When a plane crashes, it’s kind of a big deal. “Continuing coverage now on the Asiana plane crash investigation.” “Investigators try to figure out what went so terribly wrong.” People freak out. There’s usually a big investigation and a bunch of policy changes to make planes safer. A plane crash investigation committee from several nations including the United States are meeting in Tripoli to try and figure out what happened. There’s pretty much a ”zero-tolerance policy” for plane crashes in our society –and luckily planes are very safe because of it. But when a car crashes it’s not really a big deal. No one hears about car crashes on the news. We’ve decided as a society that car crashes are a cost of a really convenient thing. It’s not worth a big investigation or a bunch of news coverage. This video isn’t about cars and planes. It’s about hospitals. Sometimes doctors and nurses, despite their best intentions, hurt patients. A tricky procedure goes wrong, and the patient suffers or dies. This happens all the time in hospitals. One estimate says that at least 210,000 people die every year due to preventable harm in hospitals. That’s a huge number. You know I think we think of hospitals as this place where you go to get better and that’s just what happens, but there’s a lot of risk in, like, going to a hospital, like, there’s, like, a lot of things that go wrong and they don’t necessarily have to. Some hospitals treat medical harm incidents like plane crashes. An unacceptable problem that needs investigation and policy change Other hospitals treat them like car crashes Just a tragic loss of a risky business, but not ultimately preventable. The way hospitals react to harming their patients can have a huge impact on how often these errors occur. And that’s what this video is about–how hospitals react when they harm their patients. So I got interested in medical errors Because it’s this massive problem that we don’t really talk about in health care Sara and I headed to California to visit some people who would help us figure out how and why people are being harmed in hospitals–and whether or not it’s preventable. I quickly realized that we were looking into something that was rarely talked about, but had a huge effect on hospital patients around the country She loved dancing and running and jumping and she never sat down. I mean it’s funny because we had these, like, family… That’s Claire. Her daughter, Nora, was born with an underdeveloped lung, that required her to be in the hospital for quite a bit of time So we were using the beater and I was like, oh, yeah, there’s a song called Beat It so we put it on, and I mean, she used the beater as a microphone, and like I had a spoon and we would Just play it like as loud as possible and she would just sing like “Beat it” During her treatment, Nora contracted something called a central line infection, which I’ll explain in a minute. The day before she got that first line infection, I had a friend over with her daughter and like she was showing Nora how to do push-ups, I mean it was just you know, like totally fine. And then, that was like just that, and then like two days later she got the infection… Our lives, completely, and Nora’s life, completely changed with that first line infection. A central line is a tube that is placed in a vein that goes right to the heart. It’s given to patients who need medicine that’s too acidic to go through a normal IV or to those who need to get their blood drawn often The tube stays there. People walk around with this thing in, and it gives doctors and nurses really quick access to the blood stream. It’s a super useful invention. But we’re talking about putting a tube, through veins that go right to your heart Just as it’s good for giving medicine quickly into your bloodstream, it’s also a foreign object in your most vital organ. So if any bacteria gets in there, it’s a very bad news Nora had four of these central line infections over the course of her life. That’s way above average. Claire thinks that the Stanford hospital, where she was being treated, could have prevented them– and that’s the question we’re trying to answer: Can these infections be prevented? There has to be a better solution! Like this cannot be, because every line infection just… …took it out of her. Every line infection, you know, just took more out of her and more out of her… She’s saying, “Hi, Nora!” Yeah, because I turned it that– you know, I turned it so she could see herself. Doctors and nurses have sanitation protocols when dealing with central lines. But, even so, she contracted three more line infections while she was in the hospital. Her health was rapidly deteriorating as she approached her fourth birthday… And she just like turned to me and was like, “Hold me.” And so I picked her up, and she… like, put her arms and legs around me, and her head kind of went back and she was sort of like gasping to breathe, and then she… She said, “please help me feel better” And she just grabbed me around my neck, like so… …I mean I can still feel it, like it’s so much strength, you know, like just squeezing me, and then she just basically lost consciousness, and just kind of… Nora died. Her arms around her mother’s neck, on November 22nd 2013. Just three weeks before her fourth birthday. There are so many points along the way where like things could have gone differently, you know And there were so many… …unnecessary mistakes that just led to that moment. It’s hard to know whether or not the line infections were the direct cause of her death It’s hard to disentangle everything that was going on with her to give a neat causal story of how she died. But what’s sure is that these line infections caused her and her family immense suffering. Claire thinks that they should have never happened in the first place. She wrote a letter to the Stanford Hospital where Nora died. She basically lined out the mistakes that she saw in the hospital, and offered feedback on patient safety failures. She got this letter in return: “Unfortunately, the placement of center lines is associated with a risk of infection… ” “There is a risk of infection even in the best of circumstances which can never be entirely eliminated… ” “Please be assured, that multiple procedural protocols are in place, to promote hand washing techniques and minimize the chance of infection…” “We understand and recognize your feelings regarding Nora’s care. And we apologize that you were dissatisfied with your experience of LPCH.” So were Nora’s line infections just the result of a risky business, or could they’ve been prevented? Stanford looked at central line infections with the car crash mentality, just an inevitable tragedy, – instead of with a zero tolerance plane crash mentality. But we headed north to a hospital outside of Sacramento, that went seven years in a row without a single central line infection. We wanted to figure out what they were doing to achieve this perfect record I was really interested in this concept of like, should there be any central line infections given what we know… Is zero possible? Like what does it take to get to zero? What are the obstacles there? In 2005 this hospital had 11 central line infections. Research was just starting to come out on how to avoid these central line infections. And this Roseville hospital began to implement it. They had a few powerhouse nurses, that were dedicated to making a difference, and they did. We kind of thought you had infections. Yeah, there was no biggie. It was no big deal it developed over time You know we looked at people we looked at equipment we looked at skill set and Kind of all that came together to really develop the bundle that has been quite effective here. You can’t accept Good enough You know You have to go for eliminating those. If you’ve been at zero and you have an episode you go in and you say you pick it apart and you do a root cause analysis and you say what went wrong? They treated land infections like plane crashes A zero tolerance policy was instituted and they began to see results We got to see these nurses in action as they inserted a central line They suited us up in sterile dressing and began their work. The nurses were meticulous about the procedure They’d instituted standards of sterilization that assured minimum risk of infection Now what I’m going to do is because my hand is not sterile, I touched a tourniquet I’m going to take my first glove out, that I’m going to throw away. Now I’m still sterile. And these weren’t just compassionate nurses who had an intrinsic motivation to do right instead They were operating in a culture where they were expected to do it right. It was a team effort where they had ownership and accountability Where the line infections were unacceptable. When you have an outcome that isn’t what you wanted If you don’t say is there anything we could have done better? Is there any way we could have changed our interventions and resulted in a different outcome? People are gonna get really really sick and they’re gonna die We left the hospital understanding how they had made it to zero central line infections …you just get this very different approach from the two hospitals. One saying: Every error is a mistake, every error can be prevented in this particular type of error. And then one saying this is inevitable, this is the cost of doing business. And… It’s just really striking, two hospitals like three hours away from each other with, very diferent attitudes. As I headed back to DC I kept thinking of Nora If Stanford had an attitude a little bit more like Roseville, maybe she would still be alive today. Just another five year old little girl Surely she and her family wouldn’t have suffered as much To get the final word on this subject. We went to Baltimore to talk to Peter Pronovost at Johns Hopkins Medical Center He’s basically the Godfather of all of the research behind preventing central line infections we started investigating every infection as a defect again a very Important culture change where in the past we just accepted them and we said no no if we really view these as defects Everyone needs to be investigated and reported on and find out why they would happen We routinely invite patients back to inform us to learn with us to share with us It is both healing for them and our clinicians But importantly it also is wise and fruitful for us to learn and improve mistakes We finished up reporting, Sarah and I realized that Nora’s death actually represents two tragedies The first was of course the fact that a little girl suffered and died, but the second and perhaps more harmful tragedy Is that the hospital where it happened didn’t take the opportunity to learn from it. I think that’s worse for patients who are gonna be treated there in the future. It really makes a world of difference in healthcare whether you see patient harm as something that’s preventable or inevitable and Getting people to the preventable mindset from the inevitable one. It has the potential to alleviate a lot of suffering, to prevent a lot of deaths. I became convinced, like attitude towards harm makes all the difference, and That there’s space for our healthcare system to improve to taking a more preventable attitude towards patient harm.