to know that what whatever we did was the right thing to do. And whenever we had patients who had poor outcomes, it was usually because of what the patient had brought to the situation. But to suddenly realize that actually, what we did mattered in very concrete ways, how we organized what we did, how we paid attention to what we were doing. And as an individual, that has had a profound effect on the way my career has unfolded and the interests that I've held and developed in the patient safety and quality world since that time. ",{"type":15,"attrs":329,"content":330},{"textAlign":53},[331],{"text":332,"type":298},"[0:03:35] The idea that mistakes can't happen in our health care system, you know, it's not too far from the truth when you really think about how many successful interventions, how much is happening in community care or long-term care to keep people safe, people that are being rescued from illnesses that would have taken their lives 10 and 15 years ago, over here at the Royal Alex and at the University Hospital. It is really quite amazing what people and teams and organizations can do. But we would be blind to ignore the fact that we are human and that mistakes happen. And they happen because we are human and they happen because of the way we think and the way we act and how we are. And I don't think that we can necessarily make systems mistake-proof. I just hope we can make systems that will catch the mistake before they do harm. ",{"type":15,"attrs":334,"content":335},{"textAlign":53},[336],{"text":337,"type":298},"[0:04:41] The impact of errors that have occurred, particularly when they occur by your own hand, is profound. It does wake you up in the middle of the night. You do ask questions about your capability, your competence. “Can we do this? Can I come back and do this again tomorrow?” And I suspect there is a process that people actually have to work through to incorporate what really is a grieving loss process. It's not a loss so much in the relationship with the patient, but it's a loss in self-confidence and understanding. And I think one of the things that I have learned is that you somehow need to have an organization that is sensitive to this. Because I would never ask for help. I might be pushed to find help, probably by my wife, but I would never ask. [00:05:50] But what would make a difference is that a colleague comes up and says, “Tell me about what happened and tell me how I can help you.” Is that important, to have closure, to have acknowledgment? Absolutely. ",{"type":15,"attrs":339,"content":340},{"textAlign":53},[341],{"text":342,"type":298},"[0:06:08] You know, this was not the first event in my career where I've had the opportunity to recognize my own weaknesses or my own limitations and a system that wasn't on top of things. I can think of several examples, actually, where the comfort that it brought to me to be able to acknowledge this with the family or with the patient, was tremendous. I don't think it made it any easier at all for the family. It didn't make it any easier at all for the patient. And it didn't make it easier for me, but it made it different and it brought us to eventual understanding of our respective roles and where – in my circumstance, I'm thinking of a particular example where we could have been better and we weren't. And that was the royal we: me. ",{"type":15,"attrs":344,"content":345},{"textAlign":53},[346],{"text":347,"type":298},"[0:07:17] I wanted to share this story because it is such a profound story at so many levels. Clearly, the most significant level is in the lives of the family and in the life lost in that child. But it's not just there. Children's Hospital is a different organization because of that experience. Children's Hospital takes care of its patients differently now in a way that is safer. Children's Hospital organizes and cares for its staff in a way that is different and is safer. ",{"type":15,"attrs":349,"content":350},{"textAlign":53},[351],{"text":352,"type":298},"[00:07:52] And we've taken the approach, which I think we are obligated to, to communicate our experiences and our results to other individuals and organizations, lest they assume that they would never be subject to such an event or such an error. And I think that's actually the marvelous opportunity that has come out of this absolute tragedy. ",{"type":15,"attrs":354,"content":355},{"textAlign":53},[356],{"text":357,"type":298},"[0:08:19] I want to be confident that people who are coming into our health system and will be our health system will be better prepared and have better understanding of the pluses and the successes of health care, as well as its limitations. And its limitations, we call issues of patient safety. The limitations are the issues that we call issues of quality. And I know they are. ",{"type":15,"attrs":359,"content":360},{"textAlign":53},[361],{"text":362,"type":298},"[0:08:52] Actually, I'm amazed at the current set of trainees that I'm exposed to day to day. They truly up my game because they're far better prepared and have a far better working knowledge of many aspects that relate to safe care. They are more insightful about themselves, they are more understanding of their own reactions, but they are also more understanding of patients and how to treat them and families in a way that is respectful. ",{"type":15,"attrs":364,"content":365},{"textAlign":53},[366],{"text":367,"type":298},"[0:09:21] I think we're in a good position, but I would want all of them to remember that we have an obligation. We're fortunate in Canada to have a system in which we have an obligation, not just as taxpayers, but as providers. And that obligation is to make the system better and to make it safer for all.","youtube",{"type":12,"content":370},[371],{"type":15,"attrs":372,"content":373},{"textAlign":53},[374],{"text":375,"type":298,"marks":376},"View transcript",[377],{"type":378,"attrs":379},"link",{"href":380,"uuid":53,"anchor":53,"custom":381,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/8eeb509e66/cpsi-2015-cochrane-master.pdf",{},"_self",{"type":12,"content":384},[385,396,406,415,424,433,442,451,460,469,478,487,496,505,514,523,532,541,550,559,568,577],{"type":15,"attrs":386,"content":387},{"textAlign":53},[388,394],{"text":389,"type":298,"marks":390},"The death of a young girl at British Columbia's Children's Hospital back in 1997 spurred Dr. Doug Cochrane to rededicate his career to improved patient safety and the reduction of preventable errors in healthcare facilities across the country.",[391],{"type":392,"attrs":393},"textStyle",{"color":16},{"text":395,"type":298}," ",{"type":15,"attrs":397,"content":399},{"textAlign":398},"left",[400,405],{"text":401,"type":298,"marks":402},"The child died two weeks after a potent anti-cancer drug meant to treat her leukemia was accidentally injected into her spinal fluid instead of into an intravenous drip. Cochrane, a pediatric neurosurgeon at Children's Hospital, was part of the medical team that fought in vain to reverse the effects of that error and save the girl's life.",[403],{"type":392,"attrs":404},{"color":16},{"text":395,"type":298},{"type":15,"attrs":407,"content":408},{"textAlign":398},[409,414],{"text":410,"type":298,"marks":411},"\"It was a profound event to have a patient succumb as a result of the best intended treatments but where those treatments had failed this patient,\" Cochrane recalls.",[412],{"type":392,"attrs":413},{"color":16},{"text":395,"type":298},{"type":15,"attrs":416,"content":417},{"textAlign":398},[418,423],{"text":419,"type":298,"marks":420},"\"As an organization, the Children's Hospital went through great, great deliberations. We had courageous leadership form Pat Evans, David Matheson and our CEO, Linda Cranston, who came forward and described what had happened to this child in a very public way. I think it was the first time that we as an organization had taken a responsibility for the consequences for our actions where those outcomes were tragic.\"",[421],{"type":392,"attrs":422},{"color":16},{"text":395,"type":298},{"type":15,"attrs":425,"content":426},{"textAlign":398},[427,432],{"text":428,"type":298,"marks":429},"Cochrane, who today is the chair of the BC Patient Safety and Quality Council, in addition to serving as the Patient Safety and Quality Officer for the province, remembers the experience as an alarming wake-up call both for himself, as a cocksure physician, and for the hospital.",[430],{"type":392,"attrs":431},{"color":16},{"text":395,"type":298},{"type":15,"attrs":434,"content":435},{"textAlign":398},[436,441],{"text":437,"type":298,"marks":438},"\"As an organization we had no idea that there was the possibility of creating this kind of injury. We thought our systems were foolproof. We thought that we had systems that were resilient and rigorous and we had people in whom we had absolute, and continue to have absolute, committed trust. And yet the system failed the patient. The system failed the organization. The system failed those individuals who were treating that patient.\"",[439],{"type":392,"attrs":440},{"color":16},{"text":395,"type":298},{"type":15,"attrs":443,"content":444},{"textAlign":398},[445,450],{"text":446,"type":298,"marks":447},"In the aftermath of the little girl's death and the discovery of similar cases across North America, the Children's Hospital implemented a number of new safety measures, including changes to drug labelling. Meanwhile, Cochrane was undergoing a personal transformation of his own.",[448],{"type":392,"attrs":449},{"color":16},{"text":395,"type":298},{"type":15,"attrs":452,"content":453},{"textAlign":398},[454,459],{"text":455,"type":298,"marks":456},"\"For me it took me from the enthusiastic trainee who I guess had — well I'll be really honest — the arrogance to think that whatever we did was the right thing to do, and whenever we had patients who had poor outcomes it was usually because of what the patient had brought to the situation, to the sudden realization that actually what we did mattered in very concrete ways. How we organized what we did, how we paid attention to what we were doing. And as an individual, that has had a profound effect on the way my career has unfolded and the interests I've developed in the patient safety and quality world since that time.\"",[457],{"type":392,"attrs":458},{"color":16},{"text":395,"type":298},{"type":15,"attrs":461,"content":462},{"textAlign":398},[463,468],{"text":464,"type":298,"marks":465},"It is sometimes said that modern medicine is burdened with an unfair expectation of perfection. Patients certainly have an understandable need to consider their doctors infallible. Cochrane brings an interesting perspective to the matter.",[466],{"type":392,"attrs":467},{"color":16},{"text":395,"type":298},{"type":15,"attrs":470,"content":471},{"textAlign":398},[472,477],{"text":473,"type":298,"marks":474},"\"The idea that mistakes can't happen in our healthcare system is not too far from the truth. When you think about how many successful interventions, how much is happening in community care or long-term care to keep people safe, people that are being rescued from illnesses that would have taken their lives 10 or 15 years ago … it really is quite amazing what people and teams and organizations can do.",[475],{"type":392,"attrs":476},{"color":16},{"text":395,"type":298},{"type":15,"attrs":479,"content":480},{"textAlign":398},[481,486],{"text":482,"type":298,"marks":483},"\"But we would be blind to ignore the fact that we are human and that mistakes happen. They happen because we are human and because of the way we think and the way we act and who we are and I don't think we can necessarily make systems mistake-proof, I just hope we can make systems that will catch the mistake before they do harm.\"",[484],{"type":392,"attrs":485},{"color":16},{"text":395,"type":298},{"type":15,"attrs":488,"content":489},{"textAlign":398},[490,495],{"text":491,"type":298,"marks":492},"Cochrane is of the belief that most healthcare workers acknowledge errors quite freely; they just don't always do it in a public way that can help relieve them of the emotional trauma that sometimes only further undermines effective patient care. Many of those people — nurses, physicians and other clinicians — are confronting those mistakes in sleepless nights or heightened stress and anxiety at work and at home, he says.",[493],{"type":392,"attrs":494},{"color":16},{"text":395,"type":298},{"type":15,"attrs":497,"content":498},{"textAlign":398},[499,504],{"text":500,"type":298,"marks":501},"\"The impact of errors that have occurred, particularly when they occur by your own hand, is profound. It does wake you up in the middle of the night, you do ask questions about your capability, your competence: 'Can we do this? Can I come back and do this again tomorrow?' And I suspect there is process that people have to work through to incorporate what really is a grieving loss process. It's not only a loss in the relationship with the patient but it's a loss in self-confidence and understanding.",[502],{"type":392,"attrs":503},{"color":16},{"text":395,"type":298},{"type":15,"attrs":506,"content":507},{"textAlign":398},[508,513],{"text":509,"type":298,"marks":510},"\"I think one of the things I have learned is that you somehow need to have an organization that is sensitive to this. Because I would never ask for help. I might be pushed to find help, probably by my wife, but I would never ask. But what would make a difference is that a colleague comes up and says, 'tell me about what happened and tell me how I can help you.'\"",[511],{"type":392,"attrs":512},{"color":16},{"text":395,"type":298},{"type":15,"attrs":515,"content":516},{"textAlign":398},[517,522],{"text":518,"type":298,"marks":519},"Whenever possible, part of that healing process should include a face-to-face disclosure of the mistake to the patient or family, Cochrane adds. That's a conviction he's held since even before his experience with that little girl whose life could not be rescued.",[520],{"type":392,"attrs":521},{"color":16},{"text":395,"type":298},{"type":15,"attrs":524,"content":525},{"textAlign":398},[526,531],{"text":527,"type":298,"marks":528},"\"This was not the first event in my career where I've had the opportunity to recognize my own weaknesses, or my own limitations, and a system that wasn't on top of things. I can think of several examples where the comfort that it brought to me to be able to acknowledge this with the family, or with the patient, was tremendous,\" Cochrane says.",[529],{"type":392,"attrs":530},{"color":16},{"text":395,"type":298},{"type":15,"attrs":533,"content":534},{"textAlign":398},[535,540],{"text":536,"type":298,"marks":537},"\"I don't think it made it any easier at all for the family, it didn't make it any easier at all for the patient, and it didn't make it easier for me, but it made it different and it brought us to an eventual understanding of our respective roles and — in my circumstance I'm thinking of a particular example — where we could have been better, and we weren't. And that was the royal 'we' — me.\"",[538],{"type":392,"attrs":539},{"color":16},{"text":395,"type":298},{"type":15,"attrs":542,"content":543},{"textAlign":398},[544,549],{"text":545,"type":298,"marks":546},"As a former chair of the Canadian Patient Safety Institute (now Healthcare Excellence Canada), Cochrane understands the value and immediacy of individual stories in the campaign to raise awareness for improving patient care.",[547],{"type":392,"attrs":548},{"color":16},{"text":395,"type":298},{"type":15,"attrs":551,"content":552},{"textAlign":398},[553,558],{"text":554,"type":298,"marks":555},"\"I wanted to share this story because it is such a profound story at so many levels. Clearly the most significant level is in the lives of the family and in the life lost in that child. But it's not just there. Children's Hospital is a different organization because of that experience. Children's Hospital takes care of its patients differently now in a way that is safer. Children's Hospital organizes and cares for its staff in a way that is different and is safer. And we've taken the approach to communicate our experiences and results to other individuals and organizations less they assume they would never be subject to such an event or such an error. And I think that's actually the marvellous opportunity that has come out of this absolute tragedy.\"",[556],{"type":392,"attrs":557},{"color":16},{"text":395,"type":298},{"type":15,"attrs":560,"content":561},{"textAlign":398},[562,567],{"text":563,"type":298,"marks":564},"Cochrane hopes every new generation of healthcare providers comes into the system a little better prepared than their predecessors in understanding the strengths of health care as well as its limitations. He's encouraged by what he sees.",[565],{"type":392,"attrs":566},{"color":16},{"text":395,"type":298},{"type":15,"attrs":569,"content":570},{"textAlign":398},[571,576],{"text":572,"type":298,"marks":573},"\"I'm amazed at the current set of trainees that I'm exposed to on a day-to-day. They truly up my game. Because they're far better prepared and have a far better working knowledge of many aspects that relate to safe care. They are more insightful about themselves, they are more understanding of their own reactions, but they are also more understanding of patients and how to treat them and families in a way that is respectful. I think we are in a good position but I would want all of them to remember that we have an obligation. We're fortunate in Canada to have a system in which we have an obligation, not just as taxpayers but as providers, and that obligation is to make the system better and to make it safer for all.\"",[574],{"type":392,"attrs":575},{"color":16},{"text":395,"type":298},{"type":15,"attrs":578,"content":579},{"textAlign":398},[580,585],{"text":581,"type":298,"marks":582},"Dr. Doug Cochrane passed away peacefully at home, surrounded by his loving family, on February 17, 2024. ",[583],{"type":392,"attrs":584},{"color":16},{"text":586,"type":298},"Dr. Cochrane's exceptional contributions to education and unwavering commitment to advancing patient safety set a benchmark for excellence. His exemplary leadership and dedication to advancing healthcare quality have been an inspiration to many in British Columbia and across the country.",{"_uid":588,"title":589,"video_id":590,"component":305,"transcript":591,"video_type":368,"description":683,"video_title":589,"video_description":694},"1e48fc95-0bef-4386-a232-a709a77e72c9","Dr. Francois deWet turns “physician’s worst nightmare” into opportunity for improvement","WrnURmas8_Y",{"type":12,"content":592},[593,598,603,608,613,618,623,628,633,638,643,648,653,658,663,668,673,678],{"type":15,"attrs":594,"content":595},{"textAlign":53},[596],{"text":597,"type":298},"[0:00:10] My name is Dr. Francois deWet. I'm a family physician. I practice mainly in a place called Beaver, Newfoundland. I've been in practice for 23 years and mainly in family practice. ",{"type":15,"attrs":599,"content":600},{"textAlign":53},[601],{"text":602,"type":298},"[0:00:25] So my story and the mistake that I was involved in goes back a few years ago. I was working as an emergency physician in one of the small rural hospitals in Newfoundland. And what happened was a patient came in to the emergency room, accompanied by a couple of family members, with the story that she had had chest pain since earlier that day. We had assessed her and done EKGs very quickly after she came in through the door, and we found that she had a acute myocardial infarction; she had a heart attack. We treated her immediately with the appropriate medication and it looked like things were going well. And unfortunately, you know, the situation deteriorated. ",{"type":15,"attrs":604,"content":605},{"textAlign":53},[606],{"text":607,"type":298},"[0:01:14] To give you a bit of background about the case, this lady had not been seen in our facility or in any facility; she had not seen a doctor in approximately 14 years. Unfortunately, when she had presented the previous time, it was with a suicidal attempt. She was treated and she survived this. But according to the family, since that episode, she did not want to come to the hospital at all. She did not want to to see physicians. And they said to us that over the last couple of months especially, she had not been well. They thought she may have had diabetes because she had ulcers and so on and wasn't healing. But no matter what they did, they couldn't convince her to come to the hospital until the day that she presented. ",{"type":15,"attrs":609,"content":610},{"textAlign":53},[611],{"text":612,"type":298},"[0:02:03] And when she came in, the story was a little bit vague. We did not know how long she had had the chest pain. And with the medication we give for heart attacks, there's a time limit that you have to decide if the patient is still within the time zone where it will help. And in this case, because we didn't know, we decided to go ahead and give it to her anyway. ",{"type":15,"attrs":614,"content":615},{"textAlign":53},[616],{"text":617,"type":298},"[0:02:27] She rallied initially and I had gone out to the family and they were in the waiting room. And I said to them, “You know, this is very serious, but it looks like this is what's going on. And I think that we may be able to treat her and help her get through this.” After I talked to the family, I went back into the room where we were treating this lady and it looked like she was starting to deteriorate. She had become more short of breath and her oxygen levels in her blood was dropping fairly quickly. And I made a decision at that time to put a tube in her to intubate her to help her breathe, because we were afraid that we were going to lose our airway. ",{"type":15,"attrs":619,"content":620},{"textAlign":53},[621],{"text":622,"type":298},"[00:03:03] The two nurses were working with me that night were extremely competent. I'd work with them for many years. They were two of our senior nurses. And I had complete confidence in them and they had complete confidence in me. And so when we started the process, I told them that we have to get the medication called Scolene [ph], which is Socs\u0002a-no-coline [ph] is the name of a medication. And Socs-a-no-coline [ph] is a medication to relax the muscles that help you to intubate this lady or to put a tube down her airway to help her breathe. ",{"type":15,"attrs":624,"content":625},{"textAlign":53},[626],{"text":627,"type":298},"[0:03:37] The nurse looked at me and she said, “Scopolamine?” which is another medication we use in palliative care to dry up secretions. I, of course, heard “Scolene,” and I said, “Yes, Scolene.” She went off, got the medication. By the time she came back, I decided that we have to intubate and I asked her to give the medication to relax the lady's muscles so that we can have easier intubation. ",{"type":15,"attrs":629,"content":630},{"textAlign":53},[631],{"text":632,"type":298},"[0:04:05] We gave her the medication and nothing happened. And I was confused for a few minutes because this was not the way it's supposed to be. She was supposed to relax immediately for me to intubate. So I was running through my mind what the reason could be why this drug is not working. But it's almost like I couldn't think in that critical situation. I was looking at the monitor and I was seeing that the saturation was kind of low. And I said, “Well, you know, give another dose.” The nurse immediately gave a second dose, and again, nothing happened. And again, I was thinking to myself, “Well, there must be something wrong with the medication or maybe this patient is not susceptible to it. I've never seen this in my entire career.” It never occurred to me, you know, that maybe this was the wrong medication that was being given. ",{"type":15,"attrs":634,"content":635},{"textAlign":53},[636],{"text":637,"type":298},"[0:05:00] Anyway, I asked her for rock-a-romium [ph], which is another medication in the same line. She immediately went away, got it, we pushed this drug, and the patient immediately relaxed, we intubated her. It was a long resuscitation process, but the end result was that, unfortunately, the lady passed away and we weren't able to save her. ",{"type":15,"attrs":639,"content":640},{"textAlign":53},[641],{"text":642,"type":298},"[0:05:18] I went out, I talked to the family and kind of kind of comforted them with the fact that they had just lost a loved one and kind of explained to them what had happened and the fact that, you know, she had decompensated and that we weren't able to save her. And the family had asked if they could go in with the lady to be with her. ",{"type":15,"attrs":644,"content":645},{"textAlign":53},[646],{"text":647,"type":298},"[0:05:42] I went outside and I was sitting at the nursing station and we were just talking about what happened. Usually, when these things happen, we kind of go through the process to try and see, you know, what we did and how we did it. And the nurse said to me, “You know, I've never seen scopolamine given in a code.” And as soon as she said it, the penny dropped and it was, you know, you have this feeling in your stomach. It's between when your wife says, “Honey, we need to talk,” and your secretary calls and says, “Revenue Canada is on the phone looking for you.” It was just like someone punched me in the stomach. And immediately I knew that that’s what happened. We had given the wrong medication during the intubation process. And my mind started running because now I'm thinking, “Did that contribute to her death? Was this something that could have been avoided? I mean, is this maybe the fact of why we couldn't resuscitate?” Because at that time, I didn't understand how this drug could have contributed or not contributed to the situation. ",{"type":15,"attrs":649,"content":650},{"textAlign":53},[651],{"text":652,"type":298},"[0:06:52] The one thing I knew was that I had to go out and I had to talk to the family. And so I went outside and I talked to the lady's sister, who was the next of kin on her chart. And I told her that during the resuscitation process, we had given the wrong medication not only once, but twice. I also said that I couldn't tell her at this point in time whether or not it had any effect on the outcome. I did not think it, but I wasn't 100% sure. Considering the stress that she was under, she took it very well and she said, you know, “I'm sure you did what you could, and, you know, if we had brought her in earlier.” And she was kind of feeling bad about the situation because of the fact that she knew her sister was sick, but they didn't bring her into the hospital. ",{"type":15,"attrs":654,"content":655},{"textAlign":53},[656],{"text":657,"type":298},"[0:07:39] That evening, I contacted the internal medicine specialist on call at the hospital that we refer to, and I had a discussion with him about the medication that we had given, and he did not feel that it would have had a bad effect on the outcome. But it was still inside me, that feeling that we had not done well by this lady. We did not do the best we could do, and we did not give her the best care that she could have had, even though my brain was saying that it had nothing to do with it and it was just something unfortunate. ",{"type":15,"attrs":659,"content":660},{"textAlign":53},[661],{"text":662,"type":298},"[0:08:20] The nurse itself that had given the medication was extremely distraught because she felt that it was her mistake, even though I tried to say to her, you know, this was this was my mistake as much as it was yours, because I used the slang term or a term for the medication that she may not have been familiar with. ",{"type":15,"attrs":664,"content":665},{"textAlign":53},[666],{"text":667,"type":298},"[0:08:38] We live in a small community, and one of the fears that I had was that, you know, we would be – not only myself or my staff, but also our facility. We're very proud of the cottage [ph] hospital that we serve in. And there was a fear with me that, you know, because of this mistake, it will become public knowledge. And, you know, you run into people every day. I mean, if I go to the grocery store, I would see probably a member of the family or I would see somebody that knew about this. ",{"type":15,"attrs":669,"content":670},{"textAlign":53},[671],{"text":672,"type":298},"[0:09:08] And talking to the family, the next time I met with them again, and we went through the whole process again and talked to them about what had happened. And the family was amazing. They knew that whatever had happened was not something that was purposeful or was that malignant intent. And I think they were very supportive. Even though other people will say to you that, “You did okay,” or, “We're fine with it,” there's that inner voice that just kind of screams at you the whole time and saying, you know, “This was wrong. This shouldn't have happened. You did wrong. You’re a failure, what you do.” And you have to listen to that 24-7. ",{"type":15,"attrs":674,"content":675},{"textAlign":53},[676],{"text":677,"type":298},"[0:09:44] As a physician that has been practicing for 20 years, if I had such a hard time with it, I don't imagine how someone who’s been out of university or being practicing for a year or two, how they would deal with it, or even people in university itself, residents or students that were involved in an adverse event and may have contributed to it. I think these are things that, if you if you look at the literature, which I've done after this happened, this could be a career-ending incident for young physicians or for nurses or for other allied health care workers that are involved in these things. You know, people have actually walked away from the job because of what had happened to them and how they were dealt with. ",{"type":15,"attrs":679,"content":680},{"textAlign":53},[681],{"text":682,"type":298},"[0:10:32] It's been almost three years since this has happened. And I still see the family around town. I still see them in hospital. Some of them are my patients. And every time I see them, the my initial reaction is still kind of like there’s this shimmering of fear and shame in the back of my mind. But I also look at them and I can hold my head up high and say, “You know what? Whatever happened that night, something good came out of it,” and I think they know it.",{"type":12,"content":684},[685],{"type":15,"attrs":686,"content":687},{"textAlign":53},[688],{"text":375,"type":298,"marks":689},[690],{"type":378,"attrs":691},{"href":692,"uuid":53,"anchor":53,"custom":693,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/a6e036477a/cpsi-2015-dewet-master.pdf",{},{"type":12,"content":695},[696,705,714,723,732,741,750,759,768,777,786,795,804,813,822,831,840,849,858,867,876,885],{"type":15,"attrs":697,"content":698},{"textAlign":53},[699,704],{"text":700,"type":298,"marks":701},"The lady presenting to the emergency room that evening seemed like countless others for Dr. Francois deWet until a life-changing moment he will never forget.",[702],{"type":392,"attrs":703},{"color":16},{"text":395,"type":298},{"type":15,"attrs":706,"content":707},{"textAlign":398},[708,713],{"text":709,"type":298,"marks":710},"She had been brought into the small rural Newfoundland hospital where deWet was working by family members, who reported that she had been suffering chest pains since earlier in the day. The patient hadn't been seen by any doctors since being admitted to the hospital some 14 years earlier following a suicide attempt. She had been unwell for several weeks and her family suspected she had diabetes, but until that day had steadfastly refused to see a physician.",[711],{"type":392,"attrs":712},{"color":16},{"text":395,"type":298},{"type":15,"attrs":715,"content":716},{"textAlign":398},[717,722],{"text":718,"type":298,"marks":719},"An electrocardiogram confirmed that she'd suffered a heart attack. She was treated according to their protocols and initially seemed to stabilize but her condition then rapidly deteriorated. She became short of breath and the oxygen levels were dropping.",[720],{"type":392,"attrs":721},{"color":16},{"text":395,"type":298},{"type":15,"attrs":724,"content":725},{"textAlign":398},[726,731],{"text":727,"type":298,"marks":728},"\"I made a decision at that time to put a tube in her, to intubate her, because we were afraid we were going to lose our airway,\" deWet recalls of the case. \"The two nurses working that night were two of our senior nurses. I had complete confidence in them and they had complete confidence in me.\"",[729],{"type":392,"attrs":730},{"color":16},{"text":395,"type":298},{"type":15,"attrs":733,"content":734},{"textAlign":398},[735,740],{"text":736,"type":298,"marks":737},"DeWet turned to one of the nurses and asked for \"scoline,\" short-term slang for succinylcholine, a standard medication that relaxes the muscles to allow doctors to put a breathing tube down a patient's trachea.",[738],{"type":392,"attrs":739},{"color":16},{"text":395,"type":298},{"type":15,"attrs":742,"content":743},{"textAlign":398},[744,749],{"text":745,"type":298,"marks":746},"\"The nurse looked at me and she said, 'scopolamine?' Which is another medication we use in palliative care to dry up secretions. I, of course heard 'scoline' and I said 'yes, scoline.' So she ran off, got the medication and by the time she came back I'd decided we had to intubate,\" deWet says.",[747],{"type":392,"attrs":748},{"color":16},{"text":395,"type":298},{"type":15,"attrs":751,"content":752},{"textAlign":398},[753,758],{"text":754,"type":298,"marks":755},"\"We gave her the medication and nothing happened. I was confused for a few seconds because this was not the way it was supposed to be. She was supposed to relax immediately for me to intubate. I was running through my mind what the reason could be why this drug was not working. But it was almost like I couldn't think in that critical situation. I was looking at the monitor and I was seeing that the saturations was getting lower and I said, give another dose. The nurse immediately gave a second dose and again nothing happened.\"",[756],{"type":392,"attrs":757},{"color":16},{"text":395,"type":298},{"type":15,"attrs":760,"content":761},{"textAlign":398},[762,767],{"text":763,"type":298,"marks":764},"Confounded, deWet wondered if something was wrong with the medication or if perhaps the patient was somehow not susceptible to it. He had never seen anything like this before in his entire career. He asked for rocuronium, another medication of the same type. The patient was given that drug, she immediately relaxed and deWet and his nursing team intubated her.",[765],{"type":392,"attrs":766},{"color":16},{"text":395,"type":298},{"type":15,"attrs":769,"content":770},{"textAlign":398},[771,776],{"text":772,"type":298,"marks":773},"A long resuscitation attempt followed, but in the end the woman could not be saved. DeWet broke the news to the family and tried to comfort them. They asked to spend some time alone with their loved one.",[774],{"type":392,"attrs":775},{"color":16},{"text":395,"type":298},{"type":15,"attrs":778,"content":779},{"textAlign":398},[780,785],{"text":781,"type":298,"marks":782},"\"I went outside and I was sitting at the nursing station and we were just talking about what happened … And the nurse said to me, 'You know, I've never seen scopolamine given in a code.' And as soon as she said it, the penny dropped.",[783],{"type":392,"attrs":784},{"color":16},{"text":395,"type":298},{"type":15,"attrs":787,"content":788},{"textAlign":398},[789,794],{"text":790,"type":298,"marks":791},"\"You have this feeling in the stomach. It's between when your wife says, 'honey, we need to talk,' and your secretary calls and says \"Revenue Canada is on the phone looking for you.' It was just like someone had punched me in the stomach. And immediately I knew that that's what happened. We had given the wrong medication during the intubation process. And my mind started running because now I'm thinking did that contribute to her death, was this something that could be avoided, is this maybe why we couldn't resuscitate? At that time I didn't understand how or if this drug could have contributed or not contributed to the situation.\"",[792],{"type":392,"attrs":793},{"color":16},{"text":395,"type":298},{"type":15,"attrs":796,"content":797},{"textAlign":398},[798,803],{"text":799,"type":298,"marks":800},"In that moment deWet was confronting every physician's worst nightmare — a preventable medical error. He didn't know if the drug mix-up had contributed in any way to his patient's demise but he knew that a mistake had been made. He also knew that the first thing he had to do was tell the family. He pulled the patient's sister aside and told her what had happened, saying he didn't know if the mix-up had contributed to the death, but vowing to find out quickly and let her know. The woman took the disclosure with remarkable reserve, deWet says.",[801],{"type":392,"attrs":802},{"color":16},{"text":395,"type":298},{"type":15,"attrs":805,"content":806},{"textAlign":398},[807,812],{"text":808,"type":298,"marks":809},"The incident triggered waves of emotional turmoil among all the medical personnel involved, deWet recalls. The nurse who had administered the medication was tremendously distraught, because she felt at fault. DeWet blamed himself for using a slang term for medication she might not have been familiar with. Everyone felt that they had somehow failed in delivering the best care possible to that one patient.",[810],{"type":392,"attrs":811},{"color":16},{"text":395,"type":298},{"type":15,"attrs":814,"content":815},{"textAlign":398},[816,821],{"text":817,"type":298,"marks":818},"That evening, deWet contacted an internal medicine specialist and was given some assurance that the medication mix-up was unlikely to have contributed to the woman's death. Despite this, he and his nurses still went home the next day \"feeling absolutely terrible.\" Part of the apprehension was tied to the realities of life in a small town, where everyone knows everyone, and the fear about how the incident would be perceived around the community.",[819],{"type":392,"attrs":820},{"color":16},{"text":395,"type":298},{"type":15,"attrs":823,"content":824},{"textAlign":398},[825,830],{"text":826,"type":298,"marks":827},"When deWet met again with the family the following day, they were \"amazing\" in their understanding. The sister had already reached out to one of his nurses to assure her that they understood and they knew that it was a mistake.",[828],{"type":392,"attrs":829},{"color":16},{"text":395,"type":298},{"type":15,"attrs":832,"content":833},{"textAlign":398},[834,839],{"text":835,"type":298,"marks":836},"\"I think that they knew that whatever had happened was not something that was purposeful or something that had malignant intent. And I think they were very supportive.\"",[837],{"type":392,"attrs":838},{"color":16},{"text":395,"type":298},{"type":15,"attrs":841,"content":842},{"textAlign":398},[843,848],{"text":844,"type":298,"marks":845},"That compassion, as well as the support of his wife, a nurse herself, and his colleagues helped console deWet through some painful second-guessing, and many sleepless nights. But only to a point, he says.",[846],{"type":392,"attrs":847},{"color":16},{"text":395,"type":298},{"type":15,"attrs":850,"content":851},{"textAlign":398},[852,857],{"text":853,"type":298,"marks":854},"\"It's like this. Even though other people will say to you that you did okay, or we're fine with it, there's that inner voice that just kind of screams at you the whole time, saying this was wrong, this shouldn't have happened, you did wrong and you're a failure at what you did, and you have to listen to that 24/7.\"",[855],{"type":392,"attrs":856},{"color":16},{"text":395,"type":298},{"type":15,"attrs":859,"content":860},{"textAlign":398},[861,866],{"text":862,"type":298,"marks":863},"Looking back, deWet recalls the emotional trauma he struggled with as a practicing physician with some 20 years' experience and wonders how much greater the strain must be for health care providers who are still relatively new to the system. He's not surprised that the literature shows that such adverse episodes can be career-ending moments for many young health professionals.",[864],{"type":392,"attrs":865},{"color":16},{"text":395,"type":298},{"type":15,"attrs":868,"content":869},{"textAlign":398},[870,875],{"text":871,"type":298,"marks":872},"\"There are two ways that people can approach an incident like this. The one is the old-style circling of the wagons and the cult of silence, where I won't tell if you don't tell. But that's the wrong way of doing things. That's the old way of doing things. What should happen in these cases is that it should be assessed, it should be evaluated, it should be looked at and it should be picked apart, and the cause of what happened should be found and it should be dealt with. Because if it's happened once, it will happen again and if we don't fix these things as they come up, what will happen is someone else will be harmed in the same way and same manner.\"",[873],{"type":392,"attrs":874},{"color":16},{"text":395,"type":298},{"type":15,"attrs":877,"content":878},{"textAlign":398},[879,884],{"text":880,"type":298,"marks":881},"DeWet and his nurses made the immediate commitment that fateful night to be fully open about the incident and work towards a full quality review of what happened. As a result of that specific incident the hospital had changed procedures in administering medications in resuscitation situations, including the storage of drugs and the specific naming of drugs requested by medical personnel.",[882],{"type":392,"attrs":883},{"color":16},{"text":395,"type":298},{"type":15,"attrs":886,"content":887},{"textAlign":398},[888],{"text":889,"type":298,"marks":890},"\"It's been almost three years since this has happened and I still see the family around town, I still see them in the hospital and some of them are my patients. And every time I see them my initial reaction is still kind of like a shimmering of fear and shame in the back of my mind. But I also look at them and can hold my head up high and say whatever happened that night, something good came out of it. And I think they know it.\"",[891],{"type":392,"attrs":892},{"color":16},{"_uid":894,"title":895,"video_id":896,"component":305,"transcript":897,"video_type":368,"description":984,"video_title":895,"video_description":995},"5572c091-b9ae-4aca-9009-90fafc440c6f","Near-fatal medication error leads nurse to make patient safety a priority","MGT8yoAIun4",{"type":12,"content":898},[899,904,909,914,919,924,929,934,939,944,949,954,959,964,969,974,979],{"type":15,"attrs":900,"content":901},{"textAlign":53},[902],{"text":903,"type":298},"[0:00:10] I'm here today to share a story about a medication error that I made more than 30 years ago. And even though more than three decades have passed since that day, it feels like every moment of the time is ingrained with crystal clarity in my mind. And I hope by sharing it, to share some lessons that other health providers can learn from. ",{"type":15,"attrs":905,"content":906},{"textAlign":53},[907],{"text":908,"type":298},"[0:00:31] I'm a registered nurse and I was practicing in a neurosurgical intensive care unit back in 1985. I had been a graduate for about two years at that point and had moved from a ward setting into an intensive care unit. And in that setting, the pace is fast and I was fairly new. I'm going to say I was there less than six months in that setting and was so impressed with the rapid thinking, apparent intelligence, competence of the nurses around me, and you want to be like them. So I think when I think back to what happened, I do think some of it was trying to be better, faster maybe than I was. ",{"type":15,"attrs":910,"content":911},{"textAlign":53},[912],{"text":913,"type":298},"[0:01:20] So on the day this incident happened, I had two patients, which was normal in that unit. And the situation of the two patients I had was that one had high potassium, which means he shouldn't have any more potassium given to him. And the second patient had low potassium and they were in beds side by side and I had those two patients through the day. ",{"type":15,"attrs":915,"content":916},{"textAlign":53},[917],{"text":918,"type":298},"[0:01:45] Through a series of errors, I ended up giving medication to the wrong patient. The physician called about the patient with the low potassium and transmitted a message, an order for potassium medication to go to that patient, gave his order to the nurse in charge at the desk, so I didn't personally have the conversation. And she wrote the order, which is normal. We call that transcribing. She wrote down, “Give medication X to patient A.” ",{"type":15,"attrs":920,"content":921},{"textAlign":53},[922],{"text":923,"type":298},"[0:02:22] And in the course of calling me to the desk to tell me that this had happened, she held up the order sheet. And nurses and docs and people in hospitals will know there's usually a little identifier on the corner of the sheet. And she had her hand over it, simply, you know, picked up the paper and said, “Here's the order,” which is the normal thing you would do, “give it to patient A.” And I, wanting to appear competent and to act quickly – it’s a critical care unit – drew up the medication and then failed to do a really important thing, which is to cross check the order which had been shown to me. So remember, I had seen it, so I thought, “Okay, that makes sense.” And I knew the patient had low potassium, so it all made sense. ",{"type":15,"attrs":925,"content":926},{"textAlign":53},[927],{"text":928,"type":298},"[0:03:14] I went to the bedside and checked the patient, made sure I had the right patient, which I didn't, because I was rushing. So I took the medication, which I had drawn up potassium, and was about to give it to the patient. And this was a big lesson for me and my entire career. I thought something was wrong. Something was triggering me. “Something's wrong with this.” What I didn't do was stop. I pushed it in slowly, but pushed it in. And it wasn't two seconds after I finished, I thought, “Oh, it's the wrong patient. It's the guy with the high potassium that I just overdosed with a whole bunch more potassium.” And literally, I nearly collapsed. And I mean, I thought, “My career is over. I'm not going to lose my license. He's going to die.” And I, to this day, don't know why I didn't stop when in fact, what had happened was – everything in the chain of events had been done correctly, except when she said, “Give it to patient A,” she was wrong because it was for patient B. her hand was covering it and I didn't look at it and I didn't double check. “Are we talking about patient A or patient B?” I just said, “Okay, I know about this potassium problem,” went over, shoved it in. ",{"type":15,"attrs":930,"content":931},{"textAlign":53},[932],{"text":933,"type":298},"[0:04:40] To add to the complexity, it was a physician himself. The patient was a physician known to other physicians. ",{"type":15,"attrs":935,"content":936},{"textAlign":53},[937],{"text":938,"type":298},"[0:04:48] I don't totally remember, but I think someone took over the care. It's the only part that I can remember because I think I was so upset that they basically put me in the staff lounge. And I think I spent the whole evening shift there just waiting and wondering because I couldn't go home and rest. I thought, “He's going to die.” And I knew that I had pushed it in. ",{"type":15,"attrs":940,"content":941},{"textAlign":53},[942],{"text":943,"type":298},"[0:05:11] You know, it's 32 or 33 years ago that that happened. And it is still cemented in my mind, everything about the lighting in that room that day, the look of people around me, how I felt, what I learned about, you know, when the little man on your shoulder says, “Slow down,” you should slow down before you hurt somebody. And I always tell that to students and other nurses, “Just take that one second. Don't complicate the situation by rushing that way.” ",{"type":15,"attrs":945,"content":946},{"textAlign":53},[947],{"text":948,"type":298},"[0:05:46] In this case, it's a perfect example of what we see often in medicine and nursing, which is, the errors happen at points of handoff in care. We see it from docs and nurses; in this case, the doc to the charge nurse to Michael. And all capable people, right? In a rush. Not unusual to have a mix of very, very sick people side by side. And part of your duty as an RN in a critical care unit is to have that in mind. Each patient might have five or six or ten lines of medications running in. That's part of the job. ",{"type":15,"attrs":950,"content":951},{"textAlign":53},[952],{"text":953,"type":298},"[0:06:22] I think that a complicating factor is when physicians give orders to some intermediary person. So right away, you have the potential for an error, which happened with us; just the wrong patient. Everything else was right except the words came out of people's mouths wrong. We see it in handoffs, even in home care from registered nurses who provide plans of care and delegate care to a licensed practical nurse who may delegate that to a nursing assistant or a personal support worker, and a point of great error onto families because families provide a lot of care. So it's not just a critical care unit issue or a hospital issue. It's across the health care system that points of handoff – and the more of them there are, the more chances that there are for an error. ",{"type":15,"attrs":955,"content":956},{"textAlign":53},[957],{"text":958,"type":298},"[0:07:09] Even though I was young and scared, I did the right thing, which was, as soon as it was done, I went, “Oh my,” and immediately got help and said, “I did, this is what I did.” And that's probably what also saved my career and my license, that I wasn't cavalier about it. I didn't try to hide it. ",{"type":15,"attrs":960,"content":961},{"textAlign":53},[962],{"text":963,"type":298},"[0:07:25] I remembered that they had asked me just to wait in the staff lounge, which was attached to the intensive care unit. And I think I spent basically a whole second shift sitting back there in a panic, worried about him. I was worried about my license and my job, of course, because I had just done many, many years of school and was proud of what I had done, you know, to get to this point. And I think there's a huge cloud of fear across nursing and I think medicine, too, from the second you graduate, that if anything happens, you'll lose your license. So there's a terrible fear of error. ",{"type":15,"attrs":965,"content":966},{"textAlign":53},[967],{"text":968,"type":298},"[0:08:13] But I admitted right away what I did and got help right away and sat in the back for that entire shift. And I knew, I think, by about four or five hours in, because they were treating him with – there's a ways you treat that to reduce the potassium – that he wasn't going to die at that point. My concern is, he was already very sick. He was unconscious under my care before the incident. So he was quite ill. But as the time went by, I felt the relief mostly that he didn't die, because I really thought, what a terrible thing, to hurt somebody. ",{"type":15,"attrs":970,"content":971},{"textAlign":53},[972],{"text":973,"type":298},"[0:08:56] And so then I had the chance to speak with my, at the time was called head nurse, who was fantastic. And I was expecting, when she came in, that I might be disciplined, I might be sent home. And her comment was, “What did you learn?” The head nurse was fantastic, unbelievably supportive, and basically said, “You know, when that little man on the shoulder says stop, it's like the yellow light at the intersection. You shouldn't speed up; you should slow it down.” And I learned a huge lesson. ",{"type":15,"attrs":975,"content":976},{"textAlign":53},[977],{"text":978,"type":298},"[0:09:24] Even now in my administrative roles and my teaching roles, if I sense something's wrong, I just say to people, “I need a day to think about that.” I try to not make snap decisions and I think my decisions are better. It’s certainly shaped what I talked about in the roles I had after. So I was the instructor in that unit, became a clinical nurse specialist, eventually managed the unit for five years. And that was something I talked about with all young nurses coming in or novice nurses, not necessarily young, but young to the job. ",{"type":15,"attrs":980,"content":981},{"textAlign":53},[982],{"text":983,"type":298},"[0:09:55] For me, the big lesson is, if the triggers in your mind that something's wrong, something's probably wrong. Stop what you're doing, even for a minute, and think it through a second time. And I talk about that. Well, here we're talking about it 30-plus years later. I talk about it in every job with students and so on.",{"type":12,"content":985},[986],{"type":15,"attrs":987,"content":988},{"textAlign":53},[989],{"text":375,"type":298,"marks":990},[991],{"type":378,"attrs":992},{"href":993,"uuid":53,"anchor":53,"custom":994,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/c6493d4ba5/cpsi-2017-mike-villeneuve-master.pdf",{},{"type":12,"content":996},[997,1006,1015,1024,1033,1042,1051,1060,1069,1078,1087,1096,1105,1114,1123,1132,1141,1150,1159,1168,1177,1186,1195],{"type":15,"attrs":998,"content":999},{"textAlign":53},[1000,1005],{"text":1001,"type":298,"marks":1002},"More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity.",[1003],{"type":392,"attrs":1004},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1007,"content":1008},{"textAlign":398},[1009,1014],{"text":1010,"type":298,"marks":1011},"The little man on his shoulder was telling him 'wait a second, something is not right here,' but Villeneuve, then a cocky young nurse eager to keep pace with his colleagues in an Ontario intensive care unit, went ahead and administered the medication.",[1012],{"type":392,"attrs":1013},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1016,"content":1017},{"textAlign":398},[1018,1023],{"text":1019,"type":298,"marks":1020},"The instant he did so, he knew exactly what he'd done: right drug, wrong patient.",[1021],{"type":392,"attrs":1022},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1025,"content":1026},{"textAlign":398},[1027,1032],{"text":1028,"type":298,"marks":1029},"Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across the country.",[1030],{"type":392,"attrs":1031},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1034,"content":1035},{"textAlign":398},[1036,1041],{"text":1037,"type":298,"marks":1038},"As a youngster, Villeneuve always dreamed of becoming a surgeon. His grandmother was a director of nursing in a small rural hospital and used to take him by the hand and lead him, spellbound, along with her as she did her rounds. His ambitions shifted slightly in high school after a family friend helped him get a job as an orderly at an Ottawa hospital. He was there less than an hour before he realized he was far more fascinated by what the nurses were doing than the doctors.",[1039],{"type":392,"attrs":1040},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1043,"content":1044},{"textAlign":398},[1045,1050],{"text":1046,"type":298,"marks":1047},"\"There was something about the competence of those women,\" Villeneuve recalls. \"If you've been in an emergency department with certain women running the place, there's a kind of swagger and an attitude that's quite intoxicating when you're young. I just thought, 'I want to be like that.' That's where I ended up working in emergency intensive care, neurosurgery and so on, and never looked back. To this day, I would never change a second of it.",[1048],{"type":392,"attrs":1049},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1052,"content":1053},{"textAlign":398},[1054,1059],{"text":1055,"type":298,"marks":1056},"\"Except I wouldn't make the mistake.\"",[1057],{"type":392,"attrs":1058},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1061,"content":1062},{"textAlign":398},[1063,1068],{"text":1064,"type":298,"marks":1065},"The mistake happened back in 1985. Two years after graduating nursing school Villeneuve had moved from a ward setting into a neurosurgical intensive care unit. He'd only been there a few weeks. At that time in the profession a male nurse was still something of a novelty and Villeneuve was eager to prove his worth. In that setting, an open ward with 12 beds, the pace is fast. Villeneuve remembers being so impressed by the confident execution and rapid thinking of the nurses around him.",[1066],{"type":392,"attrs":1067},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1070,"content":1071},{"textAlign":398},[1072,1077],{"text":1073,"type":298,"marks":1074},"\"When I think back to what happened, I do think some of it was trying to be better, faster maybe than I was, if you know what I mean.\"",[1075],{"type":392,"attrs":1076},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1079,"content":1080},{"textAlign":398},[1081,1086],{"text":1082,"type":298,"marks":1083},"On the day of the incident, Villeneuve had two patients in his care — one with high potassium levels, the other with low potassium. The charge nurse took a call from a doctor, directing potassium be administered to one of his patients. She transcribed the order, called Villeneuve over and holding up the order sheet, instructed him to give medication A to patient B.",[1084],{"type":392,"attrs":1085},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1088,"content":1089},{"textAlign":398},[1090,1095],{"text":1091,"type":298,"marks":1092},"It is something in that chain of events, a partially obscured order sheet, the utterance of one patient's name rather than the other, that sent Villeneuve to the wrong bedside.",[1093],{"type":392,"attrs":1094},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1097,"content":1098},{"textAlign":398},[1099,1104],{"text":1100,"type":298,"marks":1101},"\"I took the medication, which I had drawn up, potassium, and was about to give it to the patient and — this was a big lesson for me in my entire career — I thought, something was wrong,\" Villeneuve says.",[1102],{"type":392,"attrs":1103},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1106,"content":1107},{"textAlign":398},[1108,1113],{"text":1109,"type":298,"marks":1110},"\"I thought something was triggering me, something's wrong with this. What I didn't do was stop. I pushed it in, slowly, but pushed it in. It wasn't two seconds after I finished that I thought, oh, it's the wrong patient; it's the guy with the high potassium that I just overdosed with a whole bunch more potassium. Literally I nearly collapsed. I thought, my career's over, I'm going to lose my license, he's going to die.\"",[1111],{"type":392,"attrs":1112},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1115,"content":1116},{"textAlign":398},[1117,1122],{"text":1118,"type":298,"marks":1119},"Villeneuve owned up to the error immediately and nurses and doctors swept in to attend to the patient, whose heart went into immediate distress. To make matters even worse, the patient was a senior physician himself. Villeneuve was so upset that his colleagues basically parked him in an adjacent staff lounge for the remainder of the day.",[1120],{"type":392,"attrs":1121},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1124,"content":1125},{"textAlign":398},[1126,1131],{"text":1127,"type":298,"marks":1128},"\"It's 32 or 33 years ago that that happened and it is still cemented in my mind, everything about the lighting in that room that day, the look of people around me, how I felt, what I learned about when the little man on your shoulder says, 'Slow down,' you should slow down before you hurt somebody,\" Villeneuve says.",[1129],{"type":392,"attrs":1130},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1133,"content":1134},{"textAlign":398},[1135,1140],{"text":1136,"type":298,"marks":1137},"He views his experience as a perfect example of what is confirmed so often in medicine and nursing, which is that errors most often happen at points of handoff in care.",[1138],{"type":392,"attrs":1139},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1142,"content":1143},{"textAlign":398},[1144,1149],{"text":1145,"type":298,"marks":1146},"\"We see it in handoffs even in home care from registered nurses who provide plans of care and delegate care to a licensed practical nurse who may delegate that to a nursing assistant or a personal support worker and, a point of great error, onto families,\" Villeneuve says.",[1147],{"type":392,"attrs":1148},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1151,"content":1152},{"textAlign":398},[1153,1158],{"text":1154,"type":298,"marks":1155},"\"Because families provide a lot of care. So it's not just a critical care unit issue or a hospital issue; it's across the healthcare system. Points of handoff, and the more of them there are, the more chances that there are for an error.\"",[1156],{"type":392,"attrs":1157},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1160,"content":1161},{"textAlign":398},[1162,1167],{"text":1163,"type":298,"marks":1164},"Villeneuve spent an entire second shift in that staff lounge that fateful day, panic-stricken about his patient, worried about his future, wracked by that \"terrible fear of error\" that hangs over nursing from graduation day onwards. But as the hours passed it eventually became clear the patient would survive. It was only then that Villeneuve had a chance to talk things over with his head nurse, who was wonderfully supportive.",[1165],{"type":392,"attrs":1166},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1169,"content":1170},{"textAlign":398},[1171,1176],{"text":1172,"type":298,"marks":1173},"\"I was expecting when she came in that I might be disciplined, I might be sent home. Her comment was, 'What did you learn?' \" Villeneuve recalls, choking up at the memory.",[1174],{"type":392,"attrs":1175},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1178,"content":1179},{"textAlign":398},[1180,1185],{"text":1181,"type":298,"marks":1182},"\"She said, 'slow down.' One of the nurses I really looked up to was a nurse named Jennifer who was so competent. And she said, 'You're not Jennifer yet. Settle down. Stop. Double check.' All the things I knew I should've done. And it helped me reduce my ego, which was quite constrained after that incident.\"",[1183],{"type":392,"attrs":1184},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1187,"content":1188},{"textAlign":398},[1189,1194],{"text":1190,"type":298,"marks":1191},"It was a major life lesson for him. When that little man on your shoulder says stop, it's like encountering the yellow light at the intersection. You shouldn't speed up, you should slow it down.",[1192],{"type":392,"attrs":1193},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1196,"content":1197},{"textAlign":398},[1198],{"text":1199,"type":298,"marks":1200},"Even now in my administrative roles, my teaching roles, if I sense something's wrong, I just say to people, 'I need a day to think about that.' I try to not make snap decisions and I think my decisions are better.\"",[1201],{"type":392,"attrs":1202},{"color":16},{"_uid":1204,"title":1205,"video_id":1206,"component":305,"transcript":1207,"video_type":368,"description":1254,"video_title":1205,"video_description":1265},"3713ada4-05a1-42de-8bc4-46d0915a9f88","David U fights for a blame-free culture in healthcare","Zie1wuXhhiE",{"type":12,"content":1208},[1209,1214,1219,1224,1229,1234,1239,1244,1249],{"type":15,"attrs":1210,"content":1211},{"textAlign":53},[1212],{"text":1213,"type":298},"[0:00:10] I'm David U and I'm the president and CEO of the Institute for Safe Medication Practices Canada. Our organization, ICMP Canada, actually receives a lot of voluntary reports from actual practitioners who were involved in error. I remember the time that I started the organization way back in 2000, and it’s all finger pointing and the culture of blame is very, very prevalent at that time. And now we encourage, you know, folks to talk about their problems. ",{"type":15,"attrs":1215,"content":1216},{"textAlign":53},[1217],{"text":1218,"type":298},"[0:00:47] Well, today, I want to share, you know, a couple of stories that really impressed me and really intrigued me into the work that I'm doing as a pharmacist, as a provider, and also as someone who’s actually involved maybe indirectly into, you know, medication error that affects the nurse or the pharmacist. One case is the inadvertent administration of potassium chloride that a nurse was involved. And I was very much moved by what happened. And knowing that this is a whole system issue that caused the error, I feel so sorry and so traumatic for the provider, the nurse. ",{"type":15,"attrs":1220,"content":1221},{"textAlign":53},[1222],{"text":1223,"type":298},"[0:01:40] That was way back in 2003 that I was requested by the chief coroner's office to be the expert witness in a inquest of the event of inadvertent administration of potassium chloride, a concentrate. ",{"type":15,"attrs":1225,"content":1226},{"textAlign":53},[1227],{"text":1228,"type":298},"[0:02:05] I noticed that that she actually was a very caring nurse. She's about maybe 40 years old, very, very caring nurse. She was actually trying to use normal saline to flush a line and later on noticed that it was concentrated potassium chloride. Actually, the patient died almost immediately. The ampoules of concentrated potassium chloride and sterile water and normal saline are almost identical. It's very, very easy to mix up. When I look at those situations and the conditions and how, you know, it’s so terrible that it’s a loss of life, but at the same time, I just feel terrible for the nurse. ",{"type":15,"attrs":1230,"content":1231},{"textAlign":53},[1232],{"text":1233,"type":298},"[0:03:00] I can see that this is not the nurse’s, you know, performance issue or any mistake on her own. So I just couldn't help, you know, the tears coming out from my eyes when I looked at all those documents and really, you know, tells me that I need to do something about it. One is, all hospitals in Canada should ensure that no concentrated potassium chloride be assessable to any staff outside the pharmacy department. And the second recommendation that we made, which is already fully implemented, that Health Canada should work with the industry, the manufacturer, to make sure that potassium chloride concentrate got to be redesigned in such a way that they're very distinguishable from other products. ",{"type":15,"attrs":1235,"content":1236},{"textAlign":53},[1237],{"text":1238,"type":298},"[0:03:54] I've been working on another case, actually a couple of years later, again, the outcome was fatal. It was on a miscalculation of the infusion rate causing a chemo drug to be infused much more rapidly than was intended. The nurse set the pump, supposed to be infused over four days, the rate. Somehow, it’s a lot of other issues involved, and she set it to 4 hours. ",{"type":15,"attrs":1240,"content":1241},{"textAlign":53},[1242],{"text":1243,"type":298},"[0:04:26] I don't see the family had a lot of check-ins with the provider, which is a good thing, you know, because I think we all know that they’re actually the second victim. I think in both cases, you know, the nurses left the profession. ",{"type":15,"attrs":1245,"content":1246},{"textAlign":53},[1247],{"text":1248,"type":298},"[0:04:48] We also work to improve the whole administration of Vincristine [ph], which is another chemo drug that has been quite a few times, not just in Canada, but all across the globe, that Vincristine was administered interfecally [ph] instead of intravenously. The oncologists or anesthetists actually injected to the wrong route. The best solution is more like a forcing function that connectors or the connection to both IV and to the fecal space or the spinal base have to be very different. It's like a key and lock. You know, if the connections are different, it’s unique and not changeable, then you cannot fit it in. ",{"type":15,"attrs":1250,"content":1251},{"textAlign":53},[1252],{"text":1253,"type":298},"[0:05:35] ICMP Canada has been viewed by nationally and even internationally about something that we actually do some good work and then make some difference. One of the things that we do and do well is to connect with providers, the actual staff, nurses, pharmacists, or even physicians, who contacted us either by phone or email or in a report program that we created for individual practitioner reporting, is to tell their story. We keep that information confidential, encourage them to talk to me or to ICMP Canada, and then we will use the information to try to correct the system, because that would also be part of their goal, that nothing of this kind will happen again. And I think this kind of support, a personal call and reassurance that we can do something about it, would go a long way because, you know, nothing would go to a black hole from a provider perspective. And this is what they want. They want changes. They want support. If I have one message to share a provider, if they encounter or come across some mishap or event which is not a good outcome, tell yourself that you have done your best and try to report it. And collectively, we can make sure that things would get changed. And don't be afraid.",{"type":12,"content":1255},[1256],{"type":15,"attrs":1257,"content":1258},{"textAlign":53},[1259],{"text":375,"type":298,"marks":1260},[1261],{"type":378,"attrs":1262},{"href":1263,"uuid":53,"anchor":53,"custom":1264,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/62aa4493e7/david-u-fights-for-a-blame-free-culture-in-he.pdf",{},{"type":12,"content":1266},[1267,1276,1285,1294,1303,1312,1321,1330,1339,1348,1357,1366,1375,1384,1393,1402,1411],{"type":15,"attrs":1268,"content":1269},{"textAlign":53},[1270,1275],{"text":1271,"type":298,"marks":1272},"David U was first struck by the tragic ripple effect of medication errors back in 2003.",[1273],{"type":392,"attrs":1274},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1277,"content":1278},{"textAlign":53},[1279,1284],{"text":1280,"type":298,"marks":1281},"The president and CEO of the Institute for Safe Medication Practices Canada (ISMP - Canada) had been called as an expert witness for a coroner's inquest into the death of a hospital patient. The death occurred after a nurse mistakenly flushed the patient's intravenous line with concentrated potassium chloride — a chemical used in lethal injections — rather than the intended normal saline. At the time the two solutions were stored and dispensed in almost identical vials in healthcare facilities across the country.",[1282],{"type":392,"attrs":1283},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1286,"content":1287},{"textAlign":53},[1288,1293],{"text":1289,"type":298,"marks":1290},"A pharmacist with more than 40 years of experience, U remembers staying up late one evening at his Ontario home to prepare for his testimony the following day. As he pored over the case reviews and investigative reports filed in the aftermath of the death, including the account of one deeply traumatized nurse, he was deeply moved.",[1291],{"type":392,"attrs":1292},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1295,"content":1296},{"textAlign":53},[1297,1302],{"text":1298,"type":298,"marks":1299},"\"I remember all the boxes of stuff in my little study in my house,\" U says. \"Everyone, my kids and my wife, were already asleep and it was just so sad, the fact that all these things happened. I could see that this was not the nurse's performance issue, or any mistake on her own. I just couldn't help the tears coming to my eyes when I looked at all those documents.",[1300],{"type":392,"attrs":1301},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1304,"content":1305},{"textAlign":53},[1306,1311],{"text":1307,"type":298,"marks":1308},"\"It told me I had to do something about it. I did do something about it and hopefully this will never happen again, and so far so good.\"",[1309],{"type":392,"attrs":1310},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1313,"content":1314},{"textAlign":53},[1315,1320],{"text":1316,"type":298,"marks":1317},"When U founded ISMP Canada back in 2000, the culture surrounding healthcare-associated harm in Canadian hospitals was still very much one of finger-pointing and blame. Most experienced nurses, physicians and other clinicians have been associated, in some way, with such adverse events but yet at that moment the incident occurs the health provider closest to it can often feel quite alone.",[1318],{"type":392,"attrs":1319},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1322,"content":1323},{"textAlign":53},[1324,1329],{"text":1325,"type":298,"marks":1326},"U cites the case of another fatal healthcare mishap that involved the correct medication but the wrong administration. A young cancer patient needing chemotherapy was hooked up to a mobile infusion pump that should have been set to administer the highly toxic drug over four days. Instead the chemo drug was infused over four hours and as a result the woman died almost immediately.",[1327],{"type":392,"attrs":1328},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1331,"content":1332},{"textAlign":53},[1333,1338],{"text":1334,"type":298,"marks":1335},"In that case the nurse involved did meet with the patient's family afterwards in an attempt for all parties to grieve and heal together, U recalls.",[1336],{"type":392,"attrs":1337},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1340,"content":1341},{"textAlign":53},[1342,1347],{"text":1343,"type":298,"marks":1344},"\"In both those cases I didn't see that the family held a big grudge against the provider, which is a good thing. I think we all know they are actually the second victim. I think in both cases the nurses left their profession, and that's also very, very traumatic.\"",[1345],{"type":392,"attrs":1346},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1349,"content":1350},{"textAlign":53},[1351,1356],{"text":1352,"type":298,"marks":1353},"U's organization has made great strides in recent years in the battle to reduce preventable medication errors like those that continue to stick in his mind today. Steps have been taken to restrict the availability of potassium chloride ampules that previously were widely accessible in hospital wards across Canada. The institute has worked alongside Health Canada to press manufacturers on drug package design so that products such as potassium chloride concentrate are clearly distinguishable from other medication.",[1354],{"type":392,"attrs":1355},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1358,"content":1359},{"textAlign":53},[1360,1365],{"text":1361,"type":298,"marks":1362},"ISMP Canada has also waged a campaign to reduce the risk of hospital errors involving the anti-cancer drug vincristine following a number of tragic mishaps where the medication was injected into a patient's spinal fluid instead of into an intravenous drip. It has also pushed for a national plan to roll out bar coding for medication throughout the country as a step toward standardizing the delivery of that medication and reducing the chance of human error. U is proud of the support and discretion that his organization provides to health care workers across the country who report errors.",[1363],{"type":392,"attrs":1364},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1367,"content":1368},{"textAlign":53},[1369,1374],{"text":1370,"type":298,"marks":1371},"\"One of the things that we do and do well is to connect with providers, the actual staff, nurses, pharmacists or even physicians who contact us, either through phone or email or our reporting program, to tell us their story,\" U says. \"And again we keep that information confidential, encourage them to talk to me or ISMP Canada, and then we will use their information to try and correct the system.",[1372],{"type":392,"attrs":1373},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1376,"content":1377},{"textAlign":53},[1378,1383],{"text":1379,"type":298,"marks":1380},"\"That is also their goal. The only reason they're calling me is out of altruism, they want to share this story so that nothing of this kind will happen again.\"",[1381],{"type":392,"attrs":1382},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1385,"content":1386},{"textAlign":53},[1387,1392],{"text":1388,"type":298,"marks":1389},"Everyone is human, no system is infallible and errors will happen, U says.",[1390],{"type":392,"attrs":1391},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1394,"content":1395},{"textAlign":53},[1396,1401],{"text":1397,"type":298,"marks":1398},"\"I think this kind of support, a personal call and reassurance that we can do something about it, goes a long away. Nothing goes into a black hole from the provider's perspective because that's what they want. They want changes, they want support.\"",[1399],{"type":392,"attrs":1400},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1403,"content":1404},{"textAlign":53},[1405,1410],{"text":1406,"type":298,"marks":1407},"While nobody in healthcare goes into work wanting to make a mistake, acknowledging those mistakes when they occur, however difficult that might be, is best for everyone.",[1408],{"type":392,"attrs":1409},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1412,"content":1413},{"textAlign":53},[1414,1419],{"text":1415,"type":298,"marks":1416},"\"Whatever you need to do, tell yourself that you have done your best and try to report it, and collectively we can make sure of change,\" U says. \"And don't be afraid.\"",[1417],{"type":392,"attrs":1418},{"color":16},{"text":395,"type":298},{"_uid":1421,"title":1422,"video_id":1423,"component":305,"transcript":1424,"video_type":368,"description":1506,"video_title":1422,"video_description":1517},"d6e0bb46-5dd0-4555-9ab7-364792590b6a","Patient’s unexpected death changes the way one obstetrician thinks all doctors should be educated","WmWcP0tkfoI",{"type":12,"content":1425},[1426,1431,1436,1441,1446,1451,1456,1461,1466,1471,1476,1481,1486,1491,1496,1501],{"type":15,"attrs":1427,"content":1428},{"textAlign":53},[1429],{"text":1430,"type":298},"[0:00:10] This story is about a case that had happened to me 14 months into my practice. I thought about it daily for the first ten years. It never left me. It, I think, in many ways, made me the physician that I am, the person that I am. ",{"type":15,"attrs":1432,"content":1433},{"textAlign":53},[1434],{"text":1435,"type":298},"[0:00:32] We had a patient who was in labour and I was asked to see her just as she was pushing because the baby's heartbeat was dipping. And the family doctor had already initiated doing a vacuum. And I'd come in and taken over doing the vacuum delivery. And that went quite well. But she was bleeding a bit. I couldn't see very well to do a repair of the tear in the vagina so we'd taken her to the operating room. And so it seemed to be pretty standard up to this point. ",{"type":15,"attrs":1437,"content":1438},{"textAlign":53},[1439],{"text":1440,"type":298},"[0:01:08] And then I started struggling in the operating room. So we repaired the tear. I expect her to stop bleeding. She doesn't stop bleeding. Then I work through the usual algorithm of when women are bleeding after delivery. What are the common things? And we worked on that. And still, she continued to bleed. And I called my second on-call in to give me a hand. And then the anesthesiologist said that he was struggling, too. So he called the second anesthetist to come in and help. And then it became clear that we were having trouble even accessing IV lines. So the general surgeon came in to do a cut down. And then it started drifting into, “This doesn't feel right.” This isn't working. She's not responding in the way I expect her to respond. We're all struggling now. It's not just me. Like, the entire team, every set of providers were all struggling. I was doing all the things that I was trained to do. I was doing all the right things. And yet I wasn't getting the results that we typically get when we respond in the way we do. ",{"type":15,"attrs":1442,"content":1443},{"textAlign":53},[1444],{"text":1445,"type":298},"[0:02:30] And it turned out that she had a very rare event called the amniotic fluid embolism. And at the time, while we're all trying to make things better, I think we're feeling frustrated. We're feeling lost. We're feeling bewilderment. There's controlled chaos because there's so many people coming in and out. And then when we finally closed and we brought her into ICU, she coded and she died. ",{"type":15,"attrs":1447,"content":1448},{"textAlign":53},[1449],{"text":1450,"type":298},"[0:03:07] And I sat there that night doing my dictation and going over notes and notes and then starting to tease out things about her care about, while she was induced, did she need that? Actually, she probably didn't. And that was what set this ball rolling. And it became a very acute, painful, unscheduled teaching for me about how to do an incident analysis. And yet, nobody told me how to do this. I had just the entire chart in front of me and trying to put it together so that I could actually dictate. ",{"type":15,"attrs":1452,"content":1453},{"textAlign":53},[1454],{"text":1455,"type":298},"[0:03:52] And I had called the chief of staff and told him briefly what had happened. And his response was disbelief. You're telling me what? I'm telling you that we lost a mom. You know, that hasn't happened. I know; it hasn't happened in decades. ",{"type":15,"attrs":1457,"content":1458},{"textAlign":53},[1459],{"text":1460,"type":298},"[00:04:10] I was on call, so I stayed in hospital that night. But I felt so shattered. And even in the middle of this, I went I had to go and see another patient because I was on call. And that was the patient that I ended up seeing in the office sometime later. So I felt absolutely drained. ",{"type":15,"attrs":1462,"content":1463},{"textAlign":53},[1464],{"text":1465,"type":298},"[0:04:37] And when I called the chief of staff, I let him know that, “You're going to have to find a replacement to cover me starting 8:00 tomorrow morning because I'm not safe to work.” I was off for two weeks. ",{"type":15,"attrs":1467,"content":1468},{"textAlign":53},[1469],{"text":1470,"type":298},"[0:04:48] So I had told him that – and it sounds melodramatic now, but I really did feel at the time that if this was not an embolus of some kind, that I would quit because I should have been able to save her. We should have been able to save her as a team. And we waited for the autopsy results to come back. And it had been an embolus. ",{"type":15,"attrs":1472,"content":1473},{"textAlign":53},[1474],{"text":1475,"type":298},"[0:05:14] I attended her funeral and it was amazing. I don't think I'll forget that, ever. It was completely full. And I felt so sorry for this family. ",{"type":15,"attrs":1477,"content":1478},{"textAlign":53},[1479],{"text":1480,"type":298},"[0:05:35] And I came back to work two weeks later and I'd come back to a hospital that had lost a patient and not one word of blame. Incredible support everywhere I turned. So in hindsight now, knowing what other second victims encounter and endure, I feel so very fortunate for having had that support. How was I supposed to talk to the patient's family? What was I supposed to say? I had no teaching. I had not been coached in my residency program. I'd never watched a provider have an event like this. And having to talk to the family afterwards, to provide information, to provide emotional support to the family, and then also to figure out what happened, what exactly happened here. So for all those reasons, I felt really, really inept because I hadn't been trained, hadn't encountered this before. ",{"type":15,"attrs":1482,"content":1483},{"textAlign":53},[1484],{"text":1485,"type":298},"[0:06:38] And on the other hand, I had such support from the team and from the hospital through hospital administration. So for someone who had had this encounter very early on in practice with very little training for this – in fact, no training to deal with this – I was really lucky because I was in a very supportive environment. ",{"type":15,"attrs":1487,"content":1488},{"textAlign":53},[1489],{"text":1490,"type":298},"[0:07:02] So having experienced that event and other experiences, it really inspired me to advocate for more patient safety teaching in undergraduate and postgraduate education. So I'm currently in Ottawa and in the last couple of years, we have a new patient safety lecture in the medical students’ third year. And last year, we set up a patient safety elective for students in their pre-clerkship and their clerkship. In the post graduate program, we started doing simulations for disclosure. And it's really interesting. So people, when they hear about health care simulation, they think about this $45,000 mannequin. But in fact, one of the most effective forms of simulation is a role play. And it's a really 3 effective way of teaching, training, assessing these really difficult encounters that you can't arrange in advance. ",{"type":15,"attrs":1492,"content":1493},{"textAlign":53},[1494],{"text":1495,"type":298},"[0:08:10] I would say that I was one of these people who felt this guilt that this had happened. I didn't feel ashamed. And I think that's a key point, that I was supported. I wasn't ostracized. I wasn't shamed. I wasn't blamed. People were incredibly supportive and empathetic. ",{"type":15,"attrs":1497,"content":1498},{"textAlign":53},[1499],{"text":1500,"type":298},"[0:08:34] It is such a challenging discussion to say to a family, “I'm really sorry we couldn't save your mother.” And some people have made a parallel to breaking bad news curriculum in undergraduate medical education. But I think it's fundamentally different because in breaking bad news, I could say, “I'm really sorry. Remember the test that we did last time? It shows that you have cervical cancer.” Well, it's terrible news for a patient. And I will feel terrible giving that news to her because I know what's coming. But that's fundamentally different from me saying, “I'm really sorry. You have breast cancer; we removed the wrong breast.” It is a very different, very different conversation because you now have to take ownership of your participation in the harm that came to this patient through health care. And I think this needs to be part of undergraduate education and post graduate education because we can't expect our trainees, if we don't talk about it, if we don't teach it, if we don't assess it during training, how can we possibly expect them to be competent at such an emotionally challenging time for them? ",{"type":15,"attrs":1502,"content":1503},{"textAlign":53},[1504],{"text":1505,"type":298},"[0:10:02] I see, at the mega level, the Canadian Patient Safety Institute providing education, advocating for patients and for providers. So I do think that I see change over time.",{"type":12,"content":1507},[1508],{"type":15,"attrs":1509,"content":1510},{"textAlign":53},[1511],{"text":375,"type":298,"marks":1512},[1513],{"type":378,"attrs":1514},{"href":1515,"uuid":53,"anchor":53,"custom":1516,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/861dc1e004/cpsi-2016-dr-amy-nakajima.pdf",{},{"type":12,"content":1518},[1519,1528,1537,1546,1555,1564,1573,1582,1591,1600,1609,1618,1627,1636,1659,1668],{"type":15,"attrs":1520,"content":1521},{"textAlign":53},[1522,1527],{"text":1523,"type":298,"marks":1524},"Shocked, bewildered and angry, Dr. Amy Nakajima pored over her medical notes, trying to coax from them some sense of the bloody chaos she'd just experienced.",[1525],{"type":392,"attrs":1526},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1529,"content":1530},{"textAlign":398},[1531,1536],{"text":1532,"type":298,"marks":1533},"Earlier in the day, a healthy and expectant young mother had come in for a routine delivery at the Saskatchewan hospital where Nakajima worked. It was 2001 and Nakajima was just 14 months into her practice as an obstetrician-gynecologist.",[1534],{"type":392,"attrs":1535},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1538,"content":1539},{"textAlign":398},[1540,1545],{"text":1541,"type":298,"marks":1542},"Nakajima had been called in to assist just as the woman was pushing because the baby's heart rate seemed to be dipping. A vacuum procedure went well, a healthy baby was delivered, but the woman was bleeding a bit afterwards. Nakajima repaired a tear in the vagina but the bleeding didn't stop.",[1543],{"type":392,"attrs":1544},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1547,"content":1548},{"textAlign":398},[1549,1554],{"text":1550,"type":298,"marks":1551},"\"We worked on that, and still she continued to bleed,\" Nakajima says, recalling a day that altered the course of her career.",[1552],{"type":392,"attrs":1553},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1556,"content":1557},{"textAlign":398},[1558,1563],{"text":1559,"type":298,"marks":1560},"\"I called my second on-call in to give me a hand and then the anesthesiologist said that he was struggling too. So he called a second anesthetist to come in and help. Then, it became clear that we were having trouble even accessing IV lines. So the general surgeon came in to do a cut down.",[1561],{"type":392,"attrs":1562},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1565,"content":1566},{"textAlign":398},[1567,1572],{"text":1568,"type":298,"marks":1569},"\"It had started with what appeared to be a fairly routine case, then it started drifting into 'this doesn't feel right; this isn't working; she's not responding in the way I'm expecting her to respond. We're all struggling now. It's not just me. The entire team, every set of providers, we're all struggling. It felt ... we all felt, I think, at a loss.\"",[1570],{"type":392,"attrs":1571},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1574,"content":1575},{"textAlign":398},[1576,1581],{"text":1577,"type":298,"marks":1578},"It descended into a scene of controlled confusion, with everyone doing what they've been trained to do, everyone doing the right thing to make things better, and yet getting no results. They managed to stabilize the patient enough to transfer her to the ICU, where, she shortly coded and died. At that moment, for the entire medical team, there was an immense sense of unreality, Nakajima says.",[1579],{"type":392,"attrs":1580},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1583,"content":1584},{"textAlign":398},[1585,1590],{"text":1586,"type":298,"marks":1587},"\"It was a horrible event. It was traumatic for everyone. Of course, primarily for the family. But it left such a mark on the entire team. I think just hearing that story, you can imagine how I might feel, but the guilt and the shame that come with that event, I think is really unknowable until you have encountered it yourself.\"",[1588],{"type":392,"attrs":1589},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1592,"content":1593},{"textAlign":398},[1594,1599],{"text":1595,"type":298,"marks":1596},"When she called the hospital's chief of staff and told him what had happened, his response was disbelief. They hadn't lost a mom in decades. Nakajima informed him she was scheduled to be on call for the entire weekend but she'd need a replacement to cover for the remainder of her call and would stay on call until her replacement arrived the next morning. She was absolutely drained and felt so shattered she didn't feel safe to work.",[1597],{"type":392,"attrs":1598},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1601,"content":1602},{"textAlign":398},[1603,1608],{"text":1604,"type":298,"marks":1605},"Nakajima took two weeks off work. She had told herself that if the autopsy didn't turn up embolus or some other rare cause, she would quit her young career. She knew that the medical team should have otherwise been able to save that patient.",[1606],{"type":392,"attrs":1607},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1610,"content":1611},{"textAlign":398},[1612,1617],{"text":1613,"type":298,"marks":1614},"In the end it was determined the woman had suffered an amniotic fluid embolism, a rare and usually fatal obstetric emergency that occurs when amniotic fluid enters a mother's blood stream and triggers a catastrophic, allergic-like reaction.",[1615],{"type":392,"attrs":1616},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1619,"content":1620},{"textAlign":398},[1621,1626],{"text":1622,"type":298,"marks":1623},"\"I attended her funeral. It was amazing. I don't think I'll forget that, ever. It was completely full. I felt so sorry for this family,\" Nakajima recalls. \"I came back to work two weeks later and I'd come back to a hospital where I'd lost a patient, and not one word of blame. Incredible support everywhere I turned. So, in hindsight, now knowing what other second victims encounter and endure, I feel so very fortunate for having had that support and that amount of compassion shown to me.\"",[1624],{"type":392,"attrs":1625},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1628,"content":1629},{"textAlign":398},[1630,1635],{"text":1631,"type":298,"marks":1632},"The experience marked her in many ways, Nakajima says. The helplessness and frustration she encountered that day, feeling so entirely unprepared to go out to that young father and tell him that his wife was dead and his children orphaned. She doesn't know the person she would have become had this not happened to her, Nakajima says. This event early in a fledgling career in many ways informed her choice of practice, the way she interacts with her patients and colleagues, and the way in which she teaches.",[1633],{"type":392,"attrs":1634},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1637,"content":1638},{"textAlign":398},[1639,1644,1653,1658],{"text":1640,"type":298,"marks":1641},"Nakajima provides care at Wabano Centre for Aboriginal Health, within the Family Health Team at Bruyere, and at St. Vincent's Hospital, with a specific interest in working with patients who traditionally would be considered marginalized. In her teachings with third year medical students at the University of Ottawa, she stresses patient safety, candid communication and the importance of acknowledging harm. She promotes the use of simulation to explore and teach safety issues, including disclosure skills. As the interim Director of Research and Development of ",[1642],{"type":392,"attrs":1643},{"color":16},{"text":1645,"type":298,"marks":1646},"SIM-one",[1647,1651],{"type":378,"attrs":1648},{"href":1649,"uuid":53,"anchor":53,"target":53,"linktype":1650},"http://www.sim-one.ca/","url",{"type":392,"attrs":1652},{"color":16},{"text":1654,"type":298,"marks":1655},", the non-profit healthcare simulation network, she will be developing programs on ways to use simulation to advance patient safety.",[1656],{"type":392,"attrs":1657},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1660,"content":1661},{"textAlign":398},[1662,1667],{"text":1663,"type":298,"marks":1664},"\"It is such a challenging discussion to have with a family, to say, 'I'm really sorry, we couldn't save your mother,\" she says. \"Some people have made a parallel to breaking bad news curriculum in undergraduate medical education, but I think it's fundamentally different. In breaking bad news, I could say, 'I'm really sorry, remember the tests that we did last time? It shows that you have cervical cancer.' It's terrible news for a patient. I will feel terrible giving that news to her because I know what's coming. But that's fundamentally different from me saying, 'I'm really sorry, you have breast cancer; we removed the wrong breast.\"",[1665],{"type":392,"attrs":1666},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1669,"content":1670},{"textAlign":398},[1671],{"text":1672,"type":298,"marks":1673},"Says Nakajima, \"It is a very different conversation because you now have to take ownership of your participation in the harm that came to this patient through healthcare. I think this needs to be part of undergraduate education and postgraduate education. And we need to consider how to most effectively and impactfully deliver this curriculum, so our students are thinking of how to optimize safety, and are better prepared when bad things happen.\"",[1674],{"type":392,"attrs":1675},{"color":16},{"_uid":1677,"title":1678,"video_id":1679,"component":305,"transcript":1680,"video_type":368,"description":1772,"video_title":1678,"video_description":1783},"c114b5e4-d934-401d-ba40-c4d0bc5206b0","Surgical error inspires doctor to champion the safety of all patients","IZQ55QGWyrk",{"type":12,"content":1681},[1682,1687,1692,1697,1702,1707,1712,1717,1722,1727,1732,1737,1742,1747,1752,1757,1762,1767],{"type":15,"attrs":1683,"content":1684},{"textAlign":53},[1685],{"text":1686,"type":298},"[0:00:10] My role presently is as the president and CEO of University Health Network in Toronto. In that capacity, I am also, in my view, the chief patient safety officer of the organization. I'm a surgeon and I trained many years ago now as a cancer surgeon and worked, most recently prior to my UHN role, in the United States at the University of Texas, MD Anderson Cancer Center. ",{"type":15,"attrs":1688,"content":1689},{"textAlign":53},[1690],{"text":1691,"type":298},"[0:00:39] I'm here to share a story that impacted me personally, a story of patient harm. My own interest in patient safety really began with a personal event at the time when I was working at the University of Texas, MD. Anderson Cancer Center as a professor of surgery. And on one day there, we were doing a very, very complicated operation for a patient who had disease in his esophagus in the swallowing tube. And we were doing a very complicated procedure where we take the patient's colon and we transplant it to replace the diseased esophagus. It's a complicated procedure. It involves multiple teams. The operation took nine hours to complete. Everything went well. And at the end of the operation, we routinely have a process where a team in the operating room does a sponge count. They check that we have not, by accident, missed a sponge. And the first count that was done was incorrect. This is actually fairly common in big operations, and I asked the nurses to repeat the count. ",{"type":15,"attrs":1693,"content":1694},{"textAlign":53},[1695],{"text":1696,"type":298},"[0:01:42] The second count was correct, giving me some degree of comfort, but leaving me with an element of doubt. At that point in time, the operation had been going on for a long time. The patient was cold and I felt it was absolutely impossible that I could have left a sponge in the patient. And I decided instead to let the patient go to the recovery room. There was a little bit of uncertainty and I decided to get an x-ray in the recovery room that we would do, just to be sure. ",{"type":15,"attrs":1698,"content":1699},{"textAlign":53},[1700],{"text":1701,"type":298},"[0:02:15] And as soon as that x-ray was performed, my fellow called me and said, “There's something left inside the patient.” I couldn't possibly believe that because I didn't think it was possible that I could have left something in the patient. There was nagging doubt because there were two conflicting pieces of information. I tried to reconcile first the incorrect count and then the correct count. I couldn't believe that we had possibly left something in the patient. And so I asked the fellow. We went to the bedside together. We took a different type of x-ray, this time, going across the patient. And when we did the second x-ray, we could see that definitely, there was something left inside the patient. ",{"type":15,"attrs":1703,"content":1704},{"textAlign":53},[1705],{"text":1706,"type":298},"[0:02:57] When I looked at the two x-rays that had been done, I couldn't, for the life of me, figure out what that was. And I realized at that moment that during my surgical training, during my fellowship training, in textbooks, in exams, I had never seen x-rays of foreign bodies that had been left inside patients. And as a result, I couldn't identify that foreign body, the material that I had left inside the patient. ",{"type":15,"attrs":1708,"content":1709},{"textAlign":53},[1710],{"text":1711,"type":298},"[0:03:23] So I went to talk to the patient's wife immediately. I said to her, “Something's not right. We've done an x-ray. I think that I've left something inside your husband.” As I left the first conversation with her, I remember vividly walking down the hallway with my head down, thinking, “How could this have happened? How am I going to figure this out? What am I going to do? What will this mean for me? Could this affect my family?” ",{"type":15,"attrs":1713,"content":1714},{"textAlign":53},[1715],{"text":1716,"type":298},"[0:03:53] I had reached, in many ways, the pinnacle of my career. I'd been promoted to a full professor after ten years on the faculty. I was doing amazing high-end technical surgery. We were experiencing incredible success as an organization and in our group, and I was concerned that this would really adversely affect not just me personally and professionally, but would have wider implications on the organization and could, in that environment, also extend into a world of litigation and a very complicated stream of events that's very, very unpleasant for everyone involved. ",{"type":15,"attrs":1718,"content":1719},{"textAlign":53},[1720],{"text":1721,"type":298},"[0:04:37] The fellow and I proceeded, over a period of about six hours, to x-ray every piece of equipment that we used in the operation that could possibly resemble the appearance of what we saw in the x-ray. ",{"type":15,"attrs":1723,"content":1724},{"textAlign":53},[1725],{"text":1726,"type":298},"[0:04:46] By 2:00 in the morning, I finally realized, this has to be a sponge. We X-rayed the sponge and sure enough, that's what it was. We went then with a plan to go back the next morning and re-operate. ",{"type":15,"attrs":1728,"content":1729},{"textAlign":53},[1730],{"text":1731,"type":298},"[0:05:02] I slept in the hospital that night. The next morning at 7:30, we went back to the operating room. I sat in the corner of the room on a stool and I looked and watched my fellows reopen the abdomen. It took them just 20 minutes. They reached inside, pulled out the sponge. The whole thing was over in about 30 minutes. ",{"type":15,"attrs":1733,"content":1734},{"textAlign":53},[1735],{"text":1736,"type":298},"[0:05:20] And I went back out and talked to the patient's wife. And I said, “We figured out what it was. We confirmed it. We've removed it. Your husband is going to be okay.” The patient was okay. But that moment was like no other in my career. [0:05:40] I felt horrible. I felt humiliated. I felt such grief. I could not believe that I could possibly commit an error like that. And as I began to think about this in greater detail, I began to realize that, yes, I had committed an error, but that multiple systems had failed this patient. ",{"type":15,"attrs":1738,"content":1739},{"textAlign":53},[1740],{"text":1741,"type":298},"[0:06:00] And in my later academic life, as I went to Boston and studied patient safety at the Harvard School of Public Health, I really learned a tremendous amount about the science of human error. ",{"type":15,"attrs":1743,"content":1744},{"textAlign":53},[1745],{"text":1746,"type":298},"[0:06:12] Much of what we have to do today is to acknowledge and recognize that in health care, we have had, historically, a culture of shame and blame and a practice, oftentimes, of covering up our mistakes and moving on to the next patient. We need to move past that, embrace principles and concepts of adjust culture, and employ systems thinking to better understand the complexity of the work environment that we have in health care. ",{"type":15,"attrs":1748,"content":1749},{"textAlign":53},[1750],{"text":1751,"type":298},"[0:06:37] One big opportunity that we have is to adopt principles, practices, and approaches that are used by other industries. If we look at the gains that have been made in commercial aviation or in nuclear power or chemical manufacturing, those industries are often grouped together as high-reliability organizations by academics. And by adopting many of the principles and approaches that have been taken in this group of industries and taking them to health care, we can really introduce dramatic change. ",{"type":15,"attrs":1753,"content":1754},{"textAlign":53},[1755],{"text":1756,"type":298},"[0:07:12] One of the biggest changes that we're bringing about at University Health Network is an approach and a program that we call Caring Safely. It's a program that we have designed and built and rolled out together with the Hospital for Sick Children in Toronto. It really brings about a structured approach to patient safety that begins with an effort to bring about adjust culture, to bring about an approach that encourages a process of speaking up on safety, an approach that extends not only to patients but also to employees and to workplace safety. ",{"type":15,"attrs":1758,"content":1759},{"textAlign":53},[1760],{"text":1761,"type":298},"[0:07:47] I think patients and families do understand the complexity of medical care, the way it's delivered today. They do understand that at times things don't go the way that we plan. And the candor and honesty that we demonstrate, even the uncertainty that we convey in times when we don't know, that, in a paradoxical way, builds trust with those patients and families. ",{"type":15,"attrs":1763,"content":1764},{"textAlign":53},[1765],{"text":1766,"type":298},"[0:08:14] Being involved in an episode like mine invokes tremendous emotions and all types of responses. Perhaps the best thing that can happen to many providers in this situation is to become safety champions, to realize that this event can spark an interest. Sometimes a change in your career trajectory can cause you to volunteer to be on a hospital committee, to read different literature, to understand that the science of human error is in fact a science, and that there's much that we have to learn, to think about the culture around safety in your organization or in your practice, and to really operate in the future as a champion for patient safety. ",{"type":15,"attrs":1768,"content":1769},{"textAlign":53},[1770],{"text":1771,"type":298},"[0:09:07] Those champions, especially when they are physicians, have tremendous influence in the health care environment in which they work. This, in turn, can lead to saving thousands of lives.",{"type":12,"content":1773},[1774],{"type":15,"attrs":1775,"content":1776},{"textAlign":53},[1777],{"text":375,"type":298,"marks":1778},[1779],{"type":378,"attrs":1780},{"href":1781,"uuid":53,"anchor":53,"custom":1782,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/74df0c7f21/cpsi-2016-pisters.pdf",{},{"type":12,"content":1784},[1785,1794,1803,1812,1821,1830,1839,1848,1857,1866,1875,1884,1893,1902,1911,1920,1929,1938,1947,1956,1965,1986,1995,2004,2013,2022,2031],{"type":15,"attrs":1786,"content":1787},{"textAlign":53},[1788,1793],{"text":1789,"type":298,"marks":1790},"Dr. Peter Pisters is President & CEO of University Health Network (UHN), an academic health sciences centre in Toronto. UHN is an integrated health, research and education system that includes four hospital sites, Toronto General Hospital, Toronto Western Hospital, the Princess Margaret Cancer Centre, Toronto Rehabilitation Institute, and a school, the Michener Institute of Education at UHN. But he also sees himself as UHN's Chief Patient Safety Officer.",[1791],{"type":392,"attrs":1792},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1795,"content":1796},{"textAlign":398},[1797,1802],{"text":1798,"type":298,"marks":1799},"That's a duty he takes very seriously, fuelled by the painful memory of a single surgical sponge left behind in one of his patients.",[1800],{"type":392,"attrs":1801},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1804,"content":1805},{"textAlign":398},[1806,1811],{"text":1807,"type":298,"marks":1808},"It happened more than a decade ago, when Pisters was working as a busy surgeon at the University of Texas MD Anderson Cancer Center in Houston, but the feelings of fear, anger and frustration he felt that day remain fresh in his mind.",[1809],{"type":392,"attrs":1810},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1813,"content":1814},{"textAlign":398},[1815,1820],{"text":1816,"type":298,"marks":1817},"Pisters was leading what he describes as a highly complicated operation where a patient's diseased esophagus was removed and replaced with a transplanted segment of their colon. The surgery involved multiple teams and the procedure took nine hours to complete. Everything went well, but as the surgical team was finishing the standard sponge count, conducted before and after surgery, they came up one item short. Surgical sponges are squares of gauze used to sop up blood. During a long operation, doctors may use dozens of them inside a patient to control bleeding.",[1818],{"type":392,"attrs":1819},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1822,"content":1823},{"textAlign":398},[1824,1829],{"text":1825,"type":298,"marks":1826},"False counts are not uncommon in the bustle of an operating room, and Pisters ordered a recount. On that second check, it was believed that all sponges were accounted for.",[1827],{"type":392,"attrs":1828},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1831,"content":1832},{"textAlign":398},[1833,1838],{"text":1834,"type":298,"marks":1835},"\"At that point in time the operation had been going on for a long time, the patient was cold, and I felt it was absolutely impossible that I could have left a sponge in the patient, and decided instead to let him go to the recovery room,\" Pisters recalls.",[1836],{"type":392,"attrs":1837},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1840,"content":1841},{"textAlign":398},[1842,1847],{"text":1843,"type":298,"marks":1844},"But there was still a trace of uncertainty in his mind. Just to be sure he ordered X-rays. When the images showed something had been left inside his patient, Pisters was stunned. Complicating matters, as he examined the scans, he found he could not identify with certainty what the item was.",[1845],{"type":392,"attrs":1846},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1849,"content":1850},{"textAlign":398},[1851,1856],{"text":1852,"type":298,"marks":1853},"\"I realized at that moment that during my surgical training, during my fellowship training, in textbooks, in exams, I had never seen X-rays of foreign bodies that had been left inside patients. And as a result, I couldn't identify the foreign body, the material that I had left inside the patient.\"",[1854],{"type":392,"attrs":1855},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1858,"content":1859},{"textAlign":398},[1860,1865],{"text":1861,"type":298,"marks":1862},"Pisters immediately went to the patient's wife and told her something was not right, and that he suspected something had been left behind in her husband's body.",[1863],{"type":392,"attrs":1864},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1867,"content":1868},{"textAlign":398},[1869,1874],{"text":1870,"type":298,"marks":1871},"\"As I left that first conversation I remember vividly walking down the hallway, with my head down thinking, 'how could this have happened, how am I going to figure this out, what am I going to do? What will this mean for me? Could this affect my family?\" Pisters recalled.",[1872],{"type":392,"attrs":1873},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1876,"content":1877},{"textAlign":398},[1878,1883],{"text":1879,"type":298,"marks":1880},"\"I had reached, in many ways, the pinnacle of my career. I'd been promoted to full professor after 10 years on the faculty. I was doing amazing, high-end technical surgery. We were experiencing incredible success as an organization in our group. And I was concerned that this would really adversely affect not just me personally and professionally, but would have wider implications on the organization. It could, in that environment, also extend into a world of litigation and a very complicated stream of events that's very unpleasant for everyone involved.\"",[1881],{"type":392,"attrs":1882},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1885,"content":1886},{"textAlign":398},[1887,1892],{"text":1888,"type":298,"marks":1889},"Over the next six hours, Pisters and his surgical fellows X-rayed every piece of equipment they had used in the operation that could possibly resemble the mystery object, until finally, at around 2 am, they concluded it was indeed a surgical sponge.",[1890],{"type":392,"attrs":1891},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1894,"content":1895},{"textAlign":398},[1896,1901],{"text":1897,"type":298,"marks":1898},"Pisters slept at the hospital that night and the next morning the patient was wheeled back into the operating room.",[1899],{"type":392,"attrs":1900},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1903,"content":1904},{"textAlign":398},[1905,1910],{"text":1906,"type":298,"marks":1907},"\"I sat in the corner of the room on a stool and I watched my fellows re-open the abdomen. It took them just 20 minutes. They reached inside and pulled out the sponge. The whole thing was over in 30 minutes,\" he says.",[1908],{"type":392,"attrs":1909},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1912,"content":1913},{"textAlign":398},[1914,1919],{"text":1915,"type":298,"marks":1916},"\"The patient was okay but that moment was like no other in my career. I felt horrible. I felt humiliated. I felt such grief. I could not believe that I could possibly commit an error like that. And as I began to think about this in greater detail, I began to realize that yes, I had committed an error, but multiple systems had failed this patient.\"",[1917],{"type":392,"attrs":1918},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1921,"content":1922},{"textAlign":398},[1923,1928],{"text":1924,"type":298,"marks":1925},"A surgeon made a mistake, two different sponge counts were done, and neither the physician nor the hospital had policies and protocols in place to deal with the conflicting information.",[1926],{"type":392,"attrs":1927},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1930,"content":1931},{"textAlign":398},[1932,1937],{"text":1933,"type":298,"marks":1934},"Pisters says he was personally changed by the experience and in later academic life, while studying patient safety at the Harvard School of Public Health, gained tremendous insights into the science of human error. When he moved into his leadership role at UHN in January 2015, Pisters saw it as a great opportunity to make a big difference in patient safety.",[1935],{"type":392,"attrs":1936},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1939,"content":1940},{"textAlign":398},[1941,1946],{"text":1942,"type":298,"marks":1943},"\"Much of what we have to do today is to acknowledge and recognize that in health care we have had historically a culture of shame and blame, and a practice oftentimes of covering up our mistakes and moving on to the next patient,\" he says.",[1944],{"type":392,"attrs":1945},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1948,"content":1949},{"textAlign":398},[1950,1955],{"text":1951,"type":298,"marks":1952},"\"We need to move past that, embrace principles and concepts of a just culture, and employ systems thinking to better understand the complexity of the work environment that we have in health care.\"",[1953],{"type":392,"attrs":1954},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1957,"content":1958},{"textAlign":398},[1959,1964],{"text":1960,"type":298,"marks":1961},"Pisters would like to see the Canadian health care system adopt safety approaches and principles that have been successfully deployed in other \"high reliability\" sectors like commercial aviation and chemical manufacturing.",[1962],{"type":392,"attrs":1963},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1966,"content":1967},{"textAlign":398},[1968,1973,1980,1985],{"text":1969,"type":298,"marks":1970},"\"One of the biggest changes that we're bringing about at University Health Network is an approach that we call ",[1971],{"type":392,"attrs":1972},{"color":16},{"text":1974,"type":298,"marks":1975},"Caring Safely",[1976,1978],{"type":392,"attrs":1977},{"color":16},{"type":1979},"italic",{"text":1981,"type":298,"marks":1982},". It's a program that we have designed and rolled out in conjunction with the Sick Children's Hospital in Toronto. It really brings about a structured approach to patient safety, that begins with an effort to bring about a just culture, to bring about an approach that encourages a process of speaking up on safety, an approach that extends not only to patients but to employees and to workplace safety.\"",[1983],{"type":392,"attrs":1984},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1987,"content":1988},{"textAlign":398},[1989,1994],{"text":1990,"type":298,"marks":1991},"As the conversation around greater patient safety picks up steam across Canada, many health experts are pushing hospitals to become more open about reporting and publicly disclosing preventable errors. Pisters is one of them.",[1992],{"type":392,"attrs":1993},{"color":16},{"text":395,"type":298},{"type":15,"attrs":1996,"content":1997},{"textAlign":398},[1998,2003],{"text":1999,"type":298,"marks":2000},"\"I think patients and families do understand the complexity of medical care the way it's delivered today,\" he says. \"They do understand that at times things don't go the way that we planned. And the candour and honesty that we demonstrate, even the uncertainty that we convey in times when we don't know, that in a paradoxical way builds trust with those patients and families.\"",[2001],{"type":392,"attrs":2002},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2005,"content":2006},{"textAlign":398},[2007,2012],{"text":2008,"type":298,"marks":2009},"Being involved in episodes of preventable medical error can take an emotional toll on health providers but Pisters believes the best remedy is for those providers to become safety champions within their own organizations.",[2010],{"type":392,"attrs":2011},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2014,"content":2015},{"textAlign":398},[2016,2021],{"text":2017,"type":298,"marks":2018},"\"Those champions, especially when they are physicians, have tremendous influence in the health care environment in which they work. And when they move into leadership roles or they're fortunate to be in positions like mine, they can have profound influence on patient safety and this in turn can lead to saving thousands of lives.\"",[2019],{"type":392,"attrs":2020},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2023,"content":2024},{"textAlign":398},[2025,2030],{"text":2026,"type":298,"marks":2027},"Indeed, that's one of the reasons Pisters feels compelled to share his story. He thinks more health providers in the system need to stand up and be heard.",[2028],{"type":392,"attrs":2029},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2032,"content":2033},{"textAlign":398},[2034,2039],{"text":2035,"type":298,"marks":2036},"\"All of us need to recognize that we have a role to play in patient safety and that we have an opportunity to create in Canada a transformational wave that really impacts how patients will be cared for in the future.\"",[2037],{"type":392,"attrs":2038},{"color":16},{"text":395,"type":298},{"_uid":2041,"title":2042,"video_id":2043,"component":305,"transcript":2044,"video_type":368,"description":2111,"video_title":2042,"video_description":2122},"69dc4a0e-657c-4c58-ba53-9f41008f379a","Dr. Julia Trahey calls for peer support networks to assist providers following patient safety incidents","T-7kOSuaNbE",{"type":12,"content":2045},[2046,2051,2056,2061,2066,2071,2076,2081,2086,2091,2096,2101,2106],{"type":15,"attrs":2047,"content":2048},{"textAlign":53},[2049],{"text":2050,"type":298},"[0:00:10] My name is Julia Trahey. I'm a general internal medicine specialist. I've been practicing now for close to 30 years, and I'm the clinical chief of patient safety at my organization. ",{"type":15,"attrs":2052,"content":2053},{"textAlign":53},[2054],{"text":2055,"type":298},"[0:00:30] When I think about why I do what I do now, I go back to an episode that happened very early in my career, because there is a before and after of my career from that point. And it was a patient, a young man who was only a few years older than I was at the time, who had come in with a suicide attempt and had been transferred to the hospital I was working at for care because of respiratory difficulties that he had as a result of that. ",{"type":15,"attrs":2057,"content":2058},{"textAlign":53},[2059],{"text":2060,"type":298},"[0:01:11] So we were doing the medical stabilization and things seem to be going well and we were back and forth to emergency all through the day and night. And then at about, it was sometime after midnight, I got a call saying he had jumped from the hospital room and that I was needed to come back to the hospital to run resuscitation. And the rest of that night was a blur. And of course, it was a completed suicide at that point because the resuscitation was unsuccessful. ",{"type":15,"attrs":2062,"content":2063},{"textAlign":53},[2064],{"text":2065,"type":298},"[0:01:48] I continued on call and was called in a few hours later to do another resuscitation of a patient that had been found dead at home. And then there were other patients throughout that night that I was dealing with, but it was myself and the junior intern that was with me, and we were just kind meeting with some of the family members. And it was a very, very traumatic event for the hospital, for the nursing staff, for the emergency physicians. But trying to deal with that and then going on with the rest of the work that had to be done throughout the night. And so you go into a state of kind of suspended – not feeling anything. Work to do. Get with it. Just keep going. Don't think about it. And I knew that there were going to be further meetings about this, but I didn't know what to feel. ",{"type":15,"attrs":2067,"content":2068},{"textAlign":53},[2069],{"text":2070,"type":298},"[0:03:03] And I remember driving away from the hospital, and ordinarily, I would go to my mother and talk to my mother about this. But my mom and dad were out of town that particular day. So I went to my oldest sister's house. And I remember running a red light on the way there. And I just realized it after I went through because I don't even know how to put into words. I didn't know what to think. It was just a jumble of thoughts, but then also a jumble of thoughts and a lack of feeling because I didn't know what to feel. ",{"type":15,"attrs":2072,"content":2073},{"textAlign":53},[2074],{"text":2075,"type":298},"[0:03:44] I needed someone to talk to and I needed to be able to be there for my junior intern. And my fellow physicians were more matter-of-fact about it. And perhaps because I'm female, I had the sense that if I got too emotional about it, you know, it, again, might be seen as less professional. And it wasn't so much emotional as I just needed to talk to somebody about that whole night. It's an intrinsic hit to who you are. ",{"type":15,"attrs":2077,"content":2078},{"textAlign":53},[2079],{"text":2080,"type":298},"[0:04:27] And I think certainly, those physicians of my generation and older, we were trained to feel that what we did and the outcomes for our patients reflected, on some level, how good we were as a person, how good we were as a physician, our professional role. And our personal roles were so intertwined that when things go wrong, there was little defense against feeling that somehow, you failed on as a human being and not just in your professional role. Why we have a job is because there are people who need care. ",{"type":15,"attrs":2082,"content":2083},{"textAlign":53},[2084],{"text":2085,"type":298},"[0:05:17] And I'm very happy with seeing how things are changing and improving. And it is a focus of how we do business more and more and more. And there's a greater acceptance of factoring in what really happens to patients as part of how we design the services that we deliver. ",{"type":15,"attrs":2087,"content":2088},{"textAlign":53},[2089],{"text":2090,"type":298},"[0:05:46] If there's one thing I’d change, is actually what I have chosen to change, and that is introducing into the undergraduate curriculum at our university patient safety. And as part of that, I have spoken about the need for peer support network, and that there should be no shame or no apprehension about talking about errors, and that the likelihood of them making errors is pretty much a given. Now, they may not be errors that have catastrophic outcomes, but that they need to be comfortable and accept it as normal as a part of doing a high-risk business, and also normal to talk about it. And so I've been encouraging them and teaching them that that's part of being a doctor. ",{"type":15,"attrs":2092,"content":2093},{"textAlign":53},[2094],{"text":2095,"type":298},"[0:06:48] The outcome of analyzing why this happened the way it did, and also, it was talking of medical physicians, speaking with psychiatric physicians and saying, “Well, this is our experience here, and that's your experience there and how do we come up with a solution?” And so we were able to create a psychiatric liaison service so that patients who get medically unwell or who come in, who become psychiatrically unwell when they're in medicine, that we have access to expertise to help real-time that day, the next day, and on a go-forward basis. So for me, I always look at that service as a tremendous positive that had come out of something that was really, really not positive. ",{"type":15,"attrs":2097,"content":2098},{"textAlign":53},[2099],{"text":2100,"type":298},"[0:07:50] What did that person achieve? Well, he achieved a service that has helped hundreds of patients in the intervening years. I think about the English language and how we use certain words: sorrow, grief, stoic. And I've seen that. I've been there in the room when it's been manifest, when people have been stoic in the face of horrible news. I've seen what sorrow is because it fills the room. I've seen and felt grief because you're there with people who have had really bad things happen. ",{"type":15,"attrs":2102,"content":2103},{"textAlign":53},[2104],{"text":2105,"type":298},"[0:08:37] With that particular, I didn't have a long relationship. Those other relationships that I've had with my patients over years – this was a very, very short, short duration experience, but it marked my career from before and after because of how I felt things could have been done differently that may have made a difference. And so that's how it's impacted me then, now, and why I try to do the work I do in the way that I do it. ",{"type":15,"attrs":2107,"content":2108},{"textAlign":53},[2109],{"text":2110,"type":298},"[0:09:20] I'm at an interesting point in my career. I'm heading into the final phase. I'm not a junior doctor. I'm a senior doctor. And I think it's important for other physicians and students to appreciate that these are the journeys that some people have taken through the course of their career. They will have their patients, too, that will change how they do business and to embrace them, embrace the experiences as a learning experience and to do something good with it. And I hope that they get the support that they need from their peers.",{"type":12,"content":2112},[2113],{"type":15,"attrs":2114,"content":2115},{"textAlign":53},[2116],{"text":375,"type":298,"marks":2117},[2118],{"type":378,"attrs":2119},{"href":2120,"uuid":53,"anchor":53,"custom":2121,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/5e3e316c25/cpsi-2015-trahey-master.pdf",{},{"type":12,"content":2123},[2124,2133,2142,2151,2160,2169,2178,2187,2196,2205,2214,2223,2232,2241,2250,2259,2268,2277,2286,2295],{"type":15,"attrs":2125,"content":2126},{"textAlign":53},[2127,2132],{"text":2128,"type":298,"marks":2129},"For Dr. Julia Trahey, a shattering encounter 20 years back with one troubled young man carved a lasting division in both her life and medical career.",[2130],{"type":392,"attrs":2131},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2134,"content":2135},{"textAlign":398},[2136,2141],{"text":2137,"type":298,"marks":2138},"The experience also instilled in her a deep understanding of the burden that healthcare providers can feel after a patient is harmed. That's a special empathy the native Newfoundlander brings to her work every day as a general internal medicine specialist in St. John's. ",[2139],{"type":392,"attrs":2140},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2143,"content":2144},{"textAlign":398},[2145,2150],{"text":2146,"type":298,"marks":2147},"\"When I think about why I do what I do now, I go back to an episode that happened very early in my career, because there is a before and after of my career from that point,\" Trahey says. \"It was a patient, a young man who was only a few years older than I was at the time, who had come in with a suicide attempt and had been transferred to the hospital I was working at for care because of respiratory difficulties that he had as a result of that.\"",[2148],{"type":392,"attrs":2149},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2152,"content":2153},{"textAlign":398},[2154,2159],{"text":2155,"type":298,"marks":2156},"After successfully reviving the man and working to stabilize his medical condition, Trahey remembers shuttling back and forth to emergency throughout a typically long and busy shift at the hospital. The patient seemed to be doing well.",[2157],{"type":392,"attrs":2158},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2161,"content":2162},{"textAlign":398},[2163,2168],{"text":2164,"type":298,"marks":2165},"But then she received a call at about one in the morning saying the man had again attempted suicide while under care at the hospital. For the second time in 24 hours, Trahey was called in to attempt resuscitation on the same individual. This time it was a completed suicide.",[2166],{"type":392,"attrs":2167},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2170,"content":2171},{"textAlign":398},[2172,2177],{"text":2173,"type":298,"marks":2174},"\"I continued on call and was called in a few hours later to try another resuscitation of another patient who had been found dead at home, and then there were other patients throughout that night that I was dealing with. It was myself and the junior intern who was with me, and we were meeting with some of the family members, and it was a very, very traumatic event for the hospital, for the nursing staff, for the emergency physicians. Trying to deal with that and then going on with the rest of the work that had to be done throughout the night — you go into a state of kind of suspended not-feeling-anything. Work to do, just keep going, don't think about it.\"",[2175],{"type":392,"attrs":2176},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2179,"content":2180},{"textAlign":398},[2181,2186],{"text":2182,"type":298,"marks":2183},"Soon enough, though, the emotional trauma hit home.",[2184],{"type":392,"attrs":2185},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2188,"content":2189},{"textAlign":398},[2190,2195],{"text":2191,"type":298,"marks":2192},"\"I know the next morning when I was coming off call, and I knew that there were going to further meetings about this, but I didn't know what to feel. I remember driving away from the hospital and ordinarily I would go to my mother and talk to her about this, but my mom and dad were out of town that particular day, so I went to my eldest sister's house. And I remember running a red light on the way there. And I just realized it after I went through, because I was just so — I don't even know how to put it into words. I didn't know what to think, it was just a jumble of thoughts, a jumble of thoughts and a lack of feeling because I didn't know what to feel.\"",[2193],{"type":392,"attrs":2194},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2197,"content":2198},{"textAlign":398},[2199,2204],{"text":2200,"type":298,"marks":2201},"She just needed someone to talk to. She'd needed someone to talk to back at the hospital, of course, but Trahey had wanted to be steadfast for her intern and besides, her other fellow physicians had seemed more matter of fact about her experience. A part of her also felt that, as a female, if she became too emotional it might be seen as somehow less professional on her part.",[2202],{"type":392,"attrs":2203},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2206,"content":2207},{"textAlign":398},[2208,2213],{"text":2209,"type":298,"marks":2210},"Still, an encounter with healthcare-associated harm can be an intrinsic hit to who you are as a health care professional, Trahey says, and also how you see yourself as an individual.",[2211],{"type":392,"attrs":2212},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2215,"content":2216},{"textAlign":398},[2217,2222],{"text":2218,"type":298,"marks":2219},"\"I think certainly for those physicians of my generation and older, we were trained to feel that what we did and the outcomes for our patients reflected on some level how good we were as a person,\" she says. \"Our professional role and our personal roles were so intertwined that when things go wrong there was little defense against feeling that somehow you failed as a human being, and not just in your professional role.\"",[2220],{"type":392,"attrs":2221},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2224,"content":2225},{"textAlign":398},[2226,2231],{"text":2227,"type":298,"marks":2228},"That view is changing and Trahey has been doing her part over the years to aid that shift in thinking. She's clinical head of patient safety at her organization and she's worked to ensure patient safety is a priority in the training of the next generation of Canada's health professionals.  Ask her if there's one thing she would change about her experience with that patient years ago, and she responds quickly:",[2229],{"type":392,"attrs":2230},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2233,"content":2234},{"textAlign":398},[2235,2240],{"text":2236,"type":298,"marks":2237},"\"If there is one thing I would change it's actually what I have chosen to change, and that is introducing patient safety into the undergraduate curriculum at our university\" Trahey says.",[2238],{"type":392,"attrs":2239},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2242,"content":2243},{"textAlign":398},[2244,2249],{"text":2245,"type":298,"marks":2246},"\"As part of that I have spoken about the need for a peer support network and that there should be no shame or apprehension about talking about errors, and that the likelihood of making errors is pretty much a given. Now they may not be errors that have catastrophic outcomes, but they need to be comfortable and accepted as normal as part of doing a high-risk business and also normal to talk about it. So, I've been encouraging them, and teaching them, that that's part of being a doctor.\"",[2247],{"type":392,"attrs":2248},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2251,"content":2252},{"textAlign":398},[2253,2258],{"text":2254,"type":298,"marks":2255},"The young man's death that day exposed collaborative flaws in the way that particular hospital dealt with patients with psychiatric and medical illness. In its aftermath, a new psychiatric liaison service was created to give all patients real-time access to psychiatric treatment. To this day, Trahey views that service as a tremendous positive for both patients and their physicians that arose from something that was otherwise so terribly negative.",[2256],{"type":392,"attrs":2257},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2260,"content":2261},{"textAlign":398},[2262,2267],{"text":2263,"type":298,"marks":2264},"That one life achieved a service that has helped hundreds of patients in the intervening years, she says.",[2265],{"type":392,"attrs":2266},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2269,"content":2270},{"textAlign":398},[2271,2276],{"text":2272,"type":298,"marks":2273},"\"I think about the English language and how we use certain words — sorrow, grief, stoic — and I've seen that. I've been there in the room when it's been manifest, when people have been stoic in the face of horrible news, I've seen what sorrow is because it fills the room. I've seen and felt grief because you're there with people who have had really bad things happen.",[2274],{"type":392,"attrs":2275},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2278,"content":2279},{"textAlign":398},[2280,2285],{"text":2281,"type":298,"marks":2282},"\"With that particular patient I did not have a long relationship. This was a very short duration experience, but it marked my career from before and after because of how I felt things could have been done differently that may have made a difference. That's how it's impacted me, then, now and why I try to do the work I do in the way that I do it.\"",[2283],{"type":392,"attrs":2284},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2287,"content":2288},{"textAlign":398},[2289,2294],{"text":2290,"type":298,"marks":2291},"If sharing her experience helps reduce the burden of emotional trauma for some health care providers out there, all the better, Trahey says.",[2292],{"type":392,"attrs":2293},{"color":16},{"text":395,"type":298},{"type":15,"attrs":2296,"content":2297},{"textAlign":398},[2298,2303],{"text":2299,"type":298,"marks":2300},"\"I'm at an interesting point in my career. I'm heading into the final phase. I'm not a junior doctor, I'm a senior doctor and I think it's important for other physicians and students to appreciate that these are the journeys that some people have taken through the course of their career. It can make you, I was going to say a better physician but it's not a better physician, it's a more aware physician. They will have their patients too that will change how they do business, and to embrace that as a learning experience and do something good with it. And I hope they get the support that they need from their peers.\"",[2301],{"type":392,"attrs":2302},{"color":16},{"text":395,"type":298},{"_uid":2305,"title":2306,"video_id":2307,"component":305,"transcript":2308,"video_type":368,"description":2400,"video_title":2306,"video_description":2411},"e94a2a70-4e4b-446a-a4e6-16a64d1a6c4b","Patient and Provider come together in wake of patient safety incident","Q3LRQ5MjyUw",{"type":12,"content":2309},[2310,2315,2320,2325,2330,2335,2340,2345,2350,2355,2360,2365,2370,2375,2380,2385,2390,2395],{"type":15,"attrs":2311,"content":2312},{"textAlign":53},[2313],{"text":2314,"type":298},"Deborah Prowse: [0:00:23] I'm Deborah Prowse. And in 2004, I was a family member for my mother that was in hospital. We're here together because the partnership between patients and providers should extend throughout their care to when adverse events occur so that we can go from harm to healing. My mom died as a result of a series of adverse events that led up to the ultimate event that took her life. ",{"type":15,"attrs":2316,"content":2317},{"textAlign":53},[2318],{"text":2319,"type":298},"[0:01:00] She'd had two medical stays in hospital and both occasions, there were things that didn't go well. On the last occasion, she needed to be put on to dialysis assistance. She received dialysate that was accidentally made of potassium chloride instead of sodium chloride. And this led to her passing. ",{"type":15,"attrs":2321,"content":2322},{"textAlign":53},[2323],{"text":2324,"type":298},"Steve Long: [0:01:30] The incident with Deb's mother occurred on a Friday afternoon. It was the same as any other Friday, only the pharmacist that was working in the critical care unit came downstairs and said, “You know, we've had a mix up with the dialysate solution. They've taken it to the blood gas lab and they've determined that there's potassium chloride in it. There shouldn't be potassium in it.” We went back to our manufacturing records, check the lot number on the bottle and discovered that, yes, the lot number that was associated with the preparation of that batch of dialysate was, in fact, prepared with potassium chloride. Stated that to the physicians in ICU. ",{"type":15,"attrs":2326,"content":2327},{"textAlign":53},[2328],{"text":2329,"type":298},"[0:02:23] Later that evening, I got a second call from the physician. The call was from the physician that was working in the ICU. And he essentially stated, “You've killed my patient. What are you going to do about it? How are you going to ensure it never happens again?” ",{"type":15,"attrs":2331,"content":2332},{"textAlign":53},[2333],{"text":2334,"type":298},"[0:02:42] I had been the director of pharmacy in Calgary for almost 20 years at that point. Never had I dealt directly with an error or an incident of this magnitude. We had recently opened Central Pharmacy. We had designed it. We were aware of the quality and safety 2 movement and how we could change process to reduce the risk of error. And yet, here in this new facility that was designed to make patients safe, we had done the ultimate damage. We had killed two patients, Deb's mother, and as we found, another patient by looking back.",{"type":15,"attrs":2336,"content":2337},{"textAlign":53},[2338],{"text":2339,"type":298}," Deborah Prowse: [0:03:21] Patients and family members have to trust that their care is going to be of high quality and safe. And when things go wrong, historically, there hasn't always been transparency and openness about admitting that. And that is an affront to a trusting relationship. So it's very important that when things go wrong, that there is disclosure of what happened. And three parts of disclosure is the acknowledgment that something happened, the apology, and then the action to ensure that it doesn't happen again. Patients, I think, for the most part, believe health care providers come to work with good intentions and the desire to do well and to care for patients. Sometimes that doesn't go well. I think the greatest fear is that it will be covered up if something goes wrong. ",{"type":15,"attrs":2341,"content":2342},{"textAlign":53},[2343],{"text":2344,"type":298},"Steve Long: [0:04:33] The region, as Deb has said, decided that we would disclose to the families the cause of death and disclose to the public that the error had occurred. We ended up, as a result of that, on the front page of the newspapers in Calgary for 21 days, three weeks. And it was only ended as the three outside experts were called in to do a full review of the case, much like as a plane crash or a train derailment inquiry. It was gone there. ",{"type":15,"attrs":2346,"content":2347},{"textAlign":53},[2348],{"text":2349,"type":298},"[0:05:09] What's the first thing that’s shown on the national news is the vial of sodium chloride with its blue cap and the vial of potassium chloride with its purple label and the clipping in the paper. “Don't those dummies know? Blue is good and purple is bad, and they shouldn't mix the two up.” The bottles were almost identical, and the compounding facility that we were working in, the labeling on the box was very nondescript. ",{"type":15,"attrs":2351,"content":2352},{"textAlign":53},[2353],{"text":2354,"type":298},"[0:05:34] Essentially, we were just trying to cope with all the things that were going on in that immediate period, trying to understand ourselves what happened, trying to keep the operation going, because we still had 2,500 patients in hospital beds that required our due care and attention and expertise to prepare the products that they needed to make them well again. And yet, we're doing it in this environment of distrust, where everything that we prepared, everything that we produced, was questioned, was challenged, whereas before, none of that had gone on. ",{"type":15,"attrs":2356,"content":2357},{"textAlign":53},[2358],{"text":2359,"type":298},"[00:06:13] So fear, disappointment, humiliation, failure. All of those thoughts were running through my mind as we were going through that immediate period. There was an assistant, three technicians that were involved in the preparation of the product. We believed we had a number of double checks in the system that would prevent errors from occurring and products from getting far. I did a review of the procedures that day and wrote a report, submitted that to my boss. Then my boss came in and sat down with the staff and all that were involved and walked through the process, wrote the report, submitted it. That wasn't accepted. ",{"type":15,"attrs":2361,"content":2362},{"textAlign":53},[2363],{"text":2364,"type":298},"[0:06:56] The quality and safety people then were invited to the department to do a review of the process and take that forward. That wasn't good enough. An external agency then was called upon to do a review. And so through this whole period, initially the staff stayed at work because it was recognized that the error was a substitution error, something that actually occurs fairly frequently, however, doesn't result in the catastrophic events that occurred in this instance. But as time went on, and as we got further into the review and the pressure mounted in the public sphere, the decisions were made that the staff would be sent home without pay. And so we isolated them totally from the organization and left them out there hanging, wondering whether or not they would continue to be employed or be let go. ",{"type":15,"attrs":2366,"content":2367},{"textAlign":53},[2368],{"text":2369,"type":298},"Deborah Prowse: [0:07:52] Adverse events affect both patients and providers in very significant ways. I think it's important to have policies and programs or processes that offer support to family members to ensure that they're getting grief support and that the same is offered to providers to ensure that both of us are on a path to healing. ",{"type":15,"attrs":2371,"content":2372},{"textAlign":53},[2373],{"text":2374,"type":298},"Steve Long: [0:08:19] So one of the things that challenged me to move beyond the air was the fact that we were never given the opportunity just to say the simple thing, that we were sorry, that it wasn't our intent to harm. ",{"type":15,"attrs":2376,"content":2377},{"textAlign":53},[2378],{"text":2379,"type":298},"Deborah Prowse: [0:08:33] And it was about two years later when I had become involved in the Patient Family Safety Council for the Calgary Health Region. And Steve was involved in a quality council. And a person that we knew that sat on both councils actually made the overture to bring us together. And we had that meeting. And it was from the very moment that we were both in the same room that it felt complete. It felt like the circle had now come around and that we were able to sit and talk about what happened and talk about the impact it had on both of us and what we had gone through that was so similar. ",{"type":15,"attrs":2381,"content":2382},{"textAlign":53},[2383],{"text":2384,"type":298},"[0:09:25] And following that, they went on to develop four safety policies: disclosure after harm, reporting, informing the public, and the just and trusting culture. That marked a huge change of patient safety in the province of Alberta. And because of the national highlight that these events got, it also started to change the conversation nationally about disclosure. ",{"type":15,"attrs":2386,"content":2387},{"textAlign":53},[2388],{"text":2389,"type":298},"Steve Long: [0:09:54] After the error and after credibility was lost. I mean, the one piece that I never had closure on was, we never had a chance to say we were sorry. You know, we had caused this great harm. And we know we've done it and we didn't feel very good about it. As we've said earlier, you know, we don't show up at work every day to do harm. We show up to hopefully help people and improve things. ",{"type":15,"attrs":2391,"content":2392},{"textAlign":53},[2393],{"text":2394,"type":298},"[0:10:28] If you haven't had a medication error or haven't caused harm, it's not because you're an exceptional provider; it's you've been lucky. Secondly, I guess one of my biggest regrets is that I don't know that I checked in enough on my staff to see how they were doing to ensure they got the support that they needed. And then the third thing I would say is make sure you take care of yourself. Take clues from family, from coworkers, from others, and seek help. I waited far too long before I sought professional help. ",{"type":15,"attrs":2396,"content":2397},{"textAlign":53},[2398],{"text":2399,"type":298},"Deborah Prowse: [0:11:00] I think Mom would be very pleased that she didn't die in vain, that there has been significant impact as a result of her death. And I think one of the things that has kept me going in the last ten years is the number of providers that have come up after a presentation and said, “You've impacted me. I'm going to do something different as a result of hearing your story.”",{"type":12,"content":2401},[2402],{"type":15,"attrs":2403,"content":2404},{"textAlign":53},[2405],{"text":375,"type":298,"marks":2406},[2407],{"type":378,"attrs":2408},{"href":2409,"uuid":53,"anchor":53,"custom":2410,"target":382,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/a159d9e969/cpsi-2015-prowse-long-master.pdf",{},{"type":12,"content":2412},[2413,2418,2423,2428,2433,2438,2443,2448,2453,2458,2463,2468,2473,2478,2483,2488,2493,2498,2503,2508,2513,2518,2523,2528,2533,2538,2543,2548,2553],{"type":15,"attrs":2414,"content":2415},{"textAlign":53},[2416],{"text":2417,"type":298},"Deborah Prowse and Steve Long might seem unlikely partners in the campaign to promote patient safety across Canada.",{"type":15,"attrs":2419,"content":2420},{"textAlign":53},[2421],{"text":2422,"type":298},"Prowse is the daughter of one of two patients who died in 2004 when a pharmacy at Calgary's Foothills Hospital mistakenly prepared dialysis solutions with potassium chloride instead of sodium chloride. Long was the director in charge of that pharmacy at the time.",{"type":15,"attrs":2424,"content":2425},{"textAlign":53},[2426],{"text":2427,"type":298},"It took two years before these two secondary victims of that great tragedy had a chance to meet in a healing face-to-face encounter, expressing sorrow, sharing grief and sowing the seeds for a remarkable advocacy alliance. Prowse and Long now appear together regularly, speaking with great candour about their shared painful experience.",{"type":15,"attrs":2429,"content":2430},{"textAlign":53},[2431],{"text":2432,"type":298},"The death of Prowse's 83-year-old mother Kathleen due to that medication error in March 2004 occurred at the end of a troubled 13 months of surgeries and setbacks that had already left the Prowse family highly frustrated over the state of her medical care. The shock of their mother's unexpected death left the family reeling, a trauma that only worsened amid the media firestorm that followed.",{"type":15,"attrs":2434,"content":2435},{"textAlign":53},[2436],{"text":2437,"type":298},"\"My mom died as a result of a series of adverse events that led up to the ultimate event that took her life,\" Prowse says. \"She'd had two medical stays in hospital and on both occasions there were things that did not go well.\"",{"type":15,"attrs":2439,"content":2440},{"textAlign":53},[2441],{"text":2442,"type":298},"For Long, the lasting memory is of a routine day gone horribly awry.",{"type":15,"attrs":2444,"content":2445},{"textAlign":53},[2446],{"text":2447,"type":298},"\"The incident with Deb's mother occurred on a Friday afternoon. It was the same as any other Friday only the pharmacist that was working in the critical care unit came downstairs and said 'we've had a mix-up with the dialysate solution.' They'd taken it to the blood gas lab and they'd determined that there was potassium chloride in it.\"",{"type":15,"attrs":2449,"content":2450},{"textAlign":53},[2451],{"text":2452,"type":298},"Long and his team went back to their manufacturing records, checked the lot number of the bottle and discovered that batch of dialysis solution had in fact been mistakenly prepared with potassium chloride. At the time the potassium and sodium chloride were purchased from the same manufacturer, were stocked along the same row of shelves, and came in cases and containers similar in appearance. Even the colour and printing on the labels looked the same, Long says.",{"type":15,"attrs":2454,"content":2455},{"textAlign":53},[2456],{"text":2457,"type":298},"Later that evening, Long was helping coach his daughter's basketball team when his phone rang. His halting voice as he recalls that moment bears testament to painful memories he still carries with him today.",{"type":15,"attrs":2459,"content":2460},{"textAlign":53},[2461],{"text":2462,"type":298},"\"The call was from the physician that was working in the ICU and he essentially stated 'you've killed my patient; what are you going to do about it and how are you going to ensure it never happens again?'",{"type":15,"attrs":2464,"content":2465},{"textAlign":53},[2466],{"text":2467,"type":298},"\"I had been the director of pharmacy in Calgary for almost 20 years at that point. Never had I dealt directly with an error or an incident of this magnitude. We had recently opened a central pharmacy. We had designed it. We were aware of the quality and safety movement and how we could change processes to reduce the risk of error and yet here in this new facility that was designed to make patients safe we had done the ultimate damage. We had killed two patients.\"",{"type":15,"attrs":2469,"content":2470},{"textAlign":53},[2471],{"text":2472,"type":298},"The hospital and regional health authority implemented several investigations and qualitative reviews following the deaths, under the glare of intense public and political scrutiny. Over time the health region dedicated staff and resources to implement $7 million worth of patient safety initiatives. But in those early days, amid all that rigorous institutional self-examination, there was little support for the staff and family closest to the adverse event.",{"type":15,"attrs":2474,"content":2475},{"textAlign":53},[2476],{"text":2477,"type":298},"\"Essentially we were just trying to cope with all the things that were going on in that immediate period, trying to understand ourselves what happened,\" Long says.",{"type":15,"attrs":2479,"content":2480},{"textAlign":53},[2481],{"text":2482,"type":298},"\"Trying to keep the operation going because we still had 2,500 patients in hospital beds that required our due care and attention and expertise to prepare the products that they needed to make them well again. And yet we're doing it in this environment of distrust where everything that we prepared, everything we produced, was questioned, was challenged. Whereas before none of that had gone on.",{"type":15,"attrs":2484,"content":2485},{"textAlign":53},[2486],{"text":2487,"type":298},"\"It was like being under siege. You didn't know what was going to happen, you didn't know how you were going to be dealt with. As a pharmacist with a license I didn't know whether I'd be able to practice after they'd determined what had gone on. So fear, disappointment, humiliation, failure — all of those thoughts were running through my mind as we were going through that immediate period.\"",{"type":15,"attrs":2489,"content":2490},{"textAlign":53},[2491],{"text":2492,"type":298},"Three technicians and a pharmacy assistant had been involved in the production of the fatal dialysis solution. Initially they continued to work at the hospital but as review followed review they were eventually sent home without pay, isolating them totally from their organization and any emotional support they might have found there, Long says.",{"type":15,"attrs":2494,"content":2495},{"textAlign":53},[2496],{"text":2497,"type":298},"For her part, Prowse came away from the entire experience with an iron determination to advance the voice and participation of patients and families in safety efforts across the country. Drawing on her mom's hospital odyssey, as well as her professional background and training in social work and law, Prowse became one of the a founding members of the Calgary Health Region's patient-family safety council and has since worked with Alberta Health Quality Council, Patients for Patients Safety Canada and many other such advocacy groups, including the World Health Organization's Alliance for Patient Safety.",{"type":15,"attrs":2499,"content":2500},{"textAlign":53},[2501],{"text":2502,"type":298},"\"Patients and family members have to trust that their care is going to be of high quality and safe and when things go wrong, historically, there hasn't always been transparency and openness about admitting that,\" Prowse says. \"And that is an affront to a trusting relationship.",{"type":15,"attrs":2504,"content":2505},{"textAlign":53},[2506],{"text":2507,"type":298},"\"So it's very important that when things go wrong that there is disclosure of what happened. And the three parts of disclosure are the acknowledgement that something happened, the apology and then the action ensure that it doesn't happen again. Patients, I think, for the most part believe that healthcare providers come to work with good intentions and the desire to do well and to care for patients. Sometimes that doesn't go well. I think the greatest fear is that it will be covered up if something does go wrong.\"",{"type":15,"attrs":2509,"content":2510},{"textAlign":53},[2511],{"text":2512,"type":298},"Prowse and Long spoke about their experiences in a series of sessions targeting leaders in the Calgary Health Region during the roll-out of the new patient safety procedures, including new policies governing disclosure after harm, reporting, informing the public and a just and trusting culture within health facilities.",{"type":15,"attrs":2514,"content":2515},{"textAlign":53},[2516],{"text":2517,"type":298},"\"That marked a huge change for patient safety in the province of Alberta and because of the national highlight that these events got it also started to change the conversation nationally about disclosure,\" Prowse points out.",{"type":15,"attrs":2519,"content":2520},{"textAlign":53},[2521],{"text":2522,"type":298},"\"Now I think disclosure is much more thoughtfully done. My concern is that it still does not involve the people closest involved in all of the situations that it should. And I think that that is a big feature of healing for both the patients and the providers, is that we be brought together and allowed to go through those early stages of recovery close to the events, as soon as both parties are ready to do that. I think that's important.\"",{"type":15,"attrs":2524,"content":2525},{"textAlign":53},[2526],{"text":2527,"type":298},"That point is not lost on Long, who suffered a severe emotional toll following the deaths, as did his pharmacy staff involved.",{"type":15,"attrs":2529,"content":2530},{"textAlign":53},[2531],{"text":2532,"type":298},"\"Pharmacy often is quoted in the literature as the invisible ingredient because it just magically appears up out of the basement, the drugs and the preparations, and most of the time it's correct … people get better. After the error and after credibility was lost, the one piece I never had closure on was we never had a chance to say we were sorry,\" Long says, struggling to maintain his composure.",{"type":15,"attrs":2534,"content":2535},{"textAlign":53},[2536],{"text":2537,"type":298},"\"We had caused this great harm… We knew we'd done it and we didn't feel very good about it... \"",{"type":15,"attrs":2539,"content":2540},{"textAlign":53},[2541],{"text":2542,"type":298},"If he has any message to health care providers who find themselves involved in adverse incidents, it's just to hang in there and get through it, Long says.",{"type":15,"attrs":2544,"content":2545},{"textAlign":53},[2546],{"text":2547,"type":298},"\"Firstly, if you haven't had a medication error or if you haven't caused harm it's not because you're an exceptional provider; you've been lucky,\" he says. \"Secondly, one of my biggest regrets is that I don't know that I checked in enough on my staff to see how they were doing to ensure they got the support they needed. And the third thing I'd say is make sure you take care of yourself. Take clues from family, from co-workers and others and seek help. I waited far too long before I sought professional help.\"",{"type":15,"attrs":2549,"content":2550},{"textAlign":53},[2551],{"text":2552,"type":298},"Prowse thinks her mother would be pleased by her advocacy work and the positive changes her death has triggered in patient safety. One of the things that has kept her going over the past 10 years is the number of health care providers who've come up to her after a speaking engagement and said how much her story has touched them, Prowse says.",{"type":15,"attrs":2554,"content":2555},{"textAlign":53},[2556],{"text":2557,"type":298},"\"There's a saying that I think pertains to both of us,\" Prowse says, looking over at Long. \"It's from Maya Angelou, something to the effect that over time they may forget the words you used but they will never forget the way they made you feel.\"",[143,129,122,136,150],[200,192,185],"hec-page-resource-single","healthcare-provider-stories","resources/healthcare-provider-stories",-16690,[],103604225865405,{"parent_slug":2567,"umbraco_path":2568,"umbraco_uuid":2569},"resources","/HealthcareExcellenceCanada/Resources/HealthcareProviderStories","b8b61999-0056-4f71-895f-e30843551496","d7f737e4-e32b-418e-bc69-f5a6bccfa03c","2025-11-18T19:04:33.934Z","default",[],[2575],{"path":2576,"name":2577,"lang":2578,"published":2579},"ressources/recits-du-personnel-soignant","Récits du personnel soignant","fr",true,1776087000,[],[],[2584],{"id":287,"alt":16,"content_length":2585,"content_type":2586,"copyright":16,"created_at":2587,"deleted_at":53,"focus":16,"is_private":277,"title":16,"updated_at":2588,"s3_filename":2589,"meta_data":2590},181691,"image/png","2025-11-03T16:29:38.741Z","2025-11-03T16:29:39.276Z","f/850807391887861/670x450/0df79330c2/header-2-visual.png",{},1776087491103]