I’ve had a doc made a mistake, he came to me, admitted it, told me how he was going to fix it.. and we all moved on. In appreciate his candor, and now we work really well together

I had a bad surgical outcome that left me permanently disabled with cauda equine syndrome. This fits into the yellow zone where another surgeon wouldn’t have made the same mistake, in fact after all this happened, when I went out to eat with some pre-med undergrads who were ED scribes, they immediately identified the emergency when I described my symptoms. What’s made it so much worse is how badly almost all providers I’ve seen treated me afterwards. The few doctors who knew me from before the surgery treat me with kindness and respect. With new doctors, everything I say now is either ignored or dismissed. I’ve had providers yell at me for asking a simple question. They started telling me to get over it already when I was still in the hospital. I’ve been repeatedly told that the constant excruciating neuropathy is all in my head and I’m making it up. When I had severe side effects from a medication, I was told it’s no big deal and to stop wasting their time. I had one doctor suggest that I can still go shopping, implying that that’s all women care about so why am I there asking for help. Another doctor kept telling me to smile so I’d look pretty. The list goes on. It doesn’t seem to matter what new doctor I see, they treat me like a worthless piece of shit. I am always polite to them. I really am and there has never been a single comment that I’m rude. They just seem to think that I brought this surgical mistake on myself, that it’s my fault, and I need to live with it and stop turning to them for help. They don’t want to deal with it. Well, they got what they wanted. I have no trust left in doctors and I have stopped going to all of them and will avoid them like the plague in the future. I’ve cobbled together my own solutions as best I can without their help. I am filled with rage. Mistakes happen but why is it necessary to treat me so badly on top of it? What did I ever do to deserve this? This happened at OHSU, a well known and respected teaching hospital.

I feel like people not even associated with healthcare should watch this video because it affects the litigation aspect of malpractice cases. In America I feel like simple mistakes happen in that green/yellow light scenario, and clinicians are unjustly punished not just by administrators, but by actual legal action taken against them as well. The general public may be led to believe by some lawyers that they can have some financial gain from their outcome at the expense of practitioners.

That "normalization of deviancy" has downed quite a few aircraft in its time. Silencing configuration alarms because they can give false positives, taking shortcuts from checklists because it takes longer to read it and check it off than to just do it, getting chatty about other things at critical flight times because it's routine now and you can do this in your sleep, except now, you're in the midst of burning wreckage and your last thought will be "I killed people." Doctors would do well to learn from aviation, and industries that are process and checklist driven.

Another aspect of mistakes involves bullying and intimidation. When there is a lack of teamwork due to exclusion mistakes are more likely to occur. If nurses feel like they can ask questions and get support from fellow nurses when they are unsure of something, less mistakes happen. I don't know how many times in my career I have felt like I needed to stop what I was doing and get help from other nurses on my unit. Whenever that feeling comes up, I stop and reach out. Almost 15 years into this profession, I still strongly believe the only stupid question is the one never asked. Lets help each other improve patient outcomes by working together as a team and building one another up.

The fact that you have captions is great! Thanks!

We are having these issues because we Health Care Providers, are overworked, understaffed, underpaid, and too much competition because of the insurances!!! Yes, insurances are allowing it!! Which hospital to go to? Urgent Care centers are popping up all over the place putting primary csre doctors and specialists out of business. Patients are seeking care but not paying their full deductibles!! Who has $5000 to $8000 to pay for the deductible?? Its a HUGE MESS!!! Experienced RNS AND PHYSICIANS are getting burned out!! Complacency has no place in taking care of patients....... When you stop doing your correct procedures, following the rights of patients to save time, there is a Huge Problem!!! Don't forget that most people are good people and good at their jobs. It was an unfortunate accident what happened to the Vanderbilt Nurse!! She doesn't deserve to be arrested. It wasn't malicious!!

Thank you, Zdogg, for making this video. Some of the comments on the Vanderbilt nurse case video were extremely vitriolic and ignorant. I hope this calm, measured explanation helps some come to understand what’s at stake and come to embrace a systems improvement model instead of a vengeful pound of flesh model. Healthcare professionals usually just want to help people. We need to appreciate the sacrifices they make and recognize their humanity too or we might not have enough of them to go around for much longer.

Honestly one of the biggest things that need to change are the work hours, you can't expect someone to be just as good hour one as they are on hour 20, that's how some mistakes happen. We should make sure that all our medical professionals are well rested enough to do their jobs.

I’m still in school, but thinking of studying medicine and eventually becoming a doctor. I think my biggest fear was not initially the studying, but of eventually making a mistake as a doctor. I would hope I would never intentionally harm someone so to hear that if I make a mistake which someone else could have, I am now really reassured. I hope your message gets recognised more. Thank you!

When I was admitted to induce labor (week late and that kid was very comfy and didn't want to leave) they put a series of bands on me. One was red to warn the nurses of an allergy to sulfa drugs (anaphylaxis). I was sleeping through part of the labor when a nurse came in to administer antibiotics. She should be massively greatful that my husband a) had was a former Air Force medic, b) had formal education in nursing (didn't graduate due to VA screw ups), and c) asked what she was giving me. She had failed to check my chart. She had failed to check my wristbands. She could have killed me and my daughter. All because she didn't follow procedure. My husband asked that she not be allowed in my room again. That said all the other L&D staff was great.

Love this. My first career was in the airlines. Now I’m a nurse. Lots of crossover in lots of ways. Thank you for posting. Shared and liked.

ZDogg thanks for your candor. I believe in Just Culture!

Medical neglect led to my father’s death. We tried the “fix the system” approach, but the hospital’s official response was “we did everything right.” What then? We consulted a lawyer, but they said it’s too difficult to prove the negligence since the medical records are considered the actually factually correct record of events. This case is one that could easily lead to another death (embolism following major surgery in a invalid patient with 5 major risk factors for DVT’s.) A friend’s husband was in the same facility, with a VERY similar situation, who also developed DVT, but with a different doc. His doc did ultrasounds on the legs and discovered, treated, and resolved the clot. If my dad’s doc did the same, he likely could have been saved.

Excelent show and great topic!! I wish more instructions in and out of healthcare field would apply this wonderful idea to their businesses!! Great job!!

planning a talk and you nailed it so concretely!

You should be paired up with ANA to make these applicable for CEUs

We are all human and absolutely we are responsible for our mistakes. I like your analogy "green, yellow, and red". Yellow and red individual or hospital culture mistakes must be addressed and appropriate discipline applied every time. And green mistakes must be questioned. To me the issue is to find facts. Not to absolve a doctor or nurse of an error or mistake. No that was not your point, but there are consequences for mistakes for all of us .... well not bankers that would be silly.

Where I work (SNF sub acute rehab), they add more and more tasks on as corrective actions for mistakes. A nurse made an error entering an order into the computer. Instead of focusing on that nurse and giving more training, all orders now take two nurses to confirm. One nurse is to enter it in. Another nurse is supposed to stop doing whatever else, log into the computer, and confirm the order. Our days aren’t getting any longer, our staffing isn’t getting any better, and we have more to do. I was complaining about our staffing a few days ago, and was given a BS 💩 answer. Sorry that sounds unprofessional, but the answer really wasn’t factually true. A couple weeks ago, I saw a nurse directly defy the tube feeding orders entered into the computer because the pump was programmed differently. I tried to tell her what happened since I had helped confirm orders the previous night, but she chose to ignore me. We don’t have any nursing management at night, and there was no point in me reporting her another day because I’ve seen too many times of not being taken seriously or not getting results. If speaking up for problems yields no results, then what the bleep is the point? I stay there because I at least feel I’m making a difference to my patients. At least I can fix a few things here and there.

This is the mens rea list applied with more detail & an understanding that there's a green light zone. This video does a great job of explaining this. Not to say I know best, but I have a BS in psychology & am a couple classes short of a BS in criminal justice. Also a lifetime of theatre experience, art, the tourism industry, & my own mental illness. A handful of vacations out if the US. I'm poor now, but wasn't growing up. All this has helped me understand different people in different scenarios & put myself in their shoes. People need a better understanding of the human condition, especially of those outside their own bubble, do yo speak. Studying & experience helped me understand things I didn't know I didn't know. I think it would help if more people were able & did the same.

I disagree with his statement about laziness. I've been an RN for 30 years and I've come across lots of lazy workers that use shortcuts.

My father was a neurologist who had undiagnosed narcolepsy. It got really bad, at one point he fell asleep with a needle in a patient. Luckily nobody needed to go to the Board, he retired on his own. But he was in denial for so long, thinking he could pull through it. Looking back he feels bad, knowing he probably put patients at risk. Things like this can be very tricky. We work so hard through medical school and having to retire early from disability can be devastating.

Can’t agree more!

My husband is a pilot. He has said many times that FAA regs are written in blood". People don't act until the unthinkable happens. He used get into trouble with administration because he refused to fly "broken planes" or fly in precarious weather(they didn't know he was used to be a FAA examiner and a weather officer in Air Force. We are going to go backwards where people do not report their mistakes to the detriment of the patient and future patients

Love your videos, they're very informative and your passion resinates with my own when it comes to expecting better healthcare for our patients but also expecting better working environments for those of us practicing within the system. I do have a topic request. With March being autoimmune disease awareness month and April being Spondylitis awareness month I think it would be good to maybe talk with a rheumatologist about how general practitioners can distinguishing the difference between mechanical back pain and inflammatory back pain. 1 in every 100 individuals has a form of spondylitis and the average AS patient goes undiagnosed 7-10 years from the onset of symptoms before being diagnosed. By that time fusions have begun to form resulting in permanent immobility to the joint. Early diagnosis and treatment can improve the outcomes and improve the overall quality of life to the patient. General practitioners are on the frontline of medicine and can help in early detection and facilitate needed referrals to a specialist. As both a Nurse and an AS patient education on early detection is very important to me.

Agree completely

Nice

Airlines also don’t have to deal with EMR, reimbursement, or meaningful use

Doctors shouldn't be allowed to police themselves. The entire medical system needs to be reformed doctors are covering up for one another and it's disgusting.

Safety Management Systems. It sounds like you have done some reading on the topic. Non punitive, anonymous safety reporting system. Allow people to flag and identify errors, perceived errors or safety concerns to be reviewed and acted upon. I’m an airline guy I was always skeptical of them but they work and they identify small recurrent issues before something bigger happens.

Until AI and automation completely take over, mistakes are inevitable (but we can focus on reducing them).

For the most part, I agree with your descriptions of various types of mistakes. But you seem to think that healthcare providers who make "yellow light" mistakes should be above the law because they lacked intent or recklessness. The law already differentiates intent, recklessness, and negligence (at least regarding homicide, which is what we're talking about, this is obviously a follow up to the Vanderbilt case). I also agree she shouldn't be put in jail. However, I also don't think it amounts to a reckless homicide charge, but a negligent one. In some states, she wouldn't be facing a felony or jail time for negligent homicide. If the law were more consistent across the nation where this was a misdemeanor without jail time and the prosecutor wasn't trying to make an example by bumping the charge up to reckless, I don't think we'd even be having this debate.

IMO, some behaviors are allowed and encouraged in the down low in an effort to maximize productivity. For example, a patient comes in for a procedure, the patient might have shown up late, had to use restroom, there is no H&P from doc or patient was simply a poor historian and their ride might just b a neighbor. In this case, the admitting nurse is in a lose lose situation. The nurse can't use any of those excuses as to why they were delayed in getting patient ready for a procedure. MD shows up and expects patient ready if not the nurse won't hear the end of it from management and MD. A simple error as maybe a pre-op med (usually a narc) not getting properly picked up by EHR or nurse missing one click that confirms med administration then nurse is fired for deviation. SMH. The system appears more and more like a production line in a warehouse instaed of dealing with people.

Well since they like to act like you are being ridiculous when you dont follow their every word........then it stands to reason they would be willing to take responsibility for their mistakes. Maybe if there was a better relationship between medical professionals & patients (where they are equal partners like are supposed to be) then maybe there wouldnt be a blame game situation.

Drop the ego. Admit and move on!

This totally ignores/excuses/justifies the medical professional(s) who: A. Administers, prescribes, recommends, supports, and/or does not speak up about using high-carb, low-fat eating for i.e. a obese type2 diabetic. B. ... ditto for other harmful standards-of-care ... If the (especially) M.D.'s don't use/order the beneficial treatments for conditions, other practitioners are more tightly restricted to the single standard of care.