Chasing Zero: Winning the War on Healthcare Harm


Most of us think of hospitals as cathedrals of healing and hope and we stand in awe of the doctors and nurses who work in them as the architects of miracles. but even the best hospitals can be
dangerous places with unknown hazards that can cause catastrophic harm they are the battlefield of a war with
an invisible enemy that never sleeps failing support systems that can
keep up i’m dennis quaid I found out about
healthcare harm because it happened to my family since 1999 we’ve known that more than
100,000 Americans die every year because of healthcare harm every year that’s the equivalent of more than ten
jumbo jet airliners crashing every single week and that number doubles if you include
infections that patients get from hospitals the sheer number of deaths is shocking however what’s even more shocking is
that it is possible to bring this number to almost zero so why isn’t happening? You will meet just a few with the leaders who are
making it happen they call it “chasing zero” and they are
preventing the enemy from shattering other families lives the way it almost
shattered mine Our twins were born healthy and
happy we just got them home and it wound up that they had a staph infection they had to go back into the hospital they were overdosed twice with a thousand times the amount of heparin that they should
have received our little twins were the victims of preventable
harm they came very very close to dying. I’ve been in the hospital in my life i’d never given a thought to my
own safety about being there. I always trust the doctors and nurses and they knew what they were doing and
they never make mistakes but this is preventable error. its wake
up call my wife and I to try to do as much as we could to try and
make sure this doesn’t happen to other families when the twins were in the hospital and
they had made it they made me feel that they had survived for a reason that, first off thank god that they had pulled through that they survived for reason that they were maybe going to change the world in a little way that might end up saving more lives I was looking for a way to help prevent
harm to other families and children when I met doctor Charles Denham, the
Leader of TMIT a medical research organization in
patient safety he introduced me to the heroes in the
movement and I have found a role I can play. I’ve joined the army of those
who are chasing zero harm together They’re the group of leaders in
hospitals who you can ask the step-up I’ll tell you what i’m excited about. I’m excited to be
working with people like you, Chuck. chart as topic quite a lot we are so
grateful to have somebody that’s a voice thank you fear is a major barrier to action the
great ones like the Mayo Clinic ever vigilant and humble champions
high-performance they are just one chasing 0 role models I’ll never forget the day that we’ve
learned out about the Quaid accident chill came over me I ask myself could
this happen the Mayo Clinic the answer was yes the collaborative in power and cultural
male allows nurses to redesign their workflow
they adopt safe practices and even allow the cleaning staff to get involved ok they developed their own cleaning
checklist high contact services to prevent
infections using culture methods from other industries if we can help them not to get more infection will not just
cleaning rooms we’re saving lives this is a This is a Pyxis medication dispensing unit it’s
another system safety net we have to protect patients
from the frailties of competent human beings our nurses
injure the identification number the patient
named make sure that the right medication is take an
hour to the Texas unit in the star missus put the medication
only after the part order to make sure it is the right
medication for the right patient ratios despite the efforts of places like the
Mayo Clinic healthcare harm still occurs in many
hospitals sue Sheridan is a great example of
someone who has turned her family’s tragedy in to triumph by putting aside her
anger and resentment moving forward to make things better in 1995 my son Cal was born a healthy baby and normal delivery when we were home he started changed for
ice and eventually count was be admitted into the hospital it was discovered that
his jaundice was I’m over the nurses terms off the charts
when the high is it ever seen at the hospital they treated cows John
dis with traditional treatment with oral
therapy however on the second day he was there
for about 24 hours calstart arching backwards their classic signs the answer to brain
damage from John S cal now here’s addition cochran actress is brain damage from John dearth and he
has significance real policy
hearing-impaired his speech impaired mom very bright am very witty but Tom his lifelong challenges were totally preventable we just finished a survey with surveyed
over a thousand hospitals across the country and when
you look at the bottom performing the worst performing hospitals America not a single board chair from
any of those hospitals not one thought they were below average
knees are hospitals that are at the very bottom of performance they
they are they have terrible quality and yet most %uh they were better than
average a few thought they were about average but not a single one thought they were they were below
average it’s a level up to now I’ll and and the lack of have knowledge about
their own performance and i think is shocking business performance guru Jim
Collins has documented how even the mighty fall
in his recent bestseller the principles are frighteningly
applicable to hospitals how do institutions fall how do they go from great performance to
good to mediocre too bad and maybe even
irrelevant were gone boy found is that is actually a little
bit like a stage disease that there’s a that you go through the
early stages of the disease still looking healthy on the outside UK more
easily deny that you’re sick because you look healthy now if you look inside
you might not look so healthy but you look from the
outside and you can still say see we’re still doing well if our health care leaders can get
through their denial about their feeling systems it becomes a David and Goliath story
goliath is fear fear shame your malpractice consider cost to win the war on harm we must activate
the in your David in a hospital leaders they
will find the goliath is not as big as they think years the weapons against health care harm are leadership safe practices and
technology great leaders take risks they confront
their fear to drive adoption best practices and they invest in
technologies that make it easier to be safe has this been done
before do we have role models absolutely many angry at the Institute for
Healthcare Improvement 100,000 lives campaign led by doctor Don
Berwick ignited the passions America’s health
care leaders to save lives and put us on a path to
see Rohan don’t take me back to when you stepped
up to the podium and announced the hundred thousand lives
campaign we are scared what what was it like we knew we were
going out on thin ice and I was scared a student’s on a five thousand people it
hi Chayse annual National Forum on quality improvement
healthcare and I was gonna lay out this challenge
here’s the number 100,000 and here’s the time June 14 2006 9 a.m. I really didn’t know what the
reactions would be Nile anger I’m silence course what happened was just the
opposite we got more involvement and more enthusiasm or buoyancy in the pursuit have Healthcare
Improvement and I head experienced in in my entire career what was it like to
realize that the hundred thousand lives campaign then was achieved think the goal was met the biggest
surprise in the hundred thousand miles campaign
and the farming on mice campaign that followed it was the reservoir the the immense reservoir goodwill commit and courage intention in the health care
workforce doctors nurses technicians pharmacists managers all over the nation virtually
all over the world really wanting to make here safer and
better not angry that we were challenging them
to do it but grateful that we would we would put a
stake in the ground and in in that we’d say it like let’s go do
this back that that energy it still lost me many of the main
elements to the 100,000 lives campaign have become key National Quality forum
safe practices leaders blueprint to chasing 0 the safe
practices are a roadmap there’s no need for every
hospital to reinvent the wheel these are practices that have been
proven as a strong evidence base they can be implemented every single hospital immediately leading organizations such as the Mayo
Clinic Cleveland Clinic Vanderbilt Catholic
Healthcare Partners and Brigham and Women’s Hospital are
working with T MIT to validate financial business case for
adoption the safe practices so that leaders green
light investment in safety for boards and
administrators I think the green line approach will help them not
justified the hard decisions that need to be made about investing and changes that are
going to tangibly improve safety missed a great action lists for leaders
like the National Quality forum safe practices this week we know what to
implement so far we’re approaching that as a matter a phone tourism person
please do this we know it works saves lives reduce injuries ultimately
we’re gonna have to make sure I think to the point where safe practice that’s well known as no
longer and optional matter you you have to be safe because we know how to do it
we owe it to our patients it’s an honor really be apart if offering through a safe
practices I really appreciate is that they’re
involving patients say you have said us patients are apartment
of the health care team and often unused
ones costs and out so it’s it’s it’s its the great that involving patients in process as mister quedo to understand what happened to your
twins I’ll you had on the screen picture the two
files I do have them right here they look very very much alike the one
that was one thousand times more was the one that was administered to
your children is that right yessir and once but twice over an
eight-hour period not once but twice yes how could this
have happened well the answer became very clear to us
after talking the doctors and nurses and doing a little bit of research on our
home the 10 units have have a lock and 10,000 unit of heparin are deadly
similar in their labeling in size the 10,000 unit label is dark blue and the 10 unit model is light blue into
bottles are slightly rotated which they often are when they’re stored
they are virtually indistinguishable a census pressure tragedy my wife and
I’m and found out that such errors are unfortunately all too common since our
accident the labeling miles has dramatically
changed are twins so we graze in T boone quedo are ready
protecting other kids and saving lives while my
wife Kimberly and I have been on this journey we’ve had the privilege learning about
many other families who have gone through similar tragedies cracked we always had a smile and who dis you know he he loved life he was
clean time in the dedication he spent hours at
the stairs on dad to rosa parks at me mad you know and I
think the difference between a an athlete and
a professional athlete is as their heart and their dedication
nothing branching current been one to take it real for you let’s go back to the beginning Braxton needed the surgery for sleep
apnea was Braxton worried he always put on a a at her face but yeah he was he was
concerned is very word with digital he was gonna
be okay and wasn’t true we brought back home from the hospital
in everything seemed fine you know him wasn’t playing much a
pain you know he was resting much TV and we
set out I’m watching cartoons in about four o’clock he said dad I’m hurtin so I’m I gave him his pain medicine and everything seemed alright Beatles sleep wouldn’t seem normal to me in he woke up it 7:30 and me said daddy said you know home my
choice her p you know I’ll never forget you don’t
threaten is comforted name in my hands to drag
her are you alright are you in pain he needs
them for pain in good and fine hutu last time home or I’m I’m you in months and months without any
answers from the medical examiner and you know how we wanted to know was
what happened to our side the rails went for four months without answers and then they were forced to
seek legal help the system failed them 13 months after
Braxton’s death all they had was a autopsy reports sent
any when I went to get the medical records I was given two or three pages and I was
told that they don’t keep anesthesia records and nursing notes and it just didn’t
seem right to me so I talk to some experts and was given some advice on how to get
the complete set of medical records which idea you know it really erode your
trust and it it makes you fearful you know you think
that you would have answers right away when something
adverse happens to your love going it’s been thirteen months and we still don’t have all the answers
and so you don’t have closure no closure doll you know a lot of time I think lawyers
get involved hospitals lawyers get involved in this in the focus seems
to be on risk management after an accident occurs and not to say that they were doing
everything they could to right the situation but
and is as as a human being film felt that last thing I want to do do is focus on legal issues and somebody’s liability ok you know the last thing we wanted was to
hiring returning is to get the answers that we shouldn’t
had all along on the NQF say practices states that hospitals and caregiver
should reach out to families after an adverse event without any type of communication it
makes us feel that you know fraction didn’t mean anything
to anybody but us and here he just can’t ok you have to communicate you know it its it’s the most important
thing areas it’s an understandable to hospital react
that way they do because it is a business nears
liability involved yes and I ask there to protect themselves
and take that d but the what happens in the end is that one-time problem winds up not getting fix because
a lot of things get swept under the carpet they don’t want people to talk the nurses to talk they don’t staff to
really talk so investigation into what happened stifle for Sue preventable harm struck her
family not want twice shortly after Cal’s injury I’m my husband Pat had a pain at the base this colony
cervical spine they’ve removed actually a tumor from the baseless call search pathology good does surgeon came out Obama has been was in the operating room
and he shared with me that it was a benign tuner and six months
later my husband was in pain again got another MRI you know says covered that packet
mask the size of the surgeons fist go the final pathology report from its
initial surgery indicated that pat pat cancer I’m this
misplaced path report was yet another air that shattered the future for the
sharing family ending pet’s life prematurely I’ll we to this day still know what happened
to it appears that it filed in my husband chart without anybody
seeing except for the power just pair underwent on five more surgeries baby basically moved to spine am he became disabled so I had a son using
a walker anna has been using a locker by after about a year and a half treatment am pics cancer came back
explosively in he woke up paralyzed Monday from his
waist down me they shared with us that he had about
10 days tulip pit had always told me that if you die for
his cancer he might die with family and friends in Ubuntu really
get wide and he after a long more lime pies said com I want to go to Disney World
them I watch my kids my family have the time life and so after I collected myself I picked up the phone and call dismal
and with and now I’m for days 53 miss flu to Disney the kids in parades Space Center Minnie
Mickey Pluto it was truly a celebration on the third day peptide is email of what are the biggest barriers to
getting to safe care all the time everywhere is
fear we’re trained if we make mistakes not to
come forward that this is something to hide in feel badly about and sometimes people are punished when
they acknowledge mistakes very powerful lesson gets learned
immediately when that happens generally and I for ourselves the nurses
shoes sure that no one wanted to harm our kids but its human errors harder system it should not be criminalized all
it’s going to do is alienate very people will try and bring him to
help make things better I wanted to work as a nurse in with babies since I was a
little girl in nineteen ninety I graduated from
nursing school pick for the babys up until that for years ago when this
happened and the first babies on 4th July I worked to shift and you’re busy and it was almost 1am before on I was able to and wind down and believe lived along with my hospital
on he said he was too tired to drive home
and I need to be back in a few hours to do
the day shift in Schedule former and certainly done in patient room the
patient and try to sleep in gonna on street next to me in at nine o’clock I’m not the patient chooses to very young
16-year-old girl she was so scared the plane miss they’re going to make a run %uh starts in Peterson she’s going to
YouTube Habibi I’ll Julie followed nursing unit
guidelines designed to improve readiness have patience for anesthesiologist to
give an epidural injection by sheet here to the checklist
guidelines and prepared the anesthetic medication at the same time they cheered antibiotic medication ready to go a
number of systems floss contributed to jews absolutely predictable human care so I got a relief trying to be a dick and her the term be both pigs had Annes received maybe 2 p.m. me had creamy I knew had but im henry became Pakistani mom and have to you its to determining produced and turned could shoes arrest
him people can’t immediately many new people dozens of people who new MacBook his
medications that we used Kevin said be peace in fact I said just hung this into a headache in she’s reacting personnel instrument room baby brought it to me in
the work party put it in humans it next pic you each stood Julie administered the wrong medication fatigue identical medical tubing
connectors similar IV fluid bags in a suboptimal
Parker process hospital death for the young mother hospital fired Judy she was calm untied as a single mother of four no
resources to defend urself she had to treat a misdemeanor to avoid
prison what happened to her led to the
development at the new National Quality forum see practice called care the caregiver will
george our stories really a tragedy because she was hung
out to dry I’m for making a big mistake which was
clearly card my whole host very bad systems she was
truly the second victim in two ways she was
the victim bad systems as well as being emotionally a second victim she was devastated by
her as anyone would be I’m but in addition she was the person who was the victim of these bad systems and the lesson I think years I’m not just the hospitals need to be responsible for their systems and tricks which is
clearly what they need to do but there’s a second lesson here in that
is jury trial was fired she was indicted she lost her
license because she was presumed to be
incompetent there’s no evidence that she was in
common no evidence was ever produced that she
was in common the mare crop is a hospital for missus
convicted involuntary manslaughter after a two
year old girl received a fatal injection of saline solution more than 20 times the in 10
concentration a pharmacy technician working under very
busy day accidentally mixed the clear saline
solution incorrectly by signing off on her work Eric C is favored image hit should executive places in the interior angles
at this point it’s dead it’s just if Peter it did well I think the crew musicians is a terrible thing home because both
the examples will I know the law enforcement
only been a few but in every case bearer obvious explanations 4y mistake happened and those explanations all have to do
with the systems are working in we now have a safe practice round care
if the caregiver which defining good ways to deal with the
people involved it providing and have care grieve the these
two they need help they need healing may need support work your and you need em sometimes the the best knowledge you
could ever get that will allow you to redesign the care
system for which you are responsible will come from the very people who have
been trapped in the spiderweb cause and effect this led to the injury three years after the death choose
patient hospital published in independent study repealing multiple
systems issues contributed to setting up to the scare and honest mistake anyone could have
made never shirking her accountability for
causing a death julie is moved on as a team I T patient
safety fell to help save other lives well this is part 1 general hi your patient
safety department she is helping measure lives saved and dollars invested in safety from
impacted video stories now being used in thousands of hospitals
deployed I T a mighty one of the many video stories is about a
little girl named Josie key I would like to share my story with
him I do this with the hope that when I’m about to tell you will
make a difference in how you care for your patience and how strongly committed you in your
hospital air to patient safety Jersey was admitted
after suffering first and second degree burns from climbing into a hot bath Jersey’s
death was not the fault have one doctor one nurse it was the
result a total breakdown in the system the
power stories is incredible in story power the secret weapon our article targeting
healthcare years we share some with the secret to
the power connecting the head to the heart prompt action in it we
present the preliminary results this jersey King story and its impact on
2000 hospitals it revealed that the majority of users
have seen lives saved and money invested as a direct result of
using it we can control hospital airs in each
hand save their lives other potential victims
other helpless children little battlers is wanna like to time thank it’s with the battles one mistake at the time on liked it I in the
war it’s really the end result wall will be taking acquires down zero
really so you need three things: you have to start with the gauge leaders
the and practices that work then if you implement the practice is
with great technologies that make it easier to be safe you have the winning combination in the
war on personable on here lies the sweet spot of
high-performance and safe care up many hospitals are
getting extraordinary results from ordinary things the already have today
my biggest lesson has been to empower mister we spent two months listening to
250 people in this organization about what we could do to make it better
came up with a list of 72 recommendations 71 for those came from the staff that
story implementing that’s why things are getting better
caring hello paid the demand she’s gonna be
earners that the evening an example of staff led innovations
share rounds developed at the Mayo Clinic in
Rochester Minnesota which helps nurses include patients in
the process of passing on information during shift change making the patient and family party at
their home safety net many it’s really hard to understand how
your day is going to go without visualizing the patient we used to give report right out at the nurses
station on the back room the nurse would sometimes right report or tell you in
person but you can’t really assess a person or be prepared to your
day until you actually see the patient in person so they kept the ID hood going on I’m
going have one me the first thing we do is we can get
an overall picture of how the patient is doing so they’ll write
prescriptions for you a.m. we can see that he’s doing well as pain
under control and may be addressed any need right away
I’ll be leaving now but a man doesn’t take great care you
tonight this way before I leave the patient is
comfortable and with who his next year said I feel more involved makes me feel
reassured pet owners coming home he knows exactly
what’s going on with me now they are and in coordination I can ask questions as
well and arm into something that I’m
concerned about right thinking about I can bring in a arm
because the next going off knows something that we
discussed earlier and and home an excellent reminds all those
to pass it on to NIS that’s coming are no problem have a
good evening shopping care field housing as a little bit K I definitely think that this could be
done at any hospital I’m 9 My Name Is Khan and this is Casey she’s going to be
honest this morning from seven to three just play changing 13 a little bit now
might be a bit of an adjustment it actually is just that simple as just
bringing it into the patient yesterday I don’t just think it should
be done I think it needs to be done I mean it’s provides for the safest way
to care for the patient another great cost-free initiative is the IH I open school which
puts healthcare students into the safety game
literally thousands are joining the action check a box in life that serve program devised by medical
students and urging students in promises students realize that students
wonder in training and hospitals can introduce a surgical
checklist as sort of change agents at from the
inside they calculated the medical students
calculated that a a medical student during their surgical clerkship when they’re learning surgery
is involved enough operations that if you do the math if
they could get the check was used in all the operations are involved in one wife would be saved check a box
civil I’ll Dennis are you surprise that we’re just
starting to use checklist in health care and having impact you’re an experienced
pilot you know the value of a checklist I can’t believe it stay the troop there’s not there’s its its how much
does this cost very exact it’s the most important be
some equipment really on the airport were taken the World
Health Organization checklist ima combining it with the regulatory
requirements that we can use it every operating room in america
checklists help thank things simple predictable standardized they enhance
communication just like they do in airplanes okay
we’re just going through the checklist right you were calling out we got to be
getting and I said of was a checklist say on on so we missed that we miss something yeah
check bus yeah and that’s something that’s why
checklists are important but they always had to be backed up by humint exactly her its human error good
point right when using checklists in our
operating rooms so that we can make sure that we don’t miss an element of care that we
provide safe care and that we do with the same way every
time I feel like we haven’t even touch with checklists could do press in
medicine is that a fair statement or is that unfair know it’s absolutely a fair statement
had healthcare is grossly understand that’s been checklist are a
tool to help us do our work but they standardize processes in health care we have a very autonomous
culture that is grossly understated actually got
to make sure we have a checklist to ensure it’s done on every patient every day all the time
you know what I see when I come down is or function much more to team in the
operating rooms and I think that’s huge something’s not working quite right you
can be reported and acted upon before the next case the
other checklist has been a real way and get into that buying one of the biggest patient safety
things we’ve certainly seen in the OR’s in my lifetime think it’s meant
fantastic avionics master arts masters on
emergency lights words lights on he can BK on mom technologies making easier to be safe the mom 17 gauge
leaders and staff open to improve their own practices they deliver great impact currently there’s just a handful of hospitals
within the nation that have the bar code technology they did have a sec knowledge in place I
do believe that it would save more lives I’m just gonna double check HERE the
software mansions the barcode on the medication to the
park or profiled for that patient but does that safety check have the five
rates the right medication the right dose the
right time the right patient and the rate route it does not do the critical thinking for
the nurse however it does ensure that those five things are matching for the
medication and for the patient before we have a smart company had I’m that look similar but did not have a
drug library we’d go on me the information we have on
paper and actually at are how to get the medication now
that we have the marcom first responsible for knowing how to
give these drugs to follow the policy procedure however the double check for a were able
to program the palms to know is that the
way safely give this medication the rate this is how fast you want to
run it and use me are coding system disk and medications can your patient want to get all your check that
everything Nash after that made a hair net at the end of the day this is but double
check to work and covers you as a nurse when you’re hanging medications I’ll fun
and interesting things is that using for exiting with alcohol
crap Sean that anti to want Witcher at a the more common types a at da mall
surgery and lung surgery that that Pratt produced the rate of
infections by forty percent when we looked at our
individual patient we found that if we could reduce
1 infection of this type that we would say somewhere between two and four
thousand dollars for so if we can reduce surgical site
infections in 10 patients using this it wouldn’t caged for tire conversion to
a new press for the entire institution this really has been shown with evidence in a well-designed way what exactly we
can achieve a is far surgical site infections so where’s the rationale for not doing the
computer prescriber order entry for CPOE allows doctors and other
caregivers to automatically check for accurate dosage allergies and drug interactions when
prescribing medications for their patience without CPOE this is a manual paper
process with no safety net this sophisticated technology however
may not always be implemented well I can be less effective or even cause unintended harm a real
breakthrough developed by leading experts is the CPOE
flight simulator that allows hospitals to verify their
performance before the use it on real patients unite
had the wonderful privilege to work together with doctors like doctor david
class and others on the CPOE flight simulator just a printed in layman’s terms what is
it and what’s the value their flight simulator have basically
let’s hospitals get a sense how how the the checks for
problems are around medications am when doctors ordering medication in what we
did was to develop a set no warders that their for
medications that have harmed patients in look to see how often the computer
with a warning about those those errors there’s no question that simulation is the future of medical
care I think it’s the future in everything from surgical operations to
the use of sophisticated devices to actually making sure that the
computerized order entry system works as we expected it to you can’t know until you check it and
better to know ahead of time then to find out that our expectations didn’t come about for everything from
surgical operations to teamwork in emergencies to the use a
very sophisticated devices to the u7 computers effectively
simulation in practice in rehearsal in getting it
right in the laboratory so to speak will definitely be the way we move forward this is going to be transformative in
terms of getting to safer care one of the most powerful innovations in
healthcare our automated infection identification and mitigation systems called games for short they’re being
used to identify and prevent the impact confections using computer systems and manage the
office of health care quality only the mission in this office is to
strengthen the nation’s health system and to promote quality care within this
country retiring in a variety of areas the reduction prevention and hopefully
elimination of healthcare-associated infections is a prime focus as is medication error and coordination of care in this country
is 0 the number is it rhetoric /url reality can the reality meet the
rhetoric absolutely it’s reality and we are focusing on total elimination when I receive my medical training
hospital-acquired infections were considered inevitable but in the decade since that period of
time we now recognize that they are largely preventable in our goal is complete elimination
peptide it 45 I years old in 2002 with their for real daughter in a
seven-year-old son you know he he had offensive humor to
the period honestly and he said brown he said you know whatever you do your you’ll be
successfully support whatever you do he said don’t give up and patient safety and he went on to say you cupcakes so I started speaking up about what
happened to my family and calling for change and he had unique
opportunities to testify at wanted the testimony them at the WH 0 and soon after they invited me to join them in leader program on patients from all over the world just
like me bedhead experienced tragedy in health
care yet who wanted to contribute in a really productive positive way in
effect it was a call to action by patients arm to the health care
system to partner with the health care system to work with the health care
system this is be exciting part this is the part but inspires in
nineteen people a.m. for those amassed here that have
lost family members in her children com this two-piece that gives us hope you know that the WH 0 says to us
patients here important in her voice your collective wisdom is
important to the WHL at the powerful thing for us here our future in health care to create safer more effective
healthcare depends on partnerships with patience and their families we need patients and
families and consumers who are not yet patients
our family members to become advocates in the ownership up
their own health their own health care and to hold us
accountable and racks and passed away is pretty
tough for a for a lot of the kids in and it still is tough for summer them we wanted to run a tournament that kinda exemplified
what we felt he was all about than that sportsmanship 7 kids that understand that they’re out
there to compete in there they’re gonna play against you hard but you’re still kids are still out
there playing a kids game having fun here right iraq story hasn’t finished but I think there’s a chance for a happy
ending that we and hospitals could have a working
relationship that no one would have to feel the pain
that we’ve gone through fourteen years after Cal’s birth
hospital in Sioux shared an agreed to join forces and put the past behind them to say
future patients lives this may lead to them becoming a
national role model the harm that our family experience whys
of course unintentional what used really struggled with buyers what happened after the hard work and the while silence and the isolation that
we felt it with very much like a hit-and-run we
expect the truth and essence year attempt to make every effort that will never happen
again to another him home win we have the opportunity to connect for me was actually
relatively easy because they didn’t have a lot of history but I was representing
the hospital and I know that it it’s a difficult time but it was also an awareness that it is
time to move forward we’ve come a long way in health care from where safety pins were considered a
cost to doing business that transition from a cost to doing
business to is no longer an acceptable option on the challenge
that we’re facing now is fully understanding how do we get to that point were none
will occur or the overriding sense because it’s the right thing to do
in it’s an opportunity to see what we can create together I am
absolutely convinced that we can make a huge difference I’m so I’m thankful I’m excited I I’m look forward to relationship or
challenge each other learn from each other that we’re gonna
trade a model that others are gonna wanna copy
from Boise Idaho ok happened words say am right on pp right
on brown it is true that when there’s profound
grief the best medicine for grief is doing something productive with
something bad happens in like you kinda have a choice you can shrivel up in disappear in life free come out fighting like hell only screening I don’t know if it’s
streak per se but given white my family’s
witness an experience I don’t see a any other route for me he can come out
challenging life and thank God I’m hopeful you know what
I hope it would be a pre miserable life chasing 0 is the quest to ensure that accidental death and harmonic what
happened to my kids our thing the past 0 is within our reach if we have
leadership right practices in place and we leverage innovative technology
visionary CEOs they’re willing to adopt new principles of management and
leadership and deploy them quickly are going to be
successful they will be the innovators their the
Pioneers but more than that they will have the feeling of pride in accomplishment in what they’ve done for their own
organization I want everybody to remember the
essential purpose of why people go into health care it’s because they care about people they
care about health status they care about saving lives if the future it looks like past will
achieve nothing the past 10 to 12 years we’ve
written a great deal about safety and we’ve done very little about it the
future has to be roll up your sleeves let’s get going those who dis supplied
to the hospital and medical industry need to make certain that they not only
have saved products and devices but they’re used to safely as possible
those who use these things must be certain that the used only to achieve the best possible
clinical outcome can achieve those of us who pay for the scare must
assure all those families who are paying premiums that we’re using those dollars as wisely
as possible to lead to the best possible outcomes the safest possible bird were really bringing the forces the
energy the resources that we need into this really really important sphere that nail is the
time there is enough knowledge there’s enough
energy we have enough money in the system
currently to do what we need to do what we don’t have enough his action we
should do everything we can to the people can
reach their full potential for health that’s what chasing 0 is all about and
that’s what city inspirational aspirational and realistic goal I get asked a lot by normal consumers have care what they can
do to make the care safer generally bison take someone with you
make sure that you’re not alone in your care system but I think I’m more and more thinking
that it the answers speak up we have standards we know like the
National Quality forum safe practices we we know what standards possible
should be adopting as a consumer care ask your hospital ask them if
they’re using kinds of standards that we know can make your care said so the National Quality forum safe
practices are a tremendous opportunity for all
leaders now to unleash their full potential to improve patient safety and health care quality
it’s time to act now I found the role that I can play and is to partner with the best experts and drive awareness what we can do if we
act now the Quaid foundation has merged into T a
mighty to apply the power of stories to bring
consumers in the years together our mission is to
save lives save money and bring value to the
communities we serve it fax figures and statistics reach the
head but nothing happens unless reached the heart
three stories up from real people that put the hands to work join us in this war on preventable harm 0 is the number now time by 0

30 Replies to “Chasing Zero: Winning the War on Healthcare Harm”

  1. really good video as a new nurse working night shift, i often for get how easy it is to make a nursing error, this video remind myself of how important my role is healthcare, and to get active to improve healthcare.

  2. From 1999 more than one hundred thousand Americans die every year from health care harm! Astonishing.

  3. Anyone who is involved in healthcare should be required to watch this video, especially the board of directors of a HCO!

  4. chasing zero is a excellent thought provoking video. Being a nurse for over 20 years  I can truly relate to these stories. Best piece of advice I can offer a new grad is to always remember that in nursing "There's no such thing as a dumb question" If ever in doubt find out!

  5. This video was by far the most aggressive stride toward perfect patient safety. The journey never ends, but the destination is worth the trip. Dennis Quaid, Discovery channel and TMIT have led the way in this quest to eradicate patient accidents due to medical errors. My hat is off to all of them. There are heroes among us, and they look like these people. I strive every day to emulate them. 

  6. people die because doctors just don't care. check out  on youtube,, do hospitals have a right to have your child put to death

  7. i will never forget when the doctor intruduce primacor iv, he said it would make my daughter heart pump stronger. it tore up her whole health. Some doctors are no more than a drug dealer on the streets. They take lives to support their life style, to send their children to good schools, to have big homes and etcl.. they donot care.

  8. Guns kill 32,000 people and 16,000 are suicides, 8000 are accidents the rest are justifiable homicides and illegal homicides. There are 80 million gun owners in the US.

    Based on what gets reported the medical industry kills 1 MILLION Americans each year. There are 700,000 doctors. 

    What is needed more, gun control or doctor control.

  9. My wife was denied a basic blood test, that An ER had instructed my wife to get, that latter led to harm to my wife almost killing her.  Yet our med board in WA State says this is fine for Dr.s to do.   

  10. The video is extremely informative…the captions SUCK! As a person that is deaf, I could not figure out over half of what was being said!

  11. This is amazing, thank you for sharing!! As a nurse, I think patient safety information should be teach and share all over the world… do you imagine how  patient safety is going in low income countries? God, we lots of things to improve…

  12. I got 4 slipped disks and a busted collar bone, hip, and my tailbone is protruding into my butt thanks to a Dr's over numbing me after surgery and putting the rails up, and giving me a male Aide. Then all the Dr's in my county refused me treatment to cover for their kind. You have to pull the records so they can't do this to you. YOU have the right to have any info pulled and censored.

  13. This is such a valuable tool in training nurses and doctors. This is what they need to show at orientation….and yes the whole video. If more staff had the opportunity to hear these stories and learn before mistakes it would bring such power to the care patients receive.

  14. had to watch this for my class. Vid was good, but the captions for this video are atrocious

  15. So apparently Dennis Quaid never heard of Atul Gawande? This argument has been made. There are preventable medical errors and it is a massive problem. Testimonials are more emotional, yet less convincing, than actual data. The data exist yet are not presented in this video.

  16. Doctors do screw up a lot my mother lost her leg to a doctor misstake she ended up bedbound because she couldn't learn to use the new leg a fake leg.

    I have a permanent nerve and shoulder injury that I received in a car crash I immediately went to the hospital because I couldn't feel my left arm . I was totally ignored because they didn't think they would be reimbursed by Medicare. And because since I have chronic pain they thought I was a drug seeker they actually refused to give me an x-ray. I collapsed at my job was taken to another hospital where they told me that the nerve of been crushed it between two bones in my shoulder I'm in constant pain And I have to have procedures every three months where I have to get put to sleep to control the pain this will go on for the rest of my life and the best part is is do you do about Loyer I never got reimbursed or anything the person that hit us ended up leaving the state because he had was a criminal I did up losing my job and I will never even get a settlement from this.

    I just also want to add that something has to be done about the drug companies my current medications cost around $1000 a month sometimes even more I've tried everything to get assistance for this . There is actually a law in place that says that if you had Medicare you were on able to get discount cards from the drug companies for the medications that's the law does that make sense to anybody? Are usually end up having to cut my doses take half of what I'm supposed to just to make it less their times at the end of the month where I end up just eating grilled cheese .due to my shoulder injury I lost my job I'm telling you the system is screwed up.

  17. For the people saying the CC suck. http://www.safetyleaders.org/downloads/ChasingZero_transcript.pdf this is the transcript for the film.

  18. My family and I have been abused by medical professionals. I was taught in human anatomy that if we don't pay close attention as a nurse we would harm people. I was gonna be a nurse back then. The teacher said triple check meds before giving them. I was diagnosed as poisoned by a doctor after being in another hospital that doctor didn't work at.

  19. "Hospital sets up police arrest of Doctor in retaliation for reporting patient harm and safety violations"
    https://www.youtube.com/watch?v=RNJG8lLyHQQ

    More on the story:
    https://www.austinchronicle.com/news/2017-07-07/the-doctor-vs-the-hospital/

    http://www.kvue.com/mobile/article/news/local/judge-rules-medical-board-failed-to-prove-allegations-against-lakeway-doctor/269-476748040

  20. Chasing zero would be a great concept yet we need to start with the medical profession and insurance companies recognizing diseases that exist such as vector borne illnesses or mitochondrial disorders and others. Until then healthcare is not treating patients the best that they deserve.

  21. We need to switch from "Sick care" to health care, this requires a shift away from profits and treatment, to personal responsibility and prevention. This requires funding public health and health-focused behaviors. Sadly, I doubt the average person is much interested in taking responsibility for their own health, all the while demanding the best treatment. It is a complicated mess, and one that will take a great deal of focus to fix. But it is fixable.

  22. Why is it so criminalized? I felt terrible for that RN… I certainly believe in healthcare and safety, but I feel it was harsh 🙁

  23. If this is how hospitals treat nurses and pharmacists when they make one mistake, I no longer want to be a nurse.

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