 Hi everybody, this is Donna Prosser with the Patient Safety Movement Foundation. We're here to bring you another COVID-19 update. Today I'm very excited to be joined by Dr. Danielle Ophry. She's a practicing internist at Bellevue Hospital in New York City. She's also a clinical professor of medicine at the New York University Grossman School of Medicine. She's recently published a book called When We Do Harm, a Doctor Who Runs Medical Error. Welcome Dr. Ophry, thank you so much for joining us today. It's great to be here, thank you. I wonder if you could tell us a little bit about your background and how you became to be interested in patient safety. Well, so I'm a primary care doctor. I work at Bellevue Hospital, which is the oldest public hospital in the country. And I just do sort of general primary care, you know, all comers. And I've written a few books about life in medicine, doctor of patient communication, emotions, how emotions affect the practice of medicine. But a couple of years ago my editor at Beacon Press sent me an email with an article attached. And when you're the only doctor in a publishing house full of English managers, you get all the medical questions. And so the article she attached was this report about medical error being the third leading cause of death. And so she said to me, is this really true? And the truth is I wasn't really sure. I'm thinking, boy, third leading cause of death, if that's the case, I should see it every day, or I work in a really busy clinic in a city hospital. But I don't, or at least I feel like I don't. So the question that sort of came to me is, well, either it's true and we really have blinders on, or it's not true and we're not really calculating medical error correctly. So that became the genesis of this book, my sort of journey to figure out what's going on. And then I just kind of got interested in the whole idea of medical error and patient safety. That's great. And if I can just add, the previous book I'd written was on communications. I thought I was writing a different book, but it turns out that I was almost writing the same book because the more I dug into medical error and patient safety, it was like almost everything came down to communication. And so if I could just sort of work on the first book on communication, I might sort of solve the problem of the second book. But yes, it was a really interesting discovery that almost they were very, very similar and had a lot of overlap. That's very interesting. Yes, they do because we know that most errors are caused by problems in breakdowns and communications. But we've also seen during this pandemic, hospitals across the globe have recorded an increase in medical errors, not necessarily due to COVID during this time. You very recently published an op-ed in the New York Times where you outlined some of these. Can you share some of what you saw as a frontline clinician during this pandemic? Sure, well, let me start off just by saying that what went right in our hospitals and medical systems far outweighs the things that went wrong. I mean, given what happened, and it was unbelievable. And I'll tell you, even the sort of grittiest news coverage couldn't really convey just the mobilization ramp-up that happened. And I can make the comparison I trained during the HIV crisis. And that was a really difficult time. I mean, patients were very sick and really dying at a high rate. It was like those three years into three months. And so given the enormity that happened, I mean, when we were preparing for COVID in our hospital, we actually had to start our special pathogens unit in order to deal with Ebola. And so we had a special pathogens team. We had an Ebola-forbidden unit. I mean, really ready for everything. We figured out, you know, a handful of patients will show up, and we'll take care of that. And so, as things got really bad in Italy, we really started thinking, no, this could get bad here. But even with all of that, it was not, you know, possible to imagine that we'd have almost 400 patients with COVID-19 and 110 in the ICU in the MICU. I mean, our MICU normally has 10 patients. So given all of that, I think we should be duly proud and impressed with how well things went and that the mortality rate given what we were facing was actually done quite well. And I think it was lower than we might have expected. Nevertheless, I think that there are always things we can do better. And I think either certainly patients did suffer and they suffered from harms, some of which might have been preventable. Now, a lot of the harms I think came because it was a pandemic and that we were improvising. We were dealing with numbers that were beyond we normally handle. So for example, you know, we don't have enough, you know, internists and medical doctors and ICU people to handle a number of patients. So our medical teams had orthopedists and ophthalmologists and dermatologists. I mean, we really had to pull everyone in and a lot of people were practicing outside of their comfort zone and we didn't have an option. So could we do it better? Well, yes, we probably could. Now that we know this kind of thing could happen, thinking forward, for example, you know, can we take the time to train people better for this? And the idea that sort of anyone with a pulse, you know, an MD or RN should go in there. You know, it's not quite what, you know, is not the only answer. I mean, it's an important, but we also need to think about that even though if we have to take some time that could slow things down, we might in the long run, you know, do better. So, you know, even little things like patients came in so fast and furious that sometimes it was hard to keep in track of everyone's names, people had similar names and, you know, the issues of HIPAA were a big problem. But we finally gave up on HIPAA and just started, you know, posting a piece of paper in a patient's name, we're right on their stretcher. So we couldn't mix things up. And I saw, you know, occasionally things had gotten mixed up. You know, we're trying so hard to adhere to sort of pre-pandemic HIPAA rules and it doesn't always apply. So there are things we could do better. Overall, I think things went well. The second thing I'll say is then what happened to the patients who don't have COVID? Everyone else's medical care got shunted aside. Now, maybe that had to be. I don't think we had a lot of choices, but patients certainly were harmed in that. You know, we postponed elected procedures, fine, but there are a lot of procedures that fall in between elective and emergent. So patients who were getting surgery for cancer, patients, I have a patient with a mitral valve hanging off by a thread. It wasn't an emergency, but it sure will be soon. It doesn't get that day in care really soon. And his surgery got postponed. And so thinking ahead, like how do we triage the urgent but not emergent things that really shouldn't wait too long? So there's lots of things we can do better not to say that people did things terribly. That's right. And I think it's important for everybody to remember, whenever we're talking about medical error, we're talking about those errors that are preventable from a system standpoint because we know that everybody comes to work every day in healthcare to do the best thing that they can and take care of others. So knowing what you know, what are your thoughts about moving forward? How can clinicians and administrators work together to put those safe processes in place? Well, I think the first thing we do now is have sort of the post-mortem. And that is the administrators to sit down with clinicians and say, okay, we got through this, by the skin of our teeth in some cases, but what can we do better? And I think preparing in advance for staffing surge, what will we do if we need 20 intensivists and don't have them? So later on in the game, we came up with a great idea that an intensive care group in Pittsburgh offered virtual services that, because many people were doing ICU level care on the wards and there weren't enough intensivists to be helping out the ward teams. And they needed people to talk to and our intensivists were busy in the intensive care unit. So having an offsite virtual place to ask questions of an intensivist or anesthesiologist or an ICU doctor or cardiologist, pulmonologist, that's a great way to handle surge issues. And we could start that in advance. The same thing for nursing care. I was in a number of cases where nurses were floated from everywhere and it isn't so easy to translate skills. Yes, you're a nurse, but you've never been on this unit and don't know where things are kept. That's the institutional knowledge is so important and we can't skimp on that. So maybe we have to figure out a way that every unit needs to have a core group of nurses who have been there forever, who know the place, who know the routine and then we filter in the other nurses but we can't be held to a skeleton just to think strategically in advance of how we do that. I would say the other thing we wanna sort of go forward on is thinking how do we handle all of our outpatients, the regular medical care? I mean, right now, three months have gone by, it's sort of a quarter of the medical year. Well, that chunk of patients didn't get their vaccinations, right? And particularly in pediatrics, it's really an issue and that's really a future hazard. And so we have to think in a way that what we call routine care, you can put it off for a bit but it's actually not that routine when you think about it. Getting people's diabetes checked and getting their foot care done, their ophthalmology care, those turn out to be quite urgent if they're left undone. So planning how we might take care of the routine thing so that they don't become emergencies later, particularly the vaccinations and well checks that are important. You hit the nail right on the head when you said that we need to do a post-mortem. And let me talk about the book for a second. You talk about Florence Nightingale a lot in your book. I wonder if you could just enlighten us a little bit about what you've learned about Florence and putting that culture in place. You know, I really learned a lot about Florence Nightingale. I think before that I kind of knew of her of this great nurse, she invented modern nursing but I didn't realize the extent to which she really proceeded her efforts by a century. I mean, almost everything that we talk about with patient safety and gathering data, she was there. She had different terminology, but when she went into the military hospital, the British military hospital in the 1860s, she saw that more soldiers were dying of conditions in the hospital than were dying in battle. And she sat down to measure what's happening and why food portions triage, how things are clean, how wounds are dressed. And I'll tell you, she drove her bosses crazy. They just couldn't stand her because she took so much time to do all this measurement, but she made the point that if you don't measure it, you don't know where the problems are happening and you can't fix things. And you know, within a year, she was able to have the mortality rate drop by about 70 or 80%. And if you look at Peter Poner of us checklist for the central line catheter and look at her sort of checklist there's almost the same. And they're very simple, obvious steps, cleaning the wound, clean dressing, making sure the staff are cleaned and all of these things, but it was the paying attention to these things and making them a thought away. So she's really a statistician. And I think she's sort of the founder or one of the founding mothers of epidemiology, of the patient safety and movement of the sort of way of being rigorous about how you approach the system and help people to make it easier to do things right. Yeah, she's a great person for us to emulate in medicine for sure. And we do need to measure and identify what has happened because of COVID, but I also am interested in measuring and identifying what is it that we have learned about the culture of safety, the cracks in the culture of safety that we had before our pandemic even started? I mean, to me, the biggest thing we're missing are the near misses. You know, we always talk about the near miss and the patient did okay. I had a case where a patient of mine was admitted for altered mental status. And I was told, oh, you know, lab's fine, radiology fine, just to get back to the nursing home. And I kind of shunted the patient to a back ward to be transferred back. And it turns out actually he was bleeding in his head. And I had looked at the CAT scan because someone said radiology fine. Now, if someone else saw the CAT scan, the patient did fine, their care was not impacted by my error. So it was a near miss, but the near miss just means the patient was lucky. And I still, I made the error and had I discharged the patient home, they could have died, but the error didn't get counted because, you know, someone else caught it, which is of course an important layer of safety, but the near misses feel like the big iceberg under the water. And that's where the minefield of the next error to happen will be, but we don't rigorously collect them. And so we don't know are most near misses happening with medication errors or radiology errors or, you know, interstaff communication errors, we don't know where they are. And this country is lacking a centralized database for these sorts of things. Because right now in our country, we think, oh, medical error, I'm gonna get sued in court. So I'm not gonna talk about it. Why would anyone want to voluntarily talk about a almost mistake if the patient did okay, why bother? Right, you'll get humiliated by, you know, your colleagues, you'll feel awful, you might get sued and it's just, and the paperwork is ridiculous. So why bother? And so I think it's more of a culture shift that, you know, this is a routine thing we do. The same way, you know, you notice that the paper towels are done, you know, you send a note or you call all housekeeping when I'm seeing paper towels. The same thing, you know, I almost prescribed the wrong thing. I had an example this week where a patient of mine who just had a surgery and I noticed that pre-op is creatinine was 1.4, a little above his baseline. And so he was feeling fine. So I just, you know, come by at some point, get, you know, routine labs. And I saw his labs had come back and there was no red flags. I saw the first few, okay, I'll get to this in, you know, tomorrow or the next day when I'm not so busy. When I finally scrolled down, I saw this creatinine had doubled. And I, you know, it was at the bottom and it was below my screen though. And so I hadn't seen it, it wasn't flagged to me. And that should have been, I missed it for, you know, a good couple of days. And then of course, by that time, he was at the Jersey Shore for the weekend, you know. So many things happened, and he did okay, but I thought I want to tell someone, you here's what happened, but it's so laborious to do it to figure, and the onus is on me to figure it out. I don't have time to do that. I, you know, I'm so back, but the reason I waited a few days, I'm so backed up to begin with. So a really simple, non-stressful, non-punitive way, to let people know. And I really admire in Denmark how they do things. And part of how they made it easier is they did two things. They separated the legal part from sort of the safety improvement part, and that the legal system should be there for the doctors who've been negligent or the nurses who've been, you know, really mishandled standard of care. It's rare, but it's there. And that deserves to be in the legal system. But as you said, most errors are committed clinicians who want to do the right thing. And something happens. Either the system makes it difficult to do the right thing, or they just miss something, or forgot something, or who knows, but it was not an intentional, it wasn't, you know, negligence, but it didn't come out the way as good as it should have. And so they made a system where you can just file a report. Anyone can. The doctor, the patient, family member, it costs nothing, it's a one page to do. And the goal is to see if the patient didn't get as good a care as they should have or were somehow harmed, they should get some kind of compensation. And then the data gets collected. Nobody's thrown in jail or loses their license over this. And it's such a non-punitive system that many more patients are willing, and doctors are willing to file reports. More patients get some compensation, modest, but they get some kind of acknowledgement. And it's fast. It doesn't take five or 10 years like it does here. You know, it takes a matter of months. It's a little bit more like workers' compensation. You know, did the injury at your job meet a certain standard that deserves some kind of compensation? And then if the database starts to notice, well, this hospital is getting all these reports filed, let's go investigate there. So it's a way to the patient's safety, not just a way to have a court battle to sort of find the one person you can really punish. Yes, we're very passionate here at the Patient Safety Movement Foundation about that as well. Transparency we think is very important in patient safety. And if we don't know what is happening, then we won't be able to fix it, as you mentioned. So, yes. Any final thoughts on patient safety in the future? You know, we've spent the last 20 years really kind of in hyperdrive on trying to improve quality and safety. What do you see for the next 20 years for us? Well, it was interesting. In some ways, the COVID pandemic has given us a chance to look a little more globally at the system. We haven't sat and looked at the system and its totality for a while. We saw all sorts of things. We know there are inequities in care and there's racism in medical care, but COVID-19 really showed the inequities of how our patients in underserved minorities, black and brown communities and Latino communities really suffered disproportionately and not just because of the medical system. They're the ones who had to go out and be essential workers. They couldn't easily socially isolate and that the health system doesn't exist in isolation from society and that all these things come together and that if we wanna look at improving patient outcomes and decreasing error and harm, it's a larger conversation that we look at why is it hard for some patients to get their medical care? Well, is it access issues? Why are our patients skimping on their medication? Is it financial? You know, is it a system that doesn't allow them to feel comfortable, you know, getting medical care? So looking at the whole society, how medicine fits within that, which means that the stakeholders are quite broad. It's not just the health care system and the patients, but really the broader society and how we as a whole try to make our system safer and better for our patients. Very well said. Thank you so much, Dr. Rofer, for joining us today. We really appreciate you being here and I hope that we can continue to have more conversations about the culture of safety over the next few months. Looking forward. Thank you so much. Excellent. Thank you.