Well, good afternoon, everyone, and welcome to today's webcast, entitled The Blame Game and the Culture of Safety. This webcast is brought to you by the Leadership, Empowerment, and Development Committee. This lead committee is committed to developing educational tools and networking opportunities for all the multi-professional SCCM members desiring all non-clinical professional development. Please note the disclaimer stating that the content to follow is for educational purposes only. A couple of housekeeping items before we get started. To submit questions throughout the discussion, type into the question box located on your control panel. This webcast is being recorded. The recording will be available to registered attendees within five to seven business days. Log into mysccm.org and navigate to the My Learning tab. Hi. Thanks so much, Rob. I'm Dr. Wendy Green, and I'm the Director of Acute and Critical Care Surgery at Emory University Hospital in Atlanta, Georgia. And I'm attending, in the hospitals list, Surgical Intensive Care Unit, and I have no relevant financial disclosures. For expanded moderator and speaker bios, please download the PDF in the handout section on your control panel. Also moderating today's session is Rob Gravencourt. Mr. Gravencourt is a 40-year member of SCCM and has spent 40 years as a cardiothoracic surgical ICU physician assistant. Now retired and Director Emeritus of Emory Critical Care Center Residency for Nurse Practitioners and Physician's Assistance. Mr. Gravencourt has no relevant financial disclosures. I would now like to introduce our subject matter experts. We have Cassandra Williams with us today, and Cassie is a former nurse educator who is now Principal Attorney at the law firm of Cassandra M. Williams, LLC, concentrating in the areas of nurse license defense, workers' compensation, and workplace discrimination. She has a law degree from Western Michigan Thomas M. Cooley Law School. She received her Master's of Law in Healthcare Law from Georgia State University College of Law. Cassie has no relevant financial disclosures. We also have my namesake, Dr. Wendy Wright with us. Dr. Wright is the Associate Chief Medical Officer, the Chief of Neurology, and the Stroke Director at the Emory University Hospital Midtown. She is a Professor of Neurology and Neurosurgery at the Emory University School of Medicine and has a Juris Master's degree in Health Law from Emory University School of Law. Welcome everybody. It is so nice to be with you all today. As we bring the topic of the blame game and the culture of safety, our goal is to move towards zero harm and creating a work environment that leadership promotes performance improvement that leads to high reliability and encourages everyone to participate in protecting patients from harm. This takes trust, performance improvement, reporting to create this culture of safety. The aim is not to blame free culture, to have a blame-free culture, but to separate out blameless errors that we can learn from and those that are blameworthy that require equitably applied discipline. As we work in this space, we need to eliminate intimidating behaviors and hold everyone accountable for consistent adherence to safe practices. We must balance learning and accountability. We must assess errors systematically. We must determine whether it was a deliberate harm test, whether it was some sort of incapacity that needs to be assessed, foresight testing, or substitution testing. We need to make sure that we make our spaces, brave spaces, safe spaces. We need to manage the blame game and the culture of safety. Rob, please take us from here with the questions with our panelists. It's going to be fun, Wendy. Thanks. So this afternoon, what we've done is our committee has actually reached out and garnered some questions to sort of prime the pump, just begin, get the juices flowing here. And so we're going to start. The first question, and Wendy and Cassandra, Cassie, just jump in as you see fit. The first question here is sort of under the category of leadership, or what are some of the ways that critical care leadership can support a culture of safety? Well, I don't mind jumping in. First of all, hello, everyone. Thanks so much for having me. I'm excited to listen to this event and learn from this event. And I appreciate the opportunity to participate. I think that my first initial thoughts on that question are what leadership can do is explain the culture of safety, define what it means, set expectations, explain to our teams why this is necessary, how it's going to improve patient care. But I think leadership needs to take another step and really needs to both practice the culture of safety and model it. I can't think of any quicker way to ruin a cultural issue like that than not practice what you preach. So if you're going to say we want reporting, we want accountability, and then not handle the reporting well or not hold your own self accountable, you will completely devolve any of the efforts that you're trying to achieve. I heard trust in there. That sounds like a big one. A culture of safety definitely needs trust. Did you like, did you want to respond, Cassie? Cassie, I think you're on mute. Well, while you work on that, we'll go on to the next question. Given the team model of physicians, EPPs, PharmDs, respiratory therapists, and others, what is the most important factor to assure a culture of safety within this diverse group? And how that hierarchy sometimes can play into why people do or do not report what they see. Cassie? Okay. I'm going to go ahead, if you don't mind. This is, again, where communication really comes into play. The team dynamic and the way we communicate with each other on our team is going to be a critical make or break point on how we treat each other and how we move through the day. Breaking down that hierarchy is really important when we are looking into safety issues, quality issues. We all understand that there is a necessity of hierarchy at some point in medicine or many areas of our lives. It might come down to, especially in ICUs, might come down to an emergency decision and someone's got to make the call. But when there's time to communicate and have a healthy team dynamic, that's really what's going to help build the trust at the communication level and what's going to make everyone feel like they have an opportunity to voice their safety concerns or express when they think something's gone wrong without fear of retaliation or fear of being embarrassed, fear of being fired. So, we really have to have that good group dynamic with a lot of communication. There's really not a substitute for that as far as I'm concerned. Yes, I hear you on the difficulty that may arise in the critical care setting where sometimes things are happening at a rapid fire pace. Coming from a trauma critical care background also, one of the things that we have to do sometimes is to slow down, making sure that we are repeating, we're acknowledging, we're getting a call and response, we're making sure that we're closing the loop, you know, closing the communication so that even most importantly in those very rapid fire situations that we have to be even more intentional to really make sure that when the error margin is so slim that we have to be even more intentional. I really appreciate you bringing that to light. Thank you so much. Hello, everyone. Can you hear me now? Yes, we can. Yeah. You're there, Cassie. Great. Yes, I agree. In the collaborative environment between people, you need to recognize that I think that we need to appreciate the diversity within the team that we be able to communicate with each other and be able to hear each other. And even if there was a mistake or something happened, that there would be a chance to grow and find out what went wrong as opposed to creating some culture of fault finding. Thank you for sharing that. Thank you. Having been in the ICU with all those years with physicians and pharmacists and respiratory therapists, nurses, of course, I think we've stressed as a society the role of the team in the unit that patients and shown that patients get better care with the team. And I think, as Dr. Wright mentioned a little earlier, this whole idea of the buck stops with the leader of the unit, the physician, but there's a close communication and a camaraderie that needs to take place for this pattern of safety to happen. I'm as excited to hear you guys talk about that. Anyway, let's take another look at the system. This time, a question dealing with the system, and this is a question that I think is a quite honest one. Just with the short staffing issues that we have these days on the floors and the ICUs, how do you promote safety when the situation is frequently unsafe? Cassie, do you want to jump in on that one? I don't want to go first the whole time, but I will. I can take a stab at that one. I mean, with short staffing, it's going to be very hard. The team is definitely going to have to work together if you're going to want the care to continue to be the same, but you don't have enough people in place to give the quality care that you need. So there's no way, the first thing that I would do, even if I was still nursing or a practicing physician, people are going to have to work together. Because if they don't, there's no way that they can get things done and protect themselves. And the only way that they can do that is by working together on the floor, on the unit with their patient cares, whether it's a doctor, whatever healthcare worker it is, the only thing that they can do at that point is to work together to get it done. I totally agree. And I think it makes it even more important that the team is not having communication dysfunction, right? Because we don't really have time for these personal conflicts or arguments or what have you. And I think one of the, I don't want to call it a shortcut, but one way to streamline care that we all know is protocol, protocolization, right? I mean, we don't go into rounds without a script. Who rounds without a script? Imagine listening in your multidisciplinary rounds. You don't know who's going to chime in next. You don't know what system they're talking about. We all know that speed and efficiency is created when we do things pretty much the same or approach the same problem pretty much the same. So we know what order to go in and it's not chaos. So I think that's one way, in short staffing, how many of us have had to cope with just not having enough resources the way that we're used to. So when you think about these resource-limited situations, and I would even propose that we need to speak up and speak out, that people either are struggling or need help, that they make sure that if we are the proponents for no harm for our patients and no harm for our colleagues, right? So there's harm that occurs when an untoward outcome occurs as a result of a provider's mistake. So we have to, and sometimes people get pushed into doing more with less until something untoward happens. So in that communication piece, I really think we need to actually add on to that, that you have to speak up to say the staffing shortages are too critical. I need to hold off on accepting that next patient. I need to make sure that I get a moment to tuck in this person before you bring up another one. Just helping to use some air traffic controller skills to really help manage what's going on, and that might be something to include in your systems approach to staffing shortages. So given the diversity of cultures in our nation, what is the best way to assure safety in groups with cultural differences and communication variabilities? I know, Cassie, you work in this space where there are underrepresented groups that may not feel that their treatment for the same instances is not equitable. One of the things from the Joint Commission that can destroy a culture of safety is that if you preferentially allow one group versus another group to not receive the equitable distribution of, not necessarily resources, but the punishments or the addressing some of the concerns that are going on when there's a safety concern, if you don't address it equally, whether it's the hierarchy problem or whether it's an underrepresented group, how do you think, as an organization, as healthcare providers, that we could do better in this, and what should we be aware of? I think that we're going to have to be aware that the differences and the difference in treatment is going to be something that is going to not produce the just culture that we want in that environment. What's going to happen is that people are going to leave. They're not going to be able to retain those people, those certain groups that may or may not be a minority group in the situation. And really, the strength of the organization is going to be diminished when you don't have that diversity that you can learn from each other. One of the things that I tell minority groups that find themselves in their situations where they do experience that difference in treatment is that they do have to bring attention to it. They cannot just silently suffer. They have to say something. They have to speak up to whoever that person is in charge because one of the things that even if they were to file a complaint, if they have not told anyone, if they have not spoken up and maybe given the organization even a chance to cure what is going on, then they really don't have a strong case because the first question we're going to ask and that I'm going to ask even as an attorney representing them is who did you tell? What management person did you tell about what you're experiencing? The other thing is when you don't have the diversity and equity and inclusion in your organizations, you find yourself with a lack of really skills to treat everybody because really the patient populations are diverse and you really want that diversity in your team that are treating them. Yeah, it's almost like if you have those underrepresented groups within your team, it's sort of like homeschooling. You can coach each other on how to handle situations and avoid particularly tricky cultural differences that I think sometimes we as Americans assume and when you're talking cross-culturally anyway with different people of different nations and we assume certain things that we should not. But yeah, certainly an interesting topic and can be developed more. Just a reminder, those of you who may have questions, just get it in the question box there and we'll be able to take it. Next question, how do you ensure that you have all the necessary data and facts before an incident is escalated to the next level of administration? We talked about this as we prepared for it and we were talking about this is probably very good for people that are young in the career, may not know what the pertinent data is. If our panelists would address that, it would be great. Yeah, I'll kick it off. I caution everyone that you may not have all the data that you need and in a culture of safety, part of our fair and just culture, that should be okay. We can adapt this approach to quality issues just like we would with a critically ill patient. You may see a patient and think, hmm, I wonder if that patient's going to need to get intubated, I better gather more data. Well, at some point, there's a tipping point where it becomes very obvious and you just have to move forward and then gather that data afterwards. One thing that if you're leading your team or you're speaking with leaders of your team, I think it's really helpful to bring the information that you have because better being the enemy of good, you just might miss an opportunity to catch something or even to ask the right question. So I would much rather hear about something early on, be involved with asking the questions while gathering the data than hearing about it on the back end. So sometimes you can't and sometimes you don't need to. You need enough of a sense and you'll grow that barometer, if you will, you'll grow that barometer to say, I have enough information that I need to bring this forward. I agree with you, Wendy, with that, because sometimes you're not going to have all the data, like you said, and you need to really document as soon as possible because, you know, of your memory, you need to get things down. And the longer that you wait, you may lose data that you could have could have reported that might have been important. But as the time goes on, you know, you may forget and lose it. And so you want to get as much information as you can. And hopefully the system has a process of recording whatever data you have that makes it easy and that it's not time consuming, you know, for you to do what you need to do. Because most of the time when something happens, you know, it happens to maybe one patient or one person that you're taking care of and you have others that are waiting to be to be cared for. And so you really don't have a lot of time to put down everything. So you're going to have to get it started so that you can capture that information as quickly as possible, because the longer you wait, you can lose that data. Dr. Wright, I have a question for you along that same line about the escalating incidents and especially in relation to women physicians. Do you see, is there any data to state or support that women and the women physicians have more reporting or there is an environment where they get reported on a bit more than their male colleagues? So it's not an equitable environment? It's a great question. We've, and I'm very mindful of the fact that this is being recorded. I'll tell you, that's not a popular question to answer because individual institutions would then be revealing this type of bias. So that gets talked about a lot. And whether or not that's a true phenomenon, and I have my feelings about that versus data. I think I'll state for, you know, plainly as a woman physician, I feel like there are things that I might say that would be taken quite differently if it was a male colleague saying it. And I, you know, and I can't imagine what other people's experiences if they're from a different ethnic or racial background, but that's a common feedback that we get from reportees was, listen, I said the same thing that this male doctor said, and I don't see this male doctor getting called a task for it. Couple of, and I don't mean to be evasive on your question. I'll just tell you that it's a hard question to answer because it's hard to track that data because for a really important reason, these incident reporting systems should really be pretty tightly confidential. That's part of not blaming and shaming people. That's part of, I'm hearing, and these reports come to me at my hospital. I'm hearing, or I've gotten a slew of reports about a particular doctor, maybe perhaps a female physician. What, how, how that physician is being perceived is probably not in the light that they would prefer, and it's probably not in a way that's going to help them get, be successful in the system. So I try to talk with them more about why do we think these incidents are being reported? What can we reflect on? Because until we can change society, which would be a nice goal, you know, I have to, I have to control what's in my control, which is how I communicate with another person, and communication training is really helpful in that respect because it can help the, it puts a, we have a lot of responsibilities as, as healthcare leaders, as physician leaders, even just as practicing, you know, senior practicing clinicians. People are looking up to us, so we have a lot of responsibility to adapt our communication style to the listener, and we really need to, we need to do the best we can for ourselves so that we're not embroiled in conflict. If any of you've ever had an incident report filled out about you, I hear it doesn't feel so great. I hear it's very demoralizing and very hurtful. So while I, while I take into account the fact that our behavioral standards are different and we need to work to change that, when we're handling these types of issues in a fair and just culture, what we really want to do is help the clinician, help the reportee be successful. So what is that going to take based on their individual needs? I like that. I was, so what I heard was that there's some great opportunities to improve communication, learn different communication strategies and skills so that the, the environment that you're working in is mutually supportive. And, and then that way, if we have a good supportive culture, then we will be more likely to communicate better. And if we can communicate better, we can hopefully decrease some of the zero harm incidents that we're trying to achieve. So love that. Love that. Did you want to add anything else on, Cassie? No. Okay. Thank you. So what ways can staff protect themselves in legally high risk environments? That should be right up your alley, Cassie. Absolutely. Absolutely. That we need today. One of the main things that I'm going to talk about is documentation, but let me touch on the other ways that you protect yourself in those legally high risk areas that you find yourself working in. One of the things that you need to do is know your state's nurse practice act or your medical practice act or whatever your licensing agency is. Know what it says. It needs to be your Bible for work. Because a lot of times I find that practitioners, they don't even understand what that nurse practice act says or what that medical practice act says. And they need to know because it's going to set the stage because not only does it license you, it also disciplines you because that act is there to protect the public from you. The other thing is know your scope of practice. Because that act is going to tell you your scope. It's going to tell you how far you can go. And a lot of times when you find yourself in those legally high risk environments, you're going to be pushed to do things that you normally do not do, that you normally would not even be asked to do because of whether it's short staffing, whether you can't reach whoever you need to reach to get what you need. And you find yourself having to make a decision, you know, should I do this or should I not do it? And if you know your scope, you're going to protect yourself by not operating outside that scope of practice. The other thing is know your job description. You were hired. They gave you a job description when you got hired on. They told you what your expectations or what their expectations were for you when you took that job, whether you know that you take call or you don't take call or what hours you should be there, how many hours they expect you not to go over. You know, so this is important too, to know your job description. The other thing is to know the hospital policies and procedures, because even if you have your own malpractice insurance, which that malpractice insurance coverage covers your license and the defense of your license, and especially the healthcare workers, a lot of times if you are within the hospital's policies and procedures, the hospital attorneys, they will protect you because they're protecting the entity, the corporation that you work for. But if you are violating hospital policies and procedures, you are going to find yourself needing some extra insurance because you may not be covered and you may find yourself out of a job. So you need to find out what the hospital policy says about different things that you may find yourself in, in that predicament, in that crisis. The other thing is document timely. Make sure that your documentation is thorough, that you do what I call defensive documentation, and make sure that you understand that, you know, somebody else is going to be looking at that record. That once you write it down, it no longer belongs to you. You can't erase it. You may strike through and correct errors, but it's not, it's not yours anymore. That once it's written down, it is a part of a legal document and that other eyes are going to be on that documentation. And all documentation has an audience. You just don't know who's going to look at that documentation. And so you have to understand that it's a part of the legal record once you put it down. And a lot of times the cases may take years to come down the pipe, depending on when they filed the suit. Most states, medical malpractice is a two-year statute of limitation, but they have time to file the last day, which means it's going to be even longer than two years. And your documentation is the evidence that you need to defend your case. That's what I defend your case with, the evidence of what you wrote down. And so you need to write enough so that even if we show you what you wrote years later, it's going to refresh your memory and you kind of can remember. I'm not saying to write everything because of course, you know, you don't have time, but you need to be thorough enough to know that you may have to look at it again. And somebody else definitely will look at it because it's a report and it's a recording thing and it's evidence. So that documentation is going to be very important. You know, we say that if it's not documented, it's not done. That's not true either, because we can, you know, put together something to help you and defend your case. If you have something, what we call is habit. What do you habitually do in your practice? A system that you know, you follow these steps every single time and that cuts down on you making mistakes because you can make an error. But if you have a practice that, you know, I always do these things when I see my patient, then you're going to protect yourself if you do it the same way every time. So that's the first thing that I, I mean, those are, when I looked at that, I wanted to make sure that I gave you something that you could take home with you. Um, but you need to know that, um, the other thing is the last thing that I will leave you with when I thought about this question is try not to do what we call to use workarounds. You know, when you, uh, do workarounds, these are behaviors that are designed or created to work around or circumvent a workflow because these are things that you think hinder you from giving good care. And so they're put in place to protect you. But, you know, just like, you know, I think we're going to talk about the Vanderbilt case. You know, there was a workaround where she could go into the system and try to get a medication and override, you know, what they need to do. And we find ourselves doing that all the time, you know, trying to get good care to your patient. But those when you work around and you circumvent a system that's already put in place to help you, you're going to find yourself taking a risk. Thank you so much. That was very powerful, very informative. Thank you for the time for sharing that with us. So I can't, I can't do a better job answering that obviously. And I shouldn't be able to, um, I'm going to add one soapbox issue, one tiny little shadow of soapbox issue, because I know my, I know y'all, I know my people. I have another one. Um, take care of yourself, care for yourself. So you don't make those mistakes. Like Cassie saying, you don't run out of time to document, or you don't follow your pattern or you don't, aren't tempted to do your work around sleep, exercise, self-care. And we don't do that. Right. I'm, I'm, I'm the, I'm a bad example. So I'm saying do better for yourself, because you'll do better for your patients when you're doing better for yourself. Thank you. Thank you for sharing. Self-care is, is the best care that we can put your oxygen on first. If you don't put your oxygen on first, definitely. Well, we're going, I'm going to kind of, we've got a question here that I think, kind of, um, I've got a couple of questions coming in here and I'd like to kind of field these as they come in. Cause I'd like to get answers for our, for our audience. Uh, the first question is, um, how do you promote a culture of no blaming during the morbidity and mortality conference? Certainly. Um, yeah, we've all been there and done that and seen it done. Um, so what, what, what, how, what, how would you suggest to avoid that the blame culture there in that setting? Immediate fix. Rename your conference. Rename your conference to a quality assurance conference or a quality evaluation conference. Morbidity and mortality is, was designed to be blame and shame. It's culturally entrenched. Unfortunately in our, in our healthcare society is blame and shame. Rename your conference. That's the easy one. The hard one is setting up the hard work of an organizational structure that's very consistent with the fair and just culture. So immediately when cases come in and cases should come in, you don't, you don't want to work in a system that has no incident reports, right? Because it means people are hiding things from you. When a case comes in, have a, have a standardized way so that you're not reporting more women or more people, you know, um, people of color, something like that. Standardized way to look at the case and sort it out in a way that makes sense for your institution and your role. Is this a system issue? Is this a human issue? And if it's a human issue, is it human error? Is it at risk behavior? Is it reckless behavior? And there are, there's a lot of literature about how to approach each of those particular problems. But the easiest thing I can tell you is rename that conference, rename it. Um, when that's what people think of when they are more admitted in mortality, you can make a nice clean break, say this isn't, this isn't blame and shame. This is to help us all improve our patient care. Um, there are going to be some, some healthcare providers that are really entrenched in the old way of doing things. You can teach them, you can wait them out. Um, uh, there, you know, they're going to, they're going to retire, uh, sooner or later. Um, but, but right, morbidity, morbidity and mortality conference is notorious for being this uncomfortable, nonproductive system. Uh, and so just, just do better evolve it. Yeah, that's certainly, certainly low hanging fruit there. It's all in the marketing, right? Yeah. So I'm sorry, somebody else was speaking. Oh no. I was just saying that one of the things that we did was to add on a social determinants of health, um, in our conference to, um, be, be intentional to look for what may have contributed that were, was maybe beyond the scope of their, their readmission or whatever may have happened. Um, and their outcome to see was there some component of that, that may have been, um, uh, important. Um, and some things that we look at are, uh, we, you know, we do our cam ICU score and we're, you know, looking to see, um, you know, when we're doing that, are we using the appropriate medical interpreter? You know, are we, you know, are we able to assess, we know that that affects a patient outcome. So are we using strategies to really help ourselves be, uh, give the patient the best care possible by being able to communicate with them, communication. Definitely. All right. Um, next question. Um, um, Cassie, you've talked about this a little bit, but let's flesh this out maybe just a little bit more. This is a little more drill down, maybe a little more specific. Um, how does one consider documentation after an error is incurred? What should be in the electronic record versus an informal peer protected communication? Yeah. Yeah. So, um, if you're looking at the electronic record after, um, an error has occurred, you want to make sure that, I guess, the first thing you do is tell what happened, who were the players, who were, who was there, you know, who was the patient, who were the other people involved, you know, the witnesses to it, because like I said, you want to document as thoroughly as you can. Um, after something happens, the other thing that you need to do is, um, tell what happened right before that, the, um, the, the error, you know, what happened, what were you doing? Um, so we can look back and once we are trying to do a root cause analysis or whatever, we can see, you know, how many patients did you have? What were you doing? Did you run into the room? Were you helping someone else? You know, were you doing something else and then you were diverted to go to that room or to that patient. And so you want to make sure that you tell what happened right before the incident happened. Um, make sure you tell the players, like I said, and list everybody that, you know, had a part or played a part. Um, and then the other thing is when you did something, uh, did you come back and check, you know, make sure you're thorough. Like if you gave somebody a pain medication, did you come back and check and see, did it work? Um, when you gave a medication and you need to stay there and make sure that there is no, you know, adverse reaction after they gave it, you know, you want to position yourself that, because what happens is the documentation that you make right after something happens, it is going to defend you. It is going to show us that your skills were up to par. It's going to show us how you were thinking. What were your, what was your judgment like? What was going on in your head when it happened so that we can make sure maybe that it doesn't happen again, or maybe it will justify your actions. Because I tell you, just because something adverse happened doesn't mean that something, somebody did something wrong. And a lot of times we think just because something bad happened, somebody did something wrong and that's just not true. So after an error occurs or after an adverse event occurs, make sure that you list the players, make sure that you make sure that you tell what you were doing right before it happened. You know, give us a little bit more detail, and then tell us what happened, what happened. And then how did you respond to what happened? Did you automatically notify your supervisor or your charge nurse or whoever that person is that you need to notify? And see, these are the things that we need to have in place before something adverse happens. We need to be walking our people through. If this happens, this is what you do. This needs to be an in-service, not something that we create afterwards. That's what I would say. Very, very nice. Very nice. Thank you. And along that same lines, as we are moving into a space where, you know, we had a period of time with COVID where we didn't have families around and they weren't included in the rounds like we used to do. And now that we, you know, brought families back in because we know the critical role they play as a patient advocate and helping us as providers of healthcare providers to see things that sometimes that we don't see. So, you know, they play a significant role. So what is the best way to import a feeling of safety to patients and families so that they know that when something has occurred that we aren't trying to cover it up. We're trying to learn from it. We're trying to grow from it and we're trying to keep them as informed as possible. How do we address families so that they know when an error has occurred? We're just going to have to be very transparent about what happened, be very honest and open. And you know, hopefully that will not be used against us. Most people if they feel like you're trying to be honest and open about what happened with their family member, they are unlikely to sue. They're unlikely to go after you because they know that you're not trying to hide something from them. A lot of times the cases that I have, especially in malpractice cases, when I was doing that, people sued because they wanted to know what happened, what happened. And a lot of times, you know, especially back in the early 2000s and before that, you know, doctors, they had this perception that doctors were perfect, that doctors didn't make mistakes. And then I think doctors, you know, upheld that view, you know, to the patients, even, you know, to the family that, you know, if they said, you know, this is what's going to happen, but we don't know, we can't predict what's going to happen. And sometimes we can't predict the outcomes that are going to happen, you know? And so even the best doctors are going to make mistakes because we're going to, we're going to make errors, right? Because we're human. And so if you find yourself, you know, in a position with family members and something happened adverse, you need to be honest and open with that family so that they can trust you. Because one of the reasons why they sue is that they don't trust you and they want to know what happened. Thank you. That's great. That's great. I've got another question here from the audience. I'd like to kind of chip in here. What does the reputation of a hospital, does that, does the reputation of a hospital influence the needs of the providers? In other words, I guess they're asking if the hospital has an exceptional reputation or the opposite of it does not have a good reputation. Does that put the providers at risk, additional risk? Yeah, I'm dying to hear Cassie's answer to this. So I'll just jump in briefly and say that just like, no, I mean, I'll be short because just like, just like most of us, we, you know, we live and die by our reputation as professionals, reputation is really everything. And so the highest performing hospitals should be the ones that are the most transparent and most open about their mistakes because they're excellent because they're trying to improve themselves constantly. And that's really the entire point of the culture of safety. Certainly a big mistake, a public mistake can really degrade the reputation of the hospital. Even in a, you know, some people even put them in the chain of the, you know, the first victim of medical malpractice or second, that tends to be the third victim, the hospital reputational injury. And that's a big deal that can really degrade public trust in a quick, in one fell swoop, basically. Yeah. I mean the reputation of the hospital is just like the reputation of the provider. But you're going to have all types of providers working in all types of facilities. You know, the hospital can have a great reputation and they can still have providers that are operating below the standard of care. The standard of care is going to be the same no matter what facility you go to. We are going to expect that that doctor is given the same type of care that a healthcare worker in his same or similar situation that is reasonable and prudent is going to give. Yes. I would think that the reputation of the hospital more so than not affects the community, the patients and their trust in going to that facility. At that facility, you know, if they say, Oh my God, everybody that goes to that County hospital, they die, you know, but everybody that goes here, they live, they have a fighting chance. I think it's more of a trust of the patients in the community. But if you are a provider working in, um, you know, a hospital that may not even have a great name, that's not going to really affect you unless you don't have the resources that you need, you know, because you are in that hospital. But if you are giving the standard of care, I don't care where you are, you're going to be protected. Your license is going to be protected. You're going to be respected. And what they're going to say is, you know what? I don't like that hospital, but I love those providers. They have great nurses. They have great providers. Go see Dr. So and so on. So that's what they're going to say. Hmm. That's a, that's good advice. Yeah. Um, just for clarification has Dr. Green left us. Looks like it. Okay. Um, let's talk a little bit about the situation at Vanderbilt. Um, do you observe that, um, staff have become less willing to report errors since the Vanderbilt incident and the legal fallout thereof? Maybe, maybe give us like a little, those of us that don't know that much about it, give us a little rundown on what happened at Vandy and then just kind of answer the question after that. Okay. So at Vanderbilt university hospital, there was a nurse and, um, she was taking care of a patient, um, that, um, had to go down for a PET scan. And, um, anybody know the PET scan, how you can be anxious because you're going to be pushed through this machine. Okay. And some people are claustrophobic. Well, the patient complained that she was claustrophobic. And so, um, the nurse who was taking care of her, um, she didn't have time to, um, go and give the medication they wrote for her to have Versed. Um, and so what happened was, uh, you know, to calm her down, of course, you guys know what Versed is. And so when they wrote for the Versed, the nurse, um, that went and got the medication out of the, um, PIXIS or whatever that machine is, you know, that they were using, I don't know the actual name of the dispensing machine, but you guys know we're familiar with it. Um, when she went to get it out of the machine, uh, she could not find it. Um, the order was just written and like the timing that they wrote the order. And for her to go down to, uh, radiology and give this medication, I think she missed it. So she went in and I guess went to find the medication. It was not under the patient's, um, you know, drawer or whatever when she opened it. And so she typed in VE. Okay. When she typed in VE, uh, Vecoronium, which is a, a paralyzing drug, um, it came up, she didn't type in VEC. She typed in VE. She grabs the drug. Um, it has a warning label on it that, you know, to be careful with this drug, it has to be constituted. As you guys know, Versed does not. And so there were a couple of steps that were missed, um, where she didn't look and read what the actual drug said. Um, um, because you know, Versed, you know, is two different drugs. Um, and, um, the other thing is most of the time, you know, the drug, um, is not even in the machine under that name. It's under mid mid, is it midazolam? Um, it's not under Versed. Okay. And so either way, she, she didn't get, um, she got the wrong drug. So she goes down and she has to constitute it and give it. And she gives it to the patient and she leaves. She doesn't even stay after she gives it. And they, she ends up going out and they, they called the lady and she ends up literally, um, not long after that she dies. Okay. Um, one of the things that the prosecutor said was, you know, she did not follow the right, you know, the five rights that every nurse knows, you know, right patient, right time, right dose, right drug, you know, on that, you know, every nursing student knows she did not follow that. She did not pay attention to the red label that was on the drug. And so she ended up, you know, getting, um, convicted, um, and they were going to sentence her to reckless, um, negligent, um, I think it was reckless endangerment of the patient. Anyway, what happened was thank God she actually got, um, on probation. And, um, we had a lot of, um, institutions, um, respond even my organization that I'm a part of Tana, the American association of nurse attorneys. Um, we're trying to put together, you know, a statement, but the bottom line is, you know, our nurse is going to be criminally prosecuted for making a medication error. Because as you know, in me just telling you the story, there were a couple of system errors that were flawed, um, where she, yes, she did make a mistake, but as you see, you know, she should not have been able to override and get that medication, you know, and maybe it shouldn't have even been in that dispensing machine. You know, um, it's, it's just so many things that happened in this case that, um, it was a uproar because of the fact that nurses are now saying, wait a minute, if I make a mistake, I could go to prison, you know, and even if you don't go to prison, just the stress of going through a three day trial, can you imagine? Um, and so, um, she was fired and then she also, you know, lost her license, you know, in the state of Tennessee. So that's just, you know, quickly, uh, what happened. Yeah. And, uh, I'm glad you had to summarize that, Cassie. Um, but Rob, right. And I saw, I got to see Rob's face as he was hearing the story. So Rob, the twist was the criminal prosecution. And this isn't, this is very uncommon, obviously, but there was a case a couple of years ago of a pharmacist who was criminally prosecuted for a medication error and went to jail. I mean, so these, it's not, there's risk. That's why we need to do our best. We have to do a good job. We have to be careful in all the advice that Cassie was giving us earlier about knowing our, our licensing, um, uh, requirements and knowing our scope of practice. Um, the, but, but this, this put Rob, you would have, this put a chill. I mean, this is all we talked about for a couple months, um, you know, in, in between our, in between our clinical demands, I've heard a lot of chatter about from people saying, oh, I'm not going to put anything in then. I'm not going to do the safe report. I'm not going to do the, I'm not going to tell anybody if I made a mistake that was, I think that was part of a grieving process for us all. Um, I think that our, I'm hoping that our, our ethics as a health, as healthcare professionals will make us realize that we need to do that because we need to do better next time. Um, and I'm also hoping that, um, that as time wears on, people will start to feel safe again, but that really was a big setback to have a criminal prosecution within our, with our own people. I'm the daughter of a retired nurse. So this, you know, every pretty much everyone I love minus, you know, one or two people in my world is works in healthcare. So this really does, was really just a big shock to the system. So I hope it's not going to decrease the incident report. And it almost doesn't matter because if you're really familiar with the case, you'll know that one of the twists was a whistleblower. So we, the, the walls have eyes, you know, we're, so it, we, this case really broke open because of a whistleblower. So you really don't, that's the last thing you want to do, right? The classic, it's not the crime, it's the coverup. This really was the coverup, I think that led to the public outcry, um, that, and perhaps that was one of the motivators for the criminal, the criminal charges. Yeah. And the other thing is there was no scanner to scan, you know, how we're familiar with scanning the patient's badge with the medication, um, for whatever reason, the scanner was not working. So you see there were multiple system failures for those of you that may not be familiar with, you know, why we say the system failures were important in this case as well. Not that the nurse should not have been alert, not that she shouldn't have followed her five rights. But what we're saying is there were, there could be systems in place that could have prevented even her in her error that maybe this patient would be alive. Because maybe if she could not have even accessed that drug with just typing in V E and being able to override the system and get it out. Yeah. Yeah. It seems, it seems that way. I mean, you should have to spell out the entire word basically. Yeah. Yeah. And not let the machine default into pull down menus and such. Okay, cool. Um, all right. Um, let's see, we've got, um, about six minutes left or so. Um, one of our questions here is, um, would you each address, uh, the second victim syndrome and the impact it has on personnel? Yeah. So I don't mind addressing it. Um, that second victim, um, the reason why that we even call it the second victim, because as you know, in medication error or any adverse reaction, we're here to take care of patients. And at the end of the day, we're here to keep our patients safe and give good quality care. So the first victim is going to be the patient. Um, but what we do is we overlook the fact that the second victim is that healthcare worker who, when they make a mistake psychologically, they have to deal with that. You know, even with this nurse, she blamed herself and she kept saying through the trial, they said, you know, I know that if it hadn't not been for me, this patient would be alive. And you guys know that I don't care if you did the right thing, you feel some kind of way as a healthcare worker. When your patient dies, I am 54 years old. And I still can tell you as an army nurse, when my first patient died, I know the, the name of this woman still, I know how I found her. I did nothing wrong, but it still upset me because my patient died. And to me, you know, we don't look at dying as a, as you know, a part of life because we're there to help save or extend lives. Right. And so that second victim, it literally, you know, plays in your head over and over again. What could I have done differently? What did I do wrong? You're blaming yourself, you're guilty. And with that second victim syndrome, we have to look at nurses and doctors and any healthcare providers and say, how can I help you? See, that's where that just culture comes in because there's a balance is not no culture. It's not no justice where you can be reckless and you can not do what you need to do as a healthcare provider. We're not talking about that, but we're talking about somebody that really was trying to give good care. They made an error and can we take care of them and give them the help that they need to make it through so that they can continue providing good hair care because we need healthcare workers to stay in the field. And so we need to come alongside and give them what they need to heal. One of the first things that I would tell a healthcare worker is to forgive yourself. That's one of the first things that you need to do before you can even heal and move on. And I'll just go ahead and let Wendy finish that. Yeah, that's great. It's a very, it's a complex moral injury. It leads to all these symptoms, including physical symptoms that can be very much like PTSD. It's what contributes a lot to our risk factors for substance abuse, for suicide, for divorce. So this is, you know, the wounded healer is a really scary phenomenon and we've got to work to get a handle on this. And I just want to read a, I want, I can't describe it better than this nurse. Let me just read a really brief statement she made after sentencing. I will never ever forget my role in this. I don't know what else to say that would make anything different. I'm very sorry for what happened. I've lost far more than just my nursing license in my career. I will never be the same. When the patient died, a part of me died with her. And sadly it was too late to change her outcome when I made my mistake. So this is, you know, nightmares, rumination, depression. This is a, this is a really serious problem and needs to be addressed and needs to be talked about openly. God, that's really good. Thank you. Thank you for all of that. And I love the emphasis you gave on protecting the providers. Again, we need everyone. And these are conscientious mistakes, you know, and that they happen. So we've got one last question here. I'm going to call it up from the audience and I'd like to get to it. Okay. This is, this is a, yeah, this is a little tricky. If you are working in an under-resourced facility and as a provider, this person happens to be advanced practice nurse, but we can APP or doctor or whatever, would upholding, would it be upholding the standard of care to inform the patient and family that should try to go to another facility? Perhaps since this, you know, this other facility has better resources. So, so let me just say, it really depends on what you mean by error, right? So if I'm taking care of a patient and their potassium is 3.7 and I write down that their potassium is 3.8, that's an error, right? It didn't cause any harm. It's completely inconsequential. Not saying I should, I should do better. I should pay more attention. But, but error is very tricky. And then I'm going to let Cassie handle the standard care issue. Yeah. I mean, I don't care again, where you are practicing and you're saying that you don't have the resources, I guess, to provide the patient what they need. That sounds more like an ethical question of you and your place that place that you're working. If you feel that strong about it, you know, why are you still working? There is my question because that means maybe your license is in jeopardy, you know, because you, you don't have what you need to provide good care. You don't have what you need to provide safe care, you know, because, you know, even a hospital that doesn't have everything that they may need to provide for a patient, they're going to take them to the closest place they can stabilize them before they send them, you know, elsewhere. And so hopefully that, you know, wherever you are, you know, they are following the standard of care, which is what a prudent, reasonable doctor or healthcare worker in your same or similar circumstances would do in this case with this patient, with the care that you give. And so if you feel that you have to tell this patient, listen, I can't care for you here. You could go better. Now that would be different if you're home, right? And you're telling your family member, I don't want you to go to hospital A, I want you to go to hospital B and you know, people, they do that. You can do that. But if you're actually working and you're taking care of someone, you know, I don't know what to tell you because you know, that sounds like something ethical that you're going to have to, you know, say within yourself, you know, am I right for doing this or can you take care of this patient? Can you give them what you need? You know? Right, right. Well, thank you so much for all of that. And you've given us so much to consider and think about. I'd like to thank Dr. Wright and Ms. Williams for being with us today. This has been an outstanding presentation, certainly a lot of thought provoking things. And so please be on the lookout for more professional development, educational tools, and networking opportunities coming from the LEAD committee in the near future. If for some reason you missed today's, the LEAD's previous podcast, the science behind building a high performing team, it's now available online. And as a reminder, this webcast was recorded and will be available for registered attendees within five to seven business days by logging into mysccm.org and navigating to the My Learning tab. So again, I'd like to thank everybody involved and we just look forward to things coming in the future. At this time, we'll close the webinar and everybody have a good rest of the evening and hopefully a good weekend coming up.

culture of safety

leadership

communication

teamwork

documentation

transparency

trust

second victim syndrome

Vanderbilt case

patient safety