The Surgical Mistake and the Bad Decision That Followed: Dr. David Mayer

The Surgical Mistake and the Bad Decision That Followed: Dr. David Mayer

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My guest for Episode #70 of the My Favorite Mistake podcast is Dr. David B. Mayer. He is both the Chief Executive Officer of the Patient Safety Movement Foundation and Executive Director of MedStar Institute for Quality and Safety.

In today's episode, Dave shares a compelling story from his time as an anesthesia resident. What happened after the surgeon cut into the wrong side of the patient? Was the coverup worse than the crime? What did Dave learn from this incident and the pressure to keep quiet? How has this inspired him to be a patient safety leader?

Questions and topics include:

  • Lectures now about how to respond to harm… how do the students react?
  • The book Wall of Silence about the harm caused by medical errors
  • Patients want the truth – parallels to the Garrison Brothers episode
  • CANDOR program
  • How do mistakes like this happen?
  • Culture? Feeling safe to speak up? Can’t just demand candor?
  • Just Culture
  • His ZERO hat — How many patients are harmed or killed by preventable medical error each year?
  • Moon Shot?” Video
  • What would you do if you were made Patient Safety Czar?
    • 1) Committee to talk about the moon shot 
    • 2) National patient safety authority like NHTSA or aviation
    • 3) Incentives better aligned around patient safety & quality
    • 4) Transparency 

Scroll down to find:

  • Video
  • Quotes
  • How to subscribe
  • Full transcript

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Quotes:

"It was horrifying to all of us. I never been involved in a mistake, a medical error that had harmed a patient."
"When we hide errors like that, when we bury them within our own little silos, we don't learn."
"The mistake that I've lived with for 35 years has shaped my career in many ways."

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Automated Transcript (Likely Contains Mistakes)

Mark Graban (0s):

Episode 70 Dr. David Mayer, CEO of the Patient Safety Movement Foundation,

Dr. David Mayer (7s):

It was horrifying to all of us. I never been involved in a mistake, a medical error that had harmed a patient

Mark Graban (19s):

I'm Mark Graban. This is My Favorite Mistake. In this podcast, you'll hear business leaders and other really interesting people talking about their favorite mistakes, because we all make mistakes, but what matters is learning from our mistakes instead of repeating them over and over again. So this is the place for honest reflection and conversation, personal growth and professional success. Visit our website at myfavoritemistake.podcast.com. For show notes, links, and more, you can go to markgraban.com/mistake70, please follow rate, and a review. If you like this episode, it's a very important, special message.

Mark Graban (1m 1s):

In today's episode, please share it with a colleague, share it on LinkedIn that would really help spread the show. We're joined today by Dr. David Mayer. He is the Chief Executive Officer for an organization, a non-profit called the Patient Safety Movement foundation is also the executive director for the MedStar Institute for quality and Safety, MedStar of course, being a health system. So, Dave, thank you so much for joining us. How are you? It's great to be here and we're going to hear your story and then we'll, we'll talk about the work you're involved in and we'll call this a teaser for those who are watching on video, or I'll say it out loud for those who are listening, we'll find out later what your hat means, why it says zero in big bold letters this year.

Mark Graban (1m 48s):

Yeah. So first off in the category of sharing, if you wouldn't mind, David, if you could share your story, what do you consider to be your favorite mistake?

Dr. David Mayer (2m 1s):

Well, I don't know if it's my favorite Mark, but it's one that I think changed my life dramatically and had an impact on the work I done for the last 20 plus years. And it really, you know, involve patient care. So as, again, as a physician and anesthesiologist in the operating room, I remember being a senior resident and bringing a patient into the operating room for what was to be a right-sided inguinal hernia. You know, I did my thing. I put my monitors on the patient. I made sure the patient was comfortable on the operating room table. And once we were set to go, I gave my anesthetic drugs.

Dr. David Mayer (2m 42s):

The patient went off to sleep. Then as soon as I finished my induction and said, okay, patient's stable. The surgical team immediately went into action. You know, prepping, draping, getting the room moving because as we know, speed is the essence. The more cases you can do in an operating room on a daily basis, the more profitable ass it is. So we move very quickly into the procedure and we get to the time when the surgical resident, the senior surgical resident was getting ready to make the incision. I was again in my world doing my things, charting my vitals, everybody else was in their sort of little silos.

Dr. David Mayer (3m 26s):

The surgical attending had been detained at the scrub sink by another surgeon on a question of a different patient that they were discussing. And at two minutes after the incision was made, the surgical attending walks in the room, walks up to the scrub, walks up to the operating table and looks down and says, I thought this was a right sided. England on hernia re the surgical resident on the knowings to me. Cause I wasn't paying attention, made the incision on the left side and had gotten about two minutes into the procedure before realizing the mistake was made.

Dr. David Mayer (4m 7s):

It was horrifying to all of us. I had never been involved in a mistake of medical error that had harmed the patient. The surgeon surprisingly was very calm. The resident was shook. It, the resident had to go sit on the chair in the corner, the impact of making that mistake really impacted them. So the surgical attending and the intern who was scrubbed in on the case, proceeded to close the wound on the left side, go to the right side, fix the hurting on the right side. And now at the end of the case, the patient had two surgical dressings, one on the left and one on the right woke the patient up under, you know, from my general anesthetic, the patient was very drowsy, but I took the patient to recovery room and I dreaded having to go back there in an hour to discharge the patient.

Dr. David Mayer (4m 58s):

It was always the anesthesiologist. You know, it was our job to discharge the patient. Once we felt they were stable after the anesthetic hour goes by and I get called to the recovery room. And as I'm heading to the recovery room into the bed where my patient's located, I noticed the patient's got a smile on his face and that's not making sense. So I get to the side of the bed and before I could say anything, the patient goes, today's my lucky day. And now I'm totally like deer in the headlight. Look, I'm just really confused. But as a good resident, I don't say anything. I'm just listening. And the patient says, yes, today's my lucky day.

Dr. David Mayer (5m 39s):

My surgeon discovered under anesthesia. I had two hernias and was able to fix both of them under one anesthetic, meaning Alli missed one day of work. Today's my lucky day. And I, I didn't know what to say. I was totally shocked and I paused, it seemed like an eternity. It was probably about five, 10 seconds. And I looked at him and I said, yes, today's your lucky day. And I signed that patient out. I still remember that case 35 years later. I remember that. And his face, he was in about five foot 11. They had a Tom Selleck looking mustache and it, it just really, you know, impacted my career.

Dr. David Mayer (6m 23s):

I hadn't heard about medical errors. We had gone through, I'd gone through four years of medical school, learning all this science learning a lot of clinical. I spent almost three years in anesthesia learning all the different anesthetic agents and techniques. None. No, no one ever talks about what happens when we make an error. What happens is when we harm a patient, I had never had a lecture like that. I also never had a discussion about what do we do and how do we respond to patients when air occurs? And so the, the term, the hidden curriculum sort of goes into play where you just follow the leads of what others do.

Dr. David Mayer (7m 6s):

And, and the role model that day. For me, if you want to use the term role model was, you know, deny and defend, was lie about it, how to get away with it. Don't share this and keep it within our little world. You know, me as a resident, the fear of losing my residency, the fear of medical malpractice, what would happen to my license, knowing that I was involved in this case. But I was only thinking about myself. I wasn't thinking about not only what was the right thing to do for the patient and being open and honest. But when we hide errors like that, when we bury them within our own little silos, we don't learn.

Dr. David Mayer (7m 48s):

And so what happened for years, we continued to have wrong sided surgery in healthcare. We still have it today because we haven't figured out solutions. We've gotten better with timeouts and checklists and marking the sites, but that only started coming because people started talking about their errors. And so that's why a lot of my career has really been focused on trying to understand safety, trying to understand why we make errors to err is human is the Institute of medicine report said, but how do we more importantly, put systems and processes in place that trap those errors before they occur. And I like to use the analogy that pilots in our research study make about one air every hour or two.

Dr. David Mayer (8m 35s):

They either repeat something wrong. They think they heard something differently, little things like that, but they have so many processes and systems in place that these errors are trapped before they move forward or potentially lead to mishap in the cockpit. And we're not there when it comes to safety within the environment. So the mistake that I've lived with for 35 years, but it has, I think, shaped my career in many ways.

Mark Graban (9m 4s):

And you know, and I, I appreciate you, Dave, you know, for being willing to tell that story, you know, I think, and there's a lot of followup questions that I've got jotted down here. I think there's, there's so much we can unpack from this specific mistake. And, you know, some might say, well, you know, it was a mistake to not speak up or I've heard people sometimes get really judgmental and say, well, that that nurse should have spoken up or that pharmacy tech should have spoken up. You have an obligation, but you've already pointed to things like hierarchy. And what's sometimes described as a culture of fear. I wouldn't fault you for, for not correcting the surgeon or the attending or, or correcting the patient.

Mark Graban (9m 51s):

I would frame it as, you know, you being put in a bad position. So how do we avoid doing that in the future? I know that's, that's been a big part of your mission. Can you talk a little bit about, you know, trying to change some of that culture, the education, the way people are behaving?

Dr. David Mayer (10m 8s):

Yeah, I have. And it's why I've been so involved in the CANDOR program, CANDOR's communication and optimal resolution. I was fortunate enough and look that story. It took me 19 years to share that story. And the first time I shared it was in 2004 in front of a group of medical students. So we're going through a patient safety lecture within our curriculum. I was the associate Dean for the medical school at the University of Illinois. And it put a patient safety, quality care curriculum for year longitudinal curriculum into the student's learnings while they were with us. And I shared this story for the first time after 19 years, because I had read the book Wall of Silence by Rosemary Gibson the year before.

Dr. David Mayer (10m 55s):

And I read this book in a weekend, it's a great book. It talks about what patients and families want after they've been harmed from preventable medical errors. It's not about root cause or event reviews just as what did that family want, or what did the patient want from their hospital, from their physician? And there were clearly four things that every all 75 families echo at first, they wanted the truth. They wanted their questions answered. They didn't want to have to run to a lawyer, try to get information that they felt they was deserved when hair went in a direction that nobody had anticipated.

Dr. David Mayer (11m 35s):

So honesty, second thing they wanted was an apology when appropriate, if they had hospital or they have care team had not lived up to the care standards and that arm was preventable, then they wanted some empathy and an apology. Third, they wanted, there's a lot of times issues that need to be dealt with after the fact, sometimes it's financial resolutions. As we see in courts of law for care plans and other things, many times we found at the university of Illinois, and I think it was 69 of 75 cases that we use, the seven pillars model, just the apology and being open and honest and answering questions was enough.

Dr. David Mayer (12m 17s):

It wasn't like, okay, now we want a hundred thousand dollars just to make us feel better. No, those families moved on. Did they say they never wanted to see us again? Did they share that they never wanted to see our hospital again? Yes, but at least that brought closure to them. And finally, the fourth thing was what are you going to do to improve your hospitals? So this doesn't happen to somebody else. And that were the four things I learned that from Rosemary's book. And it really, again, was something I was looking for in my soul searching of what I should have done. And so that became an impetus for me and others at the University of Illinois, when we brought Rosemary in to start our seven pillars program, which was one of the programs that eventually led to the CANDOR communication, optimal resolution.

Mark Graban (13m 6s):

So you you've touched on, I mean, it sounds like one of the big systemic changes is that the education system for physicians has changed maybe. I mean, how consistent is that education about harm and patient safety and medical education today

Dr. David Mayer (13m 24s):

It's gotten better. It still has a lot of work to do. Look, you know, we always, when I was the associate Dean, we always had a saying that assessment drives the curriculum. And so students would always say, is this on the national boards exam? Is this on the final exam? And if safety and quality are not embedded within those, you know, really high stakes exams, then they're not going to study it. They're not going to pay attention to it. You're going to think it's just something that isn't important. It's the anatomy, the biochemistry, the, you know, congestive heart failure algorithms that they're going to get tested on. So I think we still have a long way to go.

Dr. David Mayer (14m 5s):

I will say that the ACGME on the residency side has been pushing this and training within residency programs has become a lot better, but we still haven't taken it down really into, you know, medical school and nursing schools the way we should. Yeah.

Mark Graban (14m 21s):

How did the students react when you told that story and did they react the way you expected? What, what did you predict? How did they react?

Dr. David Mayer (14m 31s):

They were somewhat shocked. I mean, it was very quiet in the room. You know, it was sort of opening up and sharing that. But remember, you know, students, especially in the first couple of years are very clinically naive. They haven't been on the floors of the hospitals. They haven't seen things that go. And so we sort of, as students, they start off with such a great mindset and they start off with wanting to always do the right thing. And then the clinical environments in the world that they get into, like me show that, no, that's not the way we handle these things here. We turn it over to our legal counsel and they put up roadblocks.

Dr. David Mayer (15m 14s):

They tried to not share the medical record with the family and it becomes a legal battle and that's just wrong. And we found out through the seven pillars and tender work that not only is open and honest approaches to preventable medical harm, the right thing to do. It's also the smart thing to do because you're able to come to resolution quicker. You're able to close the events and allow the family move on to allow the care team, to move on what doctor nurse wants to go through. Sometimes five, six, seven depositions over a few years before the case finally gets to court.

Dr. David Mayer (15m 56s):

And then everybody's still arguing about right and wrong. I remember Rick Boothman had a great comment. Rick's out of Michigan and did a lot of great work in this area. And he was a trial lawyer and being on the plaintiff's side, as well as on the defense side for medical malpractice cases. And he said in the 20 years, he would be in the courtroom, not once did anybody ask, what did we learn from this? It was all about who would win and what dollars were being saved or having to be dispensed in resolution. There was no learning involved in our medical legal system. And that's why we make the same errors over over it.

Dr. David Mayer (16m 37s):

Because if you can't learn, unless you're transparent.

Mark Graban (16m 41s):

Yeah. Yeah. I want to come back to in a little bit a question of how common, you know, errors and harm and death could be. But first you want me to talk about students? You know, I, I come at this as a non-clinician who has been fortunate to work with healthcare organizations. I had a chance two years ago in San Antonio. There's a great program there where it's a kind of a bridge from high school into college, and you've got students it's called Alamo Academies. And they, I had a chance to come in and teach lead a session about healthcare improvement. So you have kids in the class, you have also all wide range of aspirations.

Mark Graban (17m 21s):

You have some who want to be pediatric neurosurgeons, and then you have some that want to be, you know, a laboratorian or they want to be a nurse or anything, or whatever points in the health system. And I wanted to bring up the idea of medical error and preventable harm. And I, and I shared an example, you know, it was a news about a wrong side surgery, sort of similar to what I think you were talking about and their jaws. And, and I could see from the looks on their faces, like, you know, they were thinking, well, how could this happen? So I tried to ask them, how do you think this could happen? And, and it was amazing how intuitive the kids were, the first hands that were raised.

Mark Graban (18m 3s):

They said things like, well, I bet there was some sort of miscommunication or, you know, maybe somebody got distracted. And so I was gonna, you know, kind of turn that question back to you, you know, how do these sorts of mistakes happen in an operating room in particular?

Dr. David Mayer (18m 19s):

Yeah. Thank you. I love the story of students. I remember when I would start the curriculum, literally the first day, eight o'clock in the morning, after new student week and all the parties and they were there. And before the first biochemistry lecture, I did an introduction to medical school lecture. And I would ask the students, what were they most afraid of? You know, you're in here now, you, you did all the work. You got the test scores, you went through the interviews. Now you are in medical school. What are you most afraid of five years straight mark. The two things that they always brought up was fair failure.

Dr. David Mayer (19m 1s):

I mean, here now, and I don't want to fail. I don't want to have to go back and tell mom, dad, my friends, I couldn't cut it. And the fear of hurting somebody had it seen and heard stories. And so they are very intuitive, but yet errors occur because you know, we're so busy. Say the operating room situation, you know, like I mentioned, there's the pressure to turn rooms over quickly to move quickly. We're doing many lateral type cases in one room. We may do five hernias in a row or five knee arthroscopies in a row. The first one might be a left. The next two might be a right and a left and a right.

Dr. David Mayer (19m 42s):

And the schedule sometimes makes a mistake and posted wrong. The consent sometimes has the wrong information. And so that's why sometimes patients get frustrated. Now, when we continue to ask them five, six times, now we are operating on your left knee. Is that correct? And the patient of why do you keep asking me that? Because we've learned all it takes is one person to catch something that could prevent an air from happening. So I think it's, it's the pressures of still volume of cases we do versus walnutty of cases we do that are reimbursed today. The last thing I'll add about the students is one of the things I'm probably most proud of is 16 years ago, we started, I founded what was called the Telluride patient safety summer camps for students and residents.

Dr. David Mayer (20m 35s):

And surprisingly, who was the one that was funding this scholarship wise, it was medical malpractice companies. It was the doctor's company out of California. It was Hopeck out of Denver. They wanted the next generation of physicians, nurses, and healthcare leaders to understand not only the importance of safe, high quality care, but we spent four and a half days with these students in Colorado. We would have every year, about 200 students go through, we've got an alumni now Mark of almost 1400 students and residents that have gone through our one week workshops over the last 16 years.

Dr. David Mayer (21m 17s):

There's a big segment of it in being open and honest, after preventable harm. And I share that story of mine with the wrong sided surgery, how I did it wrong. And then we have some patients and families where it's been done. Right? And they're part of our faculty in these Telluride summer camps for the students and they up learning from the family members as faculty.

Mark Graban (21m 41s):

Yeah. And when you talk about, you know, those, those multiple checks and, you know, there were some other practices that seem to have become more common things that I would call mistake, proofing of literally signing where the incision is going to play, take place I have with the Sharpie, the, the surgeon signing their name as part of something that can remain a double-check because once the patient's been put under anesthesia, of course you can no longer ask them. Why are you here? Like as a patient, frankly, I would say, well, it's you, you, there's a barcode. There's a, a thing around my wrist. You're supposed to be able to track why I'm here. I, you know, you know, and not rely so much on the asking, but you know, there are some of those other approaches that are meant to take away what seemed like systematic causes of error.

Mark Graban (22m 31s):

It's not a matter of bad people. It's, it's it's bad systems. It seems

Dr. David Mayer (22m 37s):

It's exactly right. I mean, no one goes to work, to harm a patient. We all go to work, to heal a patient. And we're devastated when we're involved in an air that has reached the patient and potentially caused harm. So yes, I mean, there are good people. We just haven't given them the systems, the processes, the resources, the tools, and it's sometimes the training worked together effectively, a team learning how to communicate better, giving them those different types of tools that help communication processes. So we don't have breakdowns between, you know, five different people from social work to pulmonary consultants, to internal medicine.

Dr. David Mayer (23m 19s):

You know, we have so many people taking care of a patient today. And if they're not communicating effectively, that's where breakdowns occur.

Mark Graban (23m 27s):

And you brought up the point earlier, if people are rushed, if they're under time pressure, if things have fallen behind due to factors out of their control, we, we don't want people to be pressured into, you know, cutting corners might be too harsh, but being rushed and, and, and apps being more prone to mistakes.

Dr. David Mayer (23m 48s):

Yeah. I remember being at an airport in Denver waiting to get on a plane. And they said the plane was going to be delayed 45 minutes, you know, and you get the aha, you know, everybody's but the reason the plane being delayed was because one of the windshield wipers on the window needed to be replaced. And they made sure that they did that. Even if it meant a 45 minute delay and, you know, getting people a little disappointed when I heard why there was delay, I was giving sums up and saying, I'm not sure if we do that in house care all the time. It's small little thing that we figured out.

Dr. David Mayer (24m 29s):

Don't worry. We probably won't need it anyways. Let's just get the patient in the room. I've seen that happen too many times. And that's a different mindset than maybe aviation has come to have.

Mark Graban (24m 40s):

And I mean, you know, when in aviation, the pilots safety is more directly aligned to the passengers. That might be a difference as well.

Dr. David Mayer (24m 50s):

It like that again, it's I remember a pilot telling me that one time on a panel and, you know, we finished the panel, we were sharing thoughts. This is about 15 years ago. And he told me, you know, why healthcare I'll never get, this is because the pilot is the first at the scene of an accident. And that it kind of kicked me in the gut a little bit. And I was saying to myself, is that really, you know, is there a really true, the people I've worked with, you know, they want to do the right thing. They want to make sure the patient is safe and it is as best I can. It's just that the things around them sometimes limit them from doing the job that they came to work to do that day.

Mark Graban (25m 34s):

Yeah. Yeah. That's a, that's a fair point. So it might, it might be, you know, kind of an unfair assumption that, that, that I made there. But so if that was a mistake, forgive me.

Dr. David Mayer (25m 44s):

No, you're, you're not the only one. I hear that a lot and there may be some truth to it, but like I said, people I've worked with, you know, they're not cutting corners. It's just, we need better systems and processes.

Mark Graban (26m 0s):

Sure. But you know, the, the law, I think might be some of the issue. And so I, anyway, I asked the question directly, I didn't use the crutch of like, well, some people would say,

Dr. David Mayer (26m 14s):

Well, but you're right. I mean, that's what I'm saying about the windshield wiper. I'm not sure a lot of us would say, oh, let's just wait the 45 minutes. We'd say, let's, what's the chance of anything happening. We never use that piece of equipment anyways, versus the mindset of aviation.

Mark Graban (26m 33s):

Yeah. So, you know, it seemed like there, there are two different types of mistakes we've been talking about. There's the medical mistake. And then there's what could be framed of the mistake of being honest with the patients. You know, one other question about the culture, you know, it seems unfair to just lecture people, you must speak up, you know, what, why, what, what is being done? When do you think is a best practice? What do you like to see happen within a health system? Are there ways that people in more senior positions can remove some of the fear or break down some of the hierarchy that might prevent people from speaking up when they would want to?

Dr. David Mayer (27m 16s):

Yeah, it does start at the highest levels. You've got to have a leadership, including the CEO and a board that support that. One of my favorite stories is a good friend of both of ours, Paul O'Neill. He used to say at Alcoa, I'm not upset if something goes wrong because things happen and we've got to learn to fix them. What I would be upset about is if I don't get it reported to me immediately, if I hear about it a day or two later, that's when I'll be upset. I think the CEOs have to walk that walk also in hospitals, you got to say, look, I've got your back.

Dr. David Mayer (27m 57s):

And that's what I used to say. When I was the vice president of quality and safety at MedStar to people, I said, I've got your back. If there's something that happened, you could come to me and share it with me and I've got to protect it because we need to learn. We need to engage the patient or the family member in a conversation. And it's really critical. And when you look at great places across the country, you had Cincinnati Children's or Virginia Mason. You know, I could go on Mayo. I mean, they've got that culture that it starts there. And it's the same thing with our CEO, Ken Salmon at MedStar, it was, you know, Ken was the real deal.

Dr. David Mayer (28m 37s):

And that's why I think we've done some tremendous work at MedStar around quality and safety and was involved in some of the disclosures we would have with family members, even though he wasn't part of the care team. He want to be there for those communications. That's how seriously he took it.

Mark Graban (28m 55s):

It seems like one of the high level lessons culturally, is that blame and punishment gets in the way of learning, which then hampers our progress toward reducing medical errors. And that is something like the conundrum that the playmate, the blame and punishment to some people might seem necessary or, or the right thing to do. But it seems counterproductive.

Dr. David Mayer (29m 19s):

It is. But in many ways I think hospital find it finds it's the easy way out. Oh, if you could blame a nurse for something that any nurse might've made or a physician for a mistake, any physician might've made in the same situation, boom, you solved the problem in your mind, you suspend the nurse or dismissed the physician and you solve the problem. It's easy. Let's go on. And they think the public's okay. The family would be okay with it. Doesn't work. It doesn't work the way it should. And there's been numerous examples of that happening. And then the culture of that hospital being destroyed. Look there's there's cases where people have knowingly and recklessly violated safe policies for their own benefit caregivers that have done that.

Dr. David Mayer (30m 8s):

Those people need to be held accountable because an adjust culture, you have to look at the safety science when something goes wrong and understand what happened, what was the problem now? Who was the problem? But the opposite side says you also need accountability. And when somebody is reckless and knowingly went out of their way to do something that put a patient at risk, we need to hold them accountable and need to act on those.

Mark Graban (30m 39s):

So there's a difference between a mistake and an intentional act. For sure.

Dr. David Mayer (30m 45s):

Yeah. You know, there's a, there's a whole science around this and some things require coaching. So I'm thinking why are getting the team together and figuring out what happened and putting new processes or systems in place that would prevent it from happening again, once you cross that line into something being very well-intentioned and that's where I think you were talking about the difference in making an air, which 99.9% of the time is just good people trying to do the right thing, but something going wrong with the system process breakdown at first air is completely unintentional, but the second air of lying to patients or hiding those mistakes, that is completely intentional.

Dr. David Mayer (31m 36s):

That is pretty well-resourced and very well thought out, you line up your legal console's and you use the deny and defend approach and say, we're going to defend this, even though the care is indefensible, we'll figure out a way to beat this in court. And that's that's wrong because that harm could be equally as bad if not sometimes worse than at first physical unintentional harm.

Mark Graban (32m 6s):

Yeah. Yeah. So let's, before we wrap up, I want to talk about your hat, your hat that says ZERO in, in big bold letters. And, you know, I was about to say, let's talk numbers, but I'm like, that's not the right way to frame it because each incident of harm or death is, is somebody's life. So I don't mean to just call it the numbers. But when we talk about the preponderance of how many patients are harmed or killed by preventable medical mistakes or medical error, it's a non-zero number. How, how big roughly is that number? How big of a gap is there between today's reality and a goal of zero harm?

Dr. David Mayer (32m 50s):

No, they it's a number that's been debated. You go back to the Institute of medicine and they said as high as 98,000 patients, then there was work done by David Clawson and others using the global trigger tool that said the errors and the preventable harm events might be 10 times higher than we originally thought you get John James's paper and research that said it could be as high as 440,000. The recent was the Makary study in the British Medical Journal that showed 251,000 patients die from preventable medical issues. And that made it the third leading cause of death in this country on an annual basis.

Dr. David Mayer (33m 33s):

Clearly the pandemic said over 400,000, just yesterday, but annual basis over the last 10, 15 years, you know, preventable medical error has been the third leading cause of death in this country. We always say the numbers a hundred thousand, if the numbers of million, as long as it's greater than zero it's too many. And no one in aviation would set a goal that said, Hey, we'll be really happy if we only have two plane crashes this year, no, they strive for zero. And that's my hat. If the Patient Safety Movement Foundation, we are committed to zero preventable deaths by 2030, and we want people the urgency.

Dr. David Mayer (34m 15s):

We want to really raise the stakes on, on this statement to the point where I've been talking for the last three to a three months. Now, why not create a patient safety moonshot? President Kennedy did it in the early sixties, 1960. When he said, we're going to put a man on the moon by the year, by the end of this decade by 1970. We've also said as the new president Biden was sworn in today that he was put in charge of the patient or of the cancer moonshot that before President Obama left office, he said, we are going to cure cancer in 10 years.

Dr. David Mayer (34m 59s):

And he claimed that that would be the cancer moonshot. Why not a patient safety moonshot? Why not just say enough's enough. We are going to do whatever it takes. Be it forming national patient safety authority by increasing transparency by realigning incentives. But we are going to do whatever it takes to drive and get to zero preventable harm or the end of this decade. And I'd love to see the new administration as well as others embrace that concept. We don't hit zero. I guarantee we'll still be so much better. We'll be closer to aviation where the miss apps are so rare today that they go years without significant harm happening.

Dr. David Mayer (35m 45s):

So let's drive for that because as we say at the patient safety movement, one is just still too many.

Mark Graban (35m 52s):

Yeah. And you mentioned Paul O'Neill earlier, that was certainly his view when he was CEO at Alcoa, the goal was zero employee harm. You know, he would say, as you said, zero is really the only defensible goal. When we talk about the gap, whatever the numbers are today, that non zero number, you talk about transparency or this tendency to lie or cover things up. And to me, there's this catch 22. We have these different studies that are estimates that then extrapolate out more broadly. And then I hear some people in healthcare, try to shoot that down and say, oh, well, those estimates are wrong.

Mark Graban (36m 32s):

And part of me gets a little upset and like, well, the estimates wouldn't be so bad if we actually had transparency. It's, it's, it's a frustrating who's on first back and forth. It seems

Dr. David Mayer (36m 43s):

It is. And fortunately, you know, is we are getting better. The technology being applied to the electronic health record using things like automated global triggers that in a moment's notice at real time are able to pick things out of an electronic health record that raise an alert about a potential issue or harm event that is just starting to occur. Misdiagnosis, you know, delayed responses to things, some great work being done by a number of groups out there that I think if we use these new technologies and put teams in place that can respond to these issues quickly versus 24 hours later, I think we'll start seeing a lot of these things happening.

Dr. David Mayer (37m 34s):

And, and I always said, you know, we may not have all the solutions today. We've taken ventilator associated. Pneumonia is pretty much down to zero central line infections, the great keystone project work. So we may not know how to get Clostridium difficile infections down to zero today. But if we put our minds to it and we put smart people focused in on it in a year from now, we may have that solution. So we've got to think very positive. It just because we don't know something today doesn't mean in five years, we won't have a solution that makes care safer in that area.

Mark Graban (38m 11s):

Yeah. And as we work towards zero, you know, you mentioned the hat, I don't have it handy, but I went and purchased. One of those hats is the Patient Safety Movement Foundation website. So I want to give a plug for that patient safety movement.org is the website. It's not just a hat store. There's a lot of great information out

Dr. David Mayer (38m 33s):

There. There is, there's a lot actual patient safety solutions that are evidence-based tools that have been proven to save lives and ask petals that have implemented them. And yes, and we also have hacks for zero. If you want to join the mission with us,

Mark Graban (38m 51s):

It's a conversation starter because you can wear that. What does that, do you think you're a zero.

Dr. David Mayer (38m 56s):

Yeah. Do you think, yeah. Is this a, this is a personal identity thing or is it the character trait,

Mark Graban (39m 5s):

But yeah, I mean, there's, there's so much work to be done. And you mentioned the moonshot, Dave I'll post. I saw this morning, a video that was released by the Patient Safety Movement Foundation meant to spark thought and some inspiration. So I'll, I'll put that video in the show notes and, and the, the, the page one, one final question here, we, you know, we've talked a lot about what leaders and physicians and health care organizations can do. You mentioned now president Biden. I saw him speak when he was then vice president at one of the Patient Safety Movement Foundation, annual events. I was impressed too.

Mark Graban (39m 45s):

You seem quite knowledgeable about, you know, the patient safety movement, the need for it. You know, so his knowledge and passion was really strong. W how, how many, you know, let's say policy solutions are there, or if you had a magic wand or if you were made the patient's safety are what could or should be done in the policy realm to really help here.

Dr. David Mayer (40m 9s):

Well, first Mark, I totally agree with you about the new president that we have and the new administration. I've heard President Biden talk many times on healthcare, and I've been totally amazed at his understanding his knowledge and that's achieved not only from all the work he's done versus a Senator, and then as the vice president, but also through his own issues with his first wife and the car crash, and then loss of his son, Beau Biden due to rain tumor. So he gets healthcare, not only from a legislator, but as a user of the system.

Dr. David Mayer (40m 52s):

And so I'm excited that we will hopefully have these conversations, but I guess if I had a magic wand, I'd asked for three things right now, besides putting a committee together that would start looking at this patient safety moonshot and try to do like he did with cancer, bring experts together, you start finding an agenda and an action plan, but I would hope that would include first the formation of a national patient safety authority, an organization, similar to national transportation safety board that exists for transportation and particularly aviation to learn and disseminate learnings. So all could improve.

Dr. David Mayer (41m 34s):

I would love to see incentives being much more aligned around quality and safety of care. We still, as I mentioned earlier, reward volume and productivity versus quality and safety and outcomes, and that needs to change if we're going to see, to see improvements. And then finally, the transparency area that more hospitals are rewarded for embracing the candor type approach of open and honest communication. They're sharing their outcomes in a more transparent way. So patients and families can make informed decisions about where they might want to go get their knee repair versus where they meet may need to get their diabetes treated.

Dr. David Mayer (42m 18s):

Well, some hospitals are really good at one thing, but not so good in the other and patients and families need to have that transparency, not only when errors are made, but also about a hospital's current outcomes and things are doing to improve the work in those areas.

Mark Graban (42m 34s):

Yeah. And there are incentives, the, my exposure in the health system, there are incentives based on patient experience or patient satisfaction surveys that drives a lot of attention to those issues. And it seems like what you're saying is a similar focus around safety and harm would, would be beneficial

Dr. David Mayer (42m 56s):

With those incentives. We we've moved with the pay for performance and some other things that have been implemented, but it hasn't been enough. We need to really kind of catalyze that effort and really make many more outcomes, not only on safety and quality aligned incentively and rewarded for, for the efforts being put into them.

Mark Graban (43m 22s):

Yeah. Yeah. Well, Dave, thank you so much for taking your time and, and being a guest and, and sharing your thoughts. So again, our guest is Dr. David Mayer among other things. He is the CEO of the Patient Safety Movement Foundation. You can learn a lot more online by going to their website, patientsafetymovement.org. Thank you. Thank you again so much for sharing, not just your story, but talking more broadly about mistakes and what we can do to help reduce that in healthcare. Very, very important discussion.

Dr. David Mayer (43m 54s):

No, thanks mark. For having me on. And again, they're so great and sharing our mission and being part of wanting to get to zero preventable harm. So we appreciate all you're doing to make it happen.

Mark Graban (44m 7s):

Well, thank you. So we get fired up. We'll go get to go get Back to it. Yes, we will. All right, thanks again. Thanks man. Thanks again to our guests, Dr. David Mayer from the Patient Safety Movement Foundation. Again, you can find links and show notes at mark raven.com/mistakes seven days. And I hope this podcast inspires you to reflect on your own mistakes, how you can learn from them or turn them into a positive I've had listeners tell me they've started being more open and honest about mistakes and their work. And they're trying to create a workplace culture where it's safe to speak up about problems, cause that leads to more improvement and better business results.

Mark Graban (44m 48s):

If you have feedback or a story to share, you can email me myfavoritemistakepodcast@gmail.com. And again, our website is myfavoritemistakepodcast.com. Since every podcast asks you to do it, it would be a mistake. If I didn't ask you to please follow rate and review, but most importantly, thank you. Thank you for listening.

Mark Graban is an internationally-recognized consultant, author, and professional speaker who has worked in healthcare, manufacturing, and startups. His latest book is Measures of Success: React Less, Lead Better, Improve More. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. He also published the anthology Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also a Senior Advisor to the technology company KaiNexus. He is also a Senior Advisor and Director of Strategic Marketing with the healthcare advisory firm, Value Capture.