Pathology Quality and Safety: Managing Mistakes, Mentality and Methods
February 04, 2022Information
Feb. 3, 2022
Yale Pathology Grand Rounds
Yael Kushner Heher, MD, PhD
ID7413
To CiteDCA Citation Guide
- 00:00So I will go ahead and introduce our speaker.
- 00:03So good afternoon everybody.
- 00:04I am thrilled today to host our ground
- 00:07speaker, Doctor Yael Kushner Hager of
- 00:09interest to some in the audience is,
- 00:12as already noted, is that Doctor Hayhurst.
- 00:14Currently the head of renal pathology at MGH.
- 00:17But the reason I extended the Grand
- 00:19Rapids invitation is her really
- 00:21impressive expertise in the field
- 00:23of quality and patient safety.
- 00:24And just as a way of background,
- 00:26Doctor Hager received her medical training
- 00:28at McGill University in Montreal.
- 00:30Which is one of my favorite cities in the
- 00:32world and she completed her residency there.
- 00:34Anatomic pathology in 2010 or so she
- 00:37arrived in Boston where she did a
- 00:39fellowship in renal pathology at MGH.
- 00:42Afterwards she pursued an MPH at Harvard
- 00:44School of Public Health and also as
- 00:46a graduate of the inaugural class of
- 00:48the Harvard Medical School Fellowship
- 00:50and Quality and Patient Safety.
- 00:52So there's this huge background of
- 00:55education inequality she stayed
- 00:56on as a faculty at Harvard,
- 00:59first at both Israel where she served.
- 01:01For many years as a director
- 01:02of quality and patient safety,
- 01:03there and later joined Boston
- 01:05Children's Hospital and then moved
- 01:07to MGH as well where she is again a
- 01:09director of quality and Patient Safety.
- 01:11Doctor Hager has become nationally and
- 01:14internationally sought after speaker
- 01:15and she has amassed a broad array of
- 01:17scholarship and pathology specific
- 01:19quality initiatives such as implementation
- 01:21of high reliability principles,
- 01:22safety culture,
- 01:23systems engineering,
- 01:24effective change in leadership,
- 01:26so on behalf of the department,
- 01:29I would love to welcome Doctor.
- 01:31Better to give her presentations
- 01:33and you know one of the small things
- 01:35that the COVID pandemic has changed,
- 01:36is that the required zoom platform
- 01:38does not allow for the warm applause.
- 01:40I'm sure you would get if you were
- 01:42here in person and so I really do
- 01:45hope that we get to meet in person
- 01:47in the future soon.
- 01:48So welcome and please go ahead.
- 01:52Give some. Thank you so much.
- 01:54That was an incredibly warm welcome,
- 01:56especially hard to do on zoom.
- 01:57I'm gonna share my screen
- 02:00and it makes it sound like I.
- 02:02I've been at it sounds much more
- 02:04impressive when you list it like that.
- 02:05I actually was at.
- 02:06I was in Montreal for 10 years and then
- 02:08I was at the Buy for about 10 years.
- 02:09That's pretty much it.
- 02:11I haven't moved around that much.
- 02:12I do cover Boston children,
- 02:14some work there,
- 02:14but I just do the renal service,
- 02:16which isn't the very high volume
- 02:18service as kind of a in in a sort
- 02:21of consultant neighborly capacity.
- 02:22So then I came back to MGH about
- 02:25a year and a half ago after having
- 02:27been away for about a decade after
- 02:30my when I mentor is retired so.
- 02:32Today I'm going to speak with you about
- 02:34things no one wants to speak about,
- 02:36so hopefully you guys have some lunch the
- 02:38the the worst part about zoom is I really do.
- 02:41I really do Miss meeting in person.
- 02:43I'm sure everybody is sick
- 02:44of hearing that already,
- 02:44but it is really different,
- 02:45especially when talking
- 02:47about these difficult things.
- 02:48Having a interpersonal
- 02:50connection is always nicer,
- 02:52so feel free to reach
- 02:54out to me after or doing.
- 02:57After you know the talk,
- 02:58if there's anything you want us to discuss,
- 03:00can you see my screen OK?
- 03:03Alright,
- 03:03I'll keep nodding,
- 03:04so I have a friend who's a
- 03:06professor at the Business School.
- 03:08He told me people take 2 minutes
- 03:09to decide whether they're
- 03:10going to listen to or not,
- 03:12so this is my two minutes and
- 03:14and you're competing with.
- 03:15I used to have this thing where we
- 03:17were competing with people phones
- 03:18like everyone is sitting in the room
- 03:19likes checking their phones and now
- 03:20I feel like you're just look out at
- 03:22a sea of like black boxes of people names,
- 03:24which is so hard,
- 03:25but I know everyone's so busy.
- 03:27So what I'm gonna do to compel you is tell
- 03:31you about real disasters that happened.
- 03:33At in hospital in the hospital I worked
- 03:37at due to errors in our department
- 03:39and their different flavors of error.
- 03:41So I thought that might be compelling to you
- 03:43to sort of if any of them rang true to you,
- 03:45I'd be very interested to hear about it.
- 03:49So here we go.
- 03:50Case one is entitled.
- 03:52Are you sure this is the right patient?
- 03:54So I hope your blood pressure isn't going up,
- 03:57and it's of course it's a prostate biopsy.
- 03:58It's always either a
- 03:59prostate biopsy or GI biopsy.
- 04:01I, by the way,
- 04:02I don't have any disclosures.
- 04:03Maybe my disclosure should be that I.
- 04:05That I'm not a Geo pathologist but
- 04:08I am very familiar with this case,
- 04:09so this is a case that showed
- 04:12prostate cancer.
- 04:13Do we have some trainees on the call to?
- 04:15Should we maybe?
- 04:17Maybe we can make it a little
- 04:20interactive? People are awake,
- 04:22so this shows prostate cancer.
- 04:23I'm going to ask a question about it,
- 04:25but not about the diagnosis,
- 04:26so hopefully folks are caffeinated.
- 04:29It showed cancer really,
- 04:31very routine diagnosis.
- 04:32No one thought anything about it.
- 04:34The patient underwent a prostatectomy.
- 04:36You can see by the year that these
- 04:39harmful errors don't happen so often,
- 04:41which is like nice. But then again
- 04:43I would say then we're sort of.
- 04:45We're not very nimble in knowing
- 04:46how to deal with them, right?
- 04:47So the patient underwent a prostatectomy
- 04:50and the prostatectomy was entirely benign.
- 04:53Totally benign.
- 04:55And no masses, no cancer.
- 04:57The entire specimen was submitted,
- 04:59much to the chagrin of the Sino pathologist,
- 05:0253 blocks. That's almost twice the alphabet.
- 05:06So invasive cancer, and so.
- 05:09I guess if any of the trainees,
- 05:10what what would you do if that was your case?
- 05:12What's the next step?
- 05:13Of course,
- 05:14you're worried that it's the wrong case,
- 05:15right?
- 05:16But so how do you figure that out,
- 05:19maybe?
- 05:23So I guess the first question would be,
- 05:26is that the only cord that was positive?
- 05:30And then the other question would be.
- 05:34Look at the cases that were gross
- 05:37and I guess accessioned before
- 05:39it to see if there was some
- 05:41kind of crossover event
- 05:43that's exactly perfect,
- 05:44so I think looking at the grossing
- 05:46log from that day is probably the
- 05:47first step 'cause you automatically
- 05:49are like jumping to a OK,
- 05:50we messed it up at the grossing bench.
- 05:52Of course it could be in
- 05:53the urologist office.
- 05:54It could be a lot of different
- 05:55places where that can happen,
- 05:56but of course the gross thing
- 05:57log is easy to look at,
- 05:58so we actually did do that and
- 06:02we found that it was mislabeled.
- 06:03It was pretty. Easy,
- 06:04it was just a mix up at the microtome, right?
- 06:06So we could tell when we re cut
- 06:08from the block that was wrong.
- 06:10So that patient had had surgery.
- 06:12He didn't need.
- 06:13This was his actual core,
- 06:15which was totally negative.
- 06:17Interestingly,
- 06:18you know he was quite young and
- 06:22he had all a lot of the you know,
- 06:25bad things that happen when you
- 06:27have a a radical prostatectomy,
- 06:29so that was pretty awful and
- 06:30pretty traumatic for all the
- 06:32care care members as well.
- 06:34The other patient,
- 06:35the one who was told that he was
- 06:38fine but actually had cancer.
- 06:40He opted for watchful waiting
- 06:41and this is an interesting part
- 06:43about the patient safety movement.
- 06:44So if you go by the strictest
- 06:46definitions of harm.
- 06:47Nothing happened to him right?
- 06:48'cause he was just gonna wait anyway
- 06:51and so it didn't have an impact
- 06:52like the way you might sort of do
- 06:54wrong site surgery or something like that.
- 06:56But and he was followed up with biopsies,
- 06:58they all showed the same thing and confirmed.
- 07:02You know his most recent biopsy
- 07:03was the exact same grading.
- 07:04You know, uh,
- 07:05five years later,
- 07:06but in reviewing his chart for QA,
- 07:09he actually had had a bunch of
- 07:12anxiety events in the in the years
- 07:14following this medical mix up.
- 07:16And he got better with medication.
- 07:18But I just thought it was interesting,
- 07:20and it's a good side note on how
- 07:22these types of psychological events
- 07:24can really can harm people and can
- 07:26make them distrustful of medical
- 07:28system and just generally anxious.
- 07:30So I thought that was interesting,
- 07:31and it hinges on some some other
- 07:33academic work that's been done
- 07:35around extending the patient
- 07:37safety movement to things like
- 07:39psychological harm and we're getting
- 07:40into that a little bit again now,
- 07:42with the Cures Act,
- 07:43which I'll talk about at the end in
- 07:45terms of reporting results and whether
- 07:47psychological harm is a real thing.
- 07:49So Creek?
- 07:50Oh,
- 07:50that's our malpractice insurer in
- 07:51the car captive Harvard system
- 07:53settle the suit on our behalf.
- 07:55The Department Public Health CMS came to us,
- 07:57which is, like, you know,
- 07:58not relaxing,
- 07:59and we did a border registration
- 08:01and medicine report and we had
- 08:03some Qi related changes.
- 08:05Interestingly,
- 08:05one of our QA related changes,
- 08:08which is just that you all
- 08:09know that we're human,
- 08:10was that on every requisition 'cause
- 08:11this was in the in the time when
- 08:13we still had paper requisitions,
- 08:14we used to write our right,
- 08:15our diagnosis on it,
- 08:17and someone would transcribe it.
- 08:18We had to sign the little
- 08:20thing saying, you know,
- 08:21we attest slides match the requisition,
- 08:24and you know what happened.
- 08:25If you months after, people would just
- 08:26sign that as part of their sign out,
- 08:27and they wouldn't actually
- 08:28be checking it anymore.
- 08:29And anyway it wouldn't have helped in
- 08:31this case 'cause it was labeled wrong.
- 08:32So I was thinking about this when
- 08:34I was reading the New York Times.
- 08:35A couple years ago and I saw and if the
- 08:38exact same case reported exactly the same,
- 08:41it was a 69 year old prostate cancer mix up,
- 08:44so I don't know.
- 08:45Maybe I don't know if you've
- 08:46ever had mix UPS in your lab,
- 08:47but it certainly happens with
- 08:50these small batched biopsies.
- 08:51So many people come to me and they say,
- 08:54well, we just need barcoding.
- 08:55What we need is barcoding.
- 08:56We need RFID codes.
- 08:57We need to barcode everything,
- 08:59and I guess what I would say to that is,
- 09:01yeah, it makes things better.
- 09:03But remember that Pete.
- 09:04There's still a person.
- 09:05It has to affix the label to a specimen,
- 09:08right?
- 09:08So, for example,
- 09:09we reported a case where there
- 09:12was a frameshift error in our
- 09:14cytology specimens where he had 20.
- 09:16Someone batched out all the labels
- 09:18and started one specimen off,
- 09:20so we misdiagnosed 25 patients that day,
- 09:24and online cytology.
- 09:25So it's not perfect,
- 09:26right?
- 09:26You have to think about how you're doing it,
- 09:28so that's the first case that
- 09:30was a preanalytic error case.
- 09:31The second case is actually
- 09:33not really an error,
- 09:34and I'm interested in your thoughts about it.
- 09:36These are all real.
- 09:38These are all real cases so
- 09:41so haven't gotten fired yet,
- 09:43but I'll let you know if that type.
- 09:45I'm looking for a job,
- 09:46so this is a case where it was
- 09:48reported out on the treating clinician
- 09:50actually misunderstood the report.
- 09:52OK,
- 09:52which I'm sure has never happened
- 09:54to anyone in your department.
- 09:56So it was a very young man
- 09:57and he had neck swelling.
- 09:59He was noted to have a submandibular
- 10:00mass and he was referred to
- 10:02a surgeon to get it biopsied.
- 10:03He had an SNA totally routine by this
- 10:06surgeon and and the SNA showed many,
- 10:09many fragments that looked
- 10:11exactly the same of.
- 10:13Do we have any site of
- 10:14pathologists on the call?
- 10:15Anyone interested in?
- 10:17Thinking of a word to describe these cells.
- 10:21Another disclosure I don't do
- 10:22that I don't do psychopathology.
- 10:29Joe, I saw your name.
- 10:34He's like I had my camera off and I
- 10:36left message and also leave me alone.
- 10:39Form their bland.
- 10:40They have brown nuclei on the right.
- 10:43It looks almost like it has
- 10:45asked their architecture.
- 10:45Now wonder if it's normal last
- 10:47night I'd like to see more and
- 10:49see if they have this little
- 10:51aster architecture or if it's
- 10:53neoplastic with a very uniform.
- 10:55Population of epithelial cells. Yep,
- 10:58here's another section or another
- 11:00photo of another aggregate.
- 11:03So I mean, I guess the main
- 11:04thing was you can't really tell.
- 11:06I think that's what you're getting at, right?
- 11:07So then it gets to the point of like,
- 11:09how do you express uncertainty in a
- 11:11differential diagnosis in a report,
- 11:13which is a real challenge in
- 11:15all of anatomic pathology,
- 11:16but certainly in psychopathology,
- 11:18which probably in our community does
- 11:20the best of anyone in standardizing,
- 11:22reporting and categorizing risk right?
- 11:25Joe feel free to to jump in.
- 11:27This is how it was signed out.
- 11:29Basaloid proliferation with stromal
- 11:30fragments cannot exclude celebrate
- 11:32glenlea plasm so any pathologist
- 11:34knows that's kind of like.
- 11:35OK, it's like a descriptive thing where
- 11:37they're like we don't know whatever,
- 11:39and we're thinking you know, could it be?
- 11:42There's a long list of things that could be.
- 11:44Some of them are malignant and
- 11:45some of them are benign, right?
- 11:46And that's what we think when we look
- 11:47at it and it gets to the point of,
- 11:49you know, in the note.
- 11:50Do you list all the things it could be,
- 11:52but then people will get worried if they
- 11:53see things that are sort of low risk.
- 11:55So this went back to the primary care
- 11:57physician open to any comments in real time.
- 12:00By the way,
- 12:01feel free to unmute very and very flexible,
- 12:04and they decided look,
- 12:05I don't know what this is, I don't know.
- 12:07It means we're going to watch and wait.
- 12:08It's probably nothing, alright.
- 12:11So they did that and six years later
- 12:15he came back with neurologic symptoms.
- 12:17Alright,
- 12:17this is a real patient.
- 12:18He's 45 at this point here,
- 12:20which I consider very young since
- 12:22that's my current age.
- 12:24And
- 12:26there's one comment that came up
- 12:27at asking is this a way of saying
- 12:30specimen in inadequate for diagnosis?
- 12:31No, I don't actually think it is.
- 12:33I think it was more than
- 12:35adequate for diagnosis.
- 12:35To me, adequacy is more about like
- 12:37the amount of cells and the types
- 12:40of tissue that's there, right?
- 12:41So like if you have a myocardial biopsy,
- 12:44you need like four to six fragments
- 12:46of actual myocardium renal biopsies.
- 12:48You need like 10 to 20 glomeruli.
- 12:49You can do it unless it's not
- 12:51that there wasn't enough tissue.
- 12:52It's that in that issue that you saw.
- 12:54There's a pattern,
- 12:55and there's a differential.
- 12:56That pattern,
- 12:57so it's not that it's inadequate,
- 12:58it's that.
- 13:00I mean, I guess it gets it gets
- 13:02to the interesting philosophical
- 13:03question of adequacy, right?
- 13:04Like if you need architecture,
- 13:05does that make it inadequate?
- 13:06I don't think it's inadequate.
- 13:07I think it's just like this is what
- 13:09we can tell from this specimen,
- 13:10and maybe you should excise it if you want.
- 13:12If you wanna really know, right?
- 13:15But that kind of gets to the point
- 13:17of maybe the better term would be
- 13:19the limitation of the technique.
- 13:21Yeah, maybe? Sure.
- 13:27That's an option.
- 13:28I don't know if I've considered a limitation,
- 13:31it's it's just that's the type of test.
- 13:33It is right that and, and there are some.
- 13:36It's sort of like in radiology.
- 13:37There are certain certain tests that
- 13:39are better for different things,
- 13:40and if you get into a certain category
- 13:42of diagnosis you need to do additional
- 13:43tests or you need to sort of understand
- 13:45what risk you're getting into.
- 13:47And I think the problem here was
- 13:48that they didn't understand what
- 13:49risk they were getting into,
- 13:51so the patient came back and
- 13:53they had brain Mets.
- 13:55And metastases throughout the body,
- 13:57they excised a submandibular and,
- 13:59of course it showed adenoid cystic carcinoma,
- 14:01which was like a tiny chance of
- 14:03what that would that showed up,
- 14:06and it was scary, right.
- 14:07It was widely metastatic,
- 14:09and and what's interesting about
- 14:10this case is when we went back to
- 14:12talk to the pathologist they were.
- 14:14They were sort of like look,
- 14:15I didn't do anything wrong like
- 14:17I described it,
- 14:17and I released the case and it was right.
- 14:20So, like if they didn't understand,
- 14:21that's not my problem,
- 14:22so I don't know how people feel about that.
- 14:25But I think interestingly,
- 14:26there was an Institute of Medicine,
- 14:29now called the National Academy of
- 14:31Medicine report in 2015 called around
- 14:34diagnostic error for the first time
- 14:36and they define diagnostic error
- 14:38for the first time and interest
- 14:41for pathologists and and for and
- 14:43for someone wrote.
- 14:44That's why we have the Milan system
- 14:46which I love as a as a as a fan of
- 14:48the team behind the Milan system.
- 14:50But that's right, right?
- 14:51Like standardized reporting is really clear.
- 14:54Anyway, it diagnostic error.
- 14:55About the definition actually
- 14:57include commute,
- 14:57proper communication of the results
- 14:59in the definition for the first time,
- 15:01and that was a report written for
- 15:02pathologists and radiologists,
- 15:03which really changed things for us
- 15:05like we had never really considered
- 15:07that before.
- 15:08So anyway,
- 15:09I'm going to shift to something more current.
- 15:11I don't know how you guys are doing
- 15:13with open notes and with the Cures
- 15:15Act and with whether or not you
- 15:18hold EM atomic pathology results,
- 15:20you must not,
- 15:20because it's the Cures Act went
- 15:22live right about a couple a year
- 15:24or two ago and now, for example,
- 15:26all the mass General Brigham
- 15:28patients get immediate access to
- 15:30their anatomic pathology reports
- 15:31like the the literally the second
- 15:33you click finalize or release,
- 15:35or whatever it is in your system.
- 15:37It comes to their portal.
- 15:38And it's created a lot of thanks,
- 15:40so let me tell you a story
- 15:42that started with us.
- 15:42This is again a real real story.
- 15:44A young ish woman who presented
- 15:46to the Ed with new ascites.
- 15:48She had a diagnostic tap.
- 15:51Some paracentesis that showed
- 15:54metastatic adenocarcinoma.
- 15:55What's really kind of is interesting
- 15:57from a systems perspective,
- 15:58is it?
- 15:59It came actually under hematology
- 16:01because the CP people actually noticed
- 16:03in the tap that there was metastatic
- 16:06adeno and put it in the comment
- 16:08and the patient actually received
- 16:10this diagnosis via text like on
- 16:12her in her hospital bed right?
- 16:14'cause she got a notification
- 16:15that something was finalized.
- 16:16She clicked on it and that's how she
- 16:18found out and the clinician when
- 16:20they went to go search them in epic.
- 16:22Actually couldn't even find out where
- 16:23it was and the patient was really
- 16:25distraught and it was kind of a
- 16:27disaster so we were able to take a
- 16:29screenshot of how it appeared on her phone.
- 16:32And it was sort of like a loophole
- 16:34like it was a it was a smear
- 16:36review right of a hematology where
- 16:37they put it in the comment.
- 16:39And so when the when the clinician
- 16:41went to go search it out and the
- 16:43cytology had been withheld was held.
- 16:45At that point they couldn't even find it.
- 16:46So it's really sort of a Swiss cheese
- 16:49of like what could go wrong in in an IT
- 16:52system and and then you know there's so
- 16:54many other things that can go wrong for us.
- 16:57It's amazing things go right,
- 16:58the the amount they do,
- 17:00you know we lose things all the time.
- 17:02I know your separate AP and CP,
- 17:04but I'm sure there's a lot of shared
- 17:05specimens that are really difficult.
- 17:06Those unknown lesions that could
- 17:08be micro or AP auto verification,
- 17:11Miss process assessments,
- 17:12critical values,
- 17:13people argue about what is what
- 17:14should get a call.
- 17:15What shouldn't get a call,
- 17:16challenges with interface, right?
- 17:17Like you format something in a specific
- 17:19way because you think it's safe,
- 17:21and then when it goes to the portal
- 17:22it's like completely unformatted
- 17:24and then some of the issues
- 17:25we've talked about open notes.
- 17:27So I think interestingly,
- 17:28from a safety perspective you know when
- 17:31do we actually analyze these cases.
- 17:32We do a class analysis.
- 17:34When do we tell people about
- 17:35it and to whom by whom?
- 17:37Meaning like is it the
- 17:38pathologist calling the patient?
- 17:39Is the pathologist called the treating
- 17:40clinician like how do we manage this?
- 17:42And I think one of the main problems
- 17:44we have in pathology is we're so
- 17:46overwhelmed and many of our issues are
- 17:48so complicated and shared with so many
- 17:50different non pathology team members.
- 17:53Is we really only disclose when there's harm,
- 17:56right?
- 17:57So there's this like vast, you know,
- 18:00untapped risk of like you know,
- 18:02imagine you have two GI biopsies.
- 18:04And they're like switched.
- 18:05But you know they're both benign
- 18:07and you realize it, so you're like,
- 18:09alright, we switch it back.
- 18:10We relabel it.
- 18:11There's maybe like a day delay
- 18:12in the turn around time.
- 18:13But you haven't harmed anyone.
- 18:15And I bet you don't report that.
- 18:16Or if you do, you're surely not gonna do it.
- 18:18Complicated root cause analysis on it, right?
- 18:19'cause you just don't have the bandwidth.
- 18:21So how do we tap into that risk
- 18:23to make the systems better?
- 18:25You know,
- 18:26not just at the very top of the
- 18:28like when we're really harming people,
- 18:30like in this prostate case,
- 18:31like how can you get at
- 18:33the learning and I think.
- 18:34Part of the other issue is
- 18:35labs are different, right?
- 18:37Like all those systems,
- 18:38the hospital level, graphical quality,
- 18:40the RL solutions, all these things.
- 18:41They were all designed for clinical medicine.
- 18:44They were not designed like for
- 18:46our production line manufacturing
- 18:48type systems engineering and how
- 18:49we move back and forth from like
- 18:51automated systems to human systems.
- 18:53Very nuanced diagnosis like people.
- 18:55Think of it as right or wrong.
- 18:57And in anatomic pathology,
- 18:58anyone who's ever thought about how you
- 19:00cognitively come to a diagnosis knows
- 19:02that it can be much more Gray than that.
- 19:04The other thing that's different
- 19:05about us so is people really
- 19:07don't understand what we do like.
- 19:09We'll go to a, you know,
- 19:10some bad thing happens and you go to
- 19:12present it to the board or something
- 19:13and you have to spend 10 minutes
- 19:15explaining how it normally happens
- 19:16before you even talk about what went wrong,
- 19:19right?
- 19:19Like there's no understanding
- 19:21of our processes.
- 19:23We do have this production line
- 19:24type workflow batching is common,
- 19:26you know we do we just because that's
- 19:28the way we do things which everyone
- 19:29knows this dangerous but it's just
- 19:31how can you handle it otherwise,
- 19:32especially now with the national.
- 19:34Technologist shortage shortage that
- 19:36we're all facing incredibly high
- 19:39volume people don't understand right?
- 19:42And you know,
- 19:43I think the subjective versus the
- 19:45objective result. You know people.
- 19:47You'll see something that says
- 19:49like what are the results?
- 19:51You know the results are not finalized as
- 19:54if it's like a potassium you know not.
- 19:56So I think that's a really
- 19:59interesting perception right?
- 20:00And and it puts a lot of stress on
- 20:02us multiplicity of events right?
- 20:04Like so.
- 20:04In that case, best case scenario,
- 20:06it affects 2 patients.
- 20:08There's two swapped events,
- 20:09but you can imagine a scenario we
- 20:11had a case where we miss diluted
- 20:13our formalin for like six months.
- 20:15We were buying concentrated formalin
- 20:17and diluting it at the wrong
- 20:19concentration to say to save money
- 20:21like we weren't buying prefab 10%
- 20:23buffered formalin, which we now do anyway,
- 20:26we realize that none of the IHC had
- 20:28been validated for that concentration,
- 20:30and it was like a total.
- 20:31You know, it's like for six months,
- 20:33and if you think about it, even the most.
- 20:35Dedicated patient safety professional.
- 20:37Like the volume of events that happens
- 20:39in pathology is is really a challenge.
- 20:41We had another time.
- 20:44We had a vendor who was bringing us and
- 20:47GI endoscopy specimens from an offsite,
- 20:49like private endoscopy.
- 20:51Come, you know,
- 20:52practice and they just lost an entire.
- 20:56They threw it away by accident.
- 20:57An entire bag of specimens,
- 20:59and it was like 46 patients or something.
- 21:01You had to go through every single provider,
- 21:02figure out what was retrievable,
- 21:04what wasn't, so you know it's different.
- 21:06Labs are different.
- 21:07It's not the same kind of events.
- 21:09This new legislative transparency I see
- 21:11Vanita wrote in the chat that patients.
- 21:14Do not get immediate notification,
- 21:16so that's interesting.
- 21:17I wonder how that was circumvented,
- 21:20maybe maybe there's a slight delay,
- 21:22but so I think what's interesting about
- 21:24us is we do need special systems, right?
- 21:27And they need to be able to have the
- 21:29capacity to deal with this volume,
- 21:31and we also, you know we don't
- 21:33talk to people like we're sort of
- 21:35pathologists aren't exactly known as
- 21:37the most the best communicators, right?
- 21:40Susie Densis in Seattle did a
- 21:43bunch of studies like focus groups
- 21:45and things on disclosure.
- 21:46Of of of pathology error
- 21:48and she put quotes in it.
- 21:51It was an archives paper some years ago
- 21:52and one of them said something like
- 21:54we became pathologist 'cause we don't
- 21:55want to talk to people or something.
- 21:57So that's kind of very telling about
- 21:59how motivated we'd be as pathologists
- 22:01to have difficult conversations if we
- 22:03don't want to have like any conversations,
- 22:05right?
- 22:07So I'm going to shift gears a little.
- 22:12Johnson Art says I'm pretty sure they do now,
- 22:14but they didn't used to.
- 22:15Yeah, I think actually they do not
- 22:18since I've been in conversation with
- 22:21both Alan Shao and Harlan Krumholz.
- 22:24So when we went live we did
- 22:27for a brief period of time.
- 22:29But as has been reported in the literature,
- 22:32the number of communications
- 22:33to clinicians went up by 70%,
- 22:37and so the board made a decision to
- 22:39not send alerts to patients. Works
- 22:42are available in the chart,
- 22:44but the patient are not.
- 22:46Patients are not alerted,
- 22:48and so one of our discussions was
- 22:51about the disparity of care that this
- 22:54decision by the system results in,
- 22:57because obviously educated patients
- 22:59are eager and they jump to it
- 23:02and they check their reports,
- 23:03but those. You
- 23:05know, a lot of patients don't have access.
- 23:08Super interesting,
- 23:09and I think that's kind of where.
- 23:11So you have to make them
- 23:13available immediately,
- 23:13'cause otherwise you're sort of subject line,
- 23:15so that was sort of the legal
- 23:17sort of interpretive loophole,
- 23:20so to speak that we use.
- 23:23I think one is that what you're
- 23:24talking about is like a push
- 23:26system versus a full system,
- 23:27so you did away with the push,
- 23:28and you have the pull system,
- 23:29which I think we actually did too,
- 23:33at least for anatomic pathology results.
- 23:35For CP results we left it.
- 23:36And so this was a funny loophole.
- 23:38'cause it was a hematology result,
- 23:39but I don't wanna get too far into the weeds.
- 23:41I think it's really interesting,
- 23:42and I think your disparity
- 23:43comment is really timely.
- 23:44Tejal Gandhi has written about this.
- 23:46If you're interested in,
- 23:47then in the New England Journal
- 23:49and other places around how the
- 23:51Curious Act can widen disparities.
- 23:53And it is very interesting.
- 23:55But there's so much to talk about.
- 23:56I'm going to move on a little
- 23:58just to show you everyone knows
- 23:59the three phases of pathology,
- 24:01so I'm not going to harp on it
- 24:03except to say you know everything
- 24:05that we don't have access.
- 24:07We don't have control over its preanalytic.
- 24:10You know analytic is usually what
- 24:11we control in the lab and then post
- 24:14is everything about communicating
- 24:15and turn around time and that
- 24:17kind of thing and now cures act.
- 24:19What I think is really interesting is.
- 24:23Myself and many others roughneck land.
- 24:25Others have reported that up to
- 24:2790% of errors in or safety events
- 24:30in pathology are preanalytic and
- 24:32yet we spend all our time really
- 24:34focused on analytic error, right?
- 24:35Thinking like don't miss the Melanoma.
- 24:37Don't miss the signet ring cell,
- 24:38which is really important,
- 24:39but we don't get a lot of training
- 24:40and we certainly don't spend a
- 24:41lot of resources thinking about
- 24:43the preanalytic phase,
- 24:43so I think that's really critical.
- 24:46Why don't we?
- 24:47This was a patient safety event.
- 24:49As a study we did by severity.
- 24:52Which showed that we really don't hurt that
- 24:55many people like like I was saying before.
- 24:57Most of it is just risk,
- 24:58right?
- 24:58So if you don't have a lot of bandwidth,
- 25:00you're not going to investigate
- 25:01the no harm in near Miss events,
- 25:03so I think that's partially,
- 25:04you know we have this untapped risk
- 25:06at the bottom of what they call
- 25:07the Heinrich Pyramid and the way
- 25:09I teach this to our residence is,
- 25:11you know, let's say you're driving.
- 25:13The more you sort of speed
- 25:14and do unsafe things.
- 25:15And like the more near Miss Accidents,
- 25:17you're going to have and the more risk
- 25:19you're going to have to actually have,
- 25:20like a fatal or difficult accident.
- 25:22So what you wanna do is address.
- 25:23Your style of driving so that
- 25:25you you don't get to the
- 25:27top before you do anything,
- 25:28and so that kind of gets to what
- 25:30our culture is in the lab,
- 25:32right? I think patient safety alone is a
- 25:36relatively new concept and so you know,
- 25:40we used to really focus on not being sued,
- 25:43right? Risk management was a thing and
- 25:44now the patient safety movement in general
- 25:46is more about actually just optimizing
- 25:48things and thinking about patient
- 25:49safety as opposed to just like is there
- 25:52malpractice risk here, and if not like.
- 25:54Too bad kind of thing and in the
- 25:56lab we always had like QA QC, right?
- 25:58Like is the fridge at the right temperature,
- 26:01you know is did we do 20 her two neu?
- 26:04Did we you know the whole checklist for CAP
- 26:06or don't Commission or whatever you use?
- 26:08And I think one of the things we shift
- 26:10towards is changing the language to
- 26:12quality and safety to think about culture,
- 26:14which is not something we've thought
- 26:15about often in the lab.
- 26:16And to think about continuous
- 26:18improvement as opposed to compliance.
- 26:19Like I remember when I started,
- 26:21we started these meetings where
- 26:22they would show all the CAP.
- 26:24Sort of goals.
- 26:25Back in the day when they
- 26:26had more mandated goals,
- 26:27they've dropped a lot of those and
- 26:29it would just say like 100% a 100%
- 26:31compliance and then we were done
- 26:32with the meeting and I thought like,
- 26:34well,
- 26:34of course it's 100% 'cause otherwise
- 26:36our lab would be shut down like that's
- 26:38an accreditation metric like we're
- 26:39not learning anything here, you know.
- 26:41So I think the difficulty with getting
- 26:43people to shift to like let's look
- 26:45at the things we do poorly on, right?
- 26:47Like let's have all the boxes be red.
- 26:48So then we can make things better
- 26:50like our goal is the delta.
- 26:51Not like we're not going to just look
- 26:53at the things we're already good at.
- 26:54We're going to look at.
- 26:55Capacity for growth,
- 26:56and I think that's been a really
- 26:58tough in an environment where people
- 26:59were so focused on compliance,
- 27:01especially like in CP Blood Bank
- 27:04in AP psychology,
- 27:05those are the cultures that were like
- 27:07very compliance focused to think about
- 27:08we're actually gonna shine a light
- 27:10on the stuff that we feel vulnerable about,
- 27:12so that we can make it better that just took
- 27:14a lot of feeling of like it's going to be OK,
- 27:16and we're not going to be like written up,
- 27:18and it's actually that's our goal,
- 27:20right?
- 27:20And it it, it works.
- 27:22I think we're a little behind in part,
- 27:24you know, the rest of medicine.
- 27:26They never really used the word quality
- 27:28like it wasn't in the vernacular
- 27:31of like hospitalists, or actually,
- 27:32hospitals weren't even a thing,
- 27:33probably 10-15 years ago, so you know,
- 27:36just except for kind of like ID doctors,
- 27:39it wasn't in the vernacular,
- 27:41so the quality patient safety movement
- 27:43started with kind of like Libby Zion.
- 27:46For those of you who paid
- 27:47attention to New York at that time,
- 27:49Betsy Lehman,
- 27:50for those of you who know that
- 27:52that was the The Globe reporter
- 27:54who was who was killed at the.
- 27:56At the Dana Farber because of an overdose of
- 28:00chemotherapy because of a medication error,
- 28:03and ironically she was a medical globe
- 28:05reporter and there were a bunch of
- 28:08other pretty high profile medical error
- 28:10cases that led people to realize that,
- 28:12like you know the the there are other
- 28:15things besides the natural evolution
- 28:17of disease that kill patients right?
- 28:19And and one of those things is
- 28:21mistakes and so you know, accepting
- 28:24that and being transparent about it.
- 28:26Became part of the general
- 28:29culture of medicine.
- 28:30I think what was different about
- 28:32the labs is we use the word
- 28:34quality and safety forever, right?
- 28:35But for us it meant something different.
- 28:37It meant compliance and it
- 28:39meant like environmental safety,
- 28:41like the formalin levels.
- 28:42You know,
- 28:43the eyewash station and this and that,
- 28:45and so shifting that from thinking OK,
- 28:48we need to do all those things
- 28:49like to stay in business,
- 28:50but that's not what we're talking about when
- 28:52we talk about quality and safety, right?
- 28:53We're talking about the broader patient
- 28:55safety movement and how to apply it to labs.
- 28:57And the broader quality culture.
- 29:00So one thing we struggle with at Harvard.
- 29:02I mean if you do at Yale also.
- 29:06I'm not a football fan,
- 29:07but I do know that there's a
- 29:09deep rivalry between the two,
- 29:11at least the tailgating is worth going to
- 29:13alone is that we focus all of our energy on,
- 29:17sort of the few you know,
- 29:19translational and basic science research,
- 29:21and that's where we put a ton of resources.
- 29:25It's like sexy,
- 29:26it's you get tons of publications.
- 29:28It's what we're proud of, right?
- 29:29But I think what's really amazing to me is
- 29:32behind the wall of all this fabulousness,
- 29:35and these are.
- 29:36Publications from mass general faculty from
- 29:38cell from Nature from all kinds of things,
- 29:41the that issue that led to all these
- 29:43publications is still processed like this,
- 29:45right?
- 29:45Like it literally comes in Tupper
- 29:48Ware containers in plastic bags in,
- 29:50you know, labeled in with a label.
- 29:52Nothing about the preanalytic
- 29:53phase has changed,
- 29:54nothing right?
- 29:55And so all the risk that's
- 29:57there is still there.
- 29:59You know you can make it
- 30:00look pretty good afterwards,
- 30:01but you know very little has
- 30:04changed in in surgical pathology.
- 30:06So I think the overarching goal for
- 30:08us needs to be to change how we even
- 30:10think about quality and safety,
- 30:11which originally traditionally was
- 30:12like we're gonna just be compliant
- 30:14like we're gonna get cap.
- 30:15That's gonna give us the seal
- 30:17of approval to go forward.
- 30:19We're going to like take care of patients.
- 30:20And then we're going to.
- 30:21Yeah, maybe we'll like manage operations,
- 30:23will firefight.
- 30:23And then if we have any energy
- 30:25left whatsoever,
- 30:26we'll do quality improvement, right?
- 30:29And what I would say is it needs to
- 30:31change like the base needs to be.
- 30:33The culture, like people need to feel safe.
- 30:35They need to feel like they can
- 30:37bring forward.
- 30:37Those risks and that somebody
- 30:39will be there to,
- 30:40you, know, listen,
- 30:41they need to be involved in the solution.
- 30:43If they call it events,
- 30:44you actually have to follow up with them.
- 30:46Tools need to kind of be disseminated,
- 30:48like root, cause analysis,
- 30:50safety events, eminems,
- 30:51whatever you wanna do.
- 30:53Those tools need to sort of be pushed
- 30:54out to the front line and they need
- 30:57to feel comfortable using them or or,
- 30:58you know, get some assistance or
- 31:00standardized because obviously
- 31:01no one resource to create a
- 31:03division to assist every single
- 31:04person with every single risk.
- 31:05And I don't want you to think we are either.
- 31:09I think the other thing about labs
- 31:11that's kind of overwhelming is,
- 31:14you know, when I say, oh, you know,
- 31:15don't worry about the compliance.
- 31:17That should just be a
- 31:18small part of what you do.
- 31:19Well, easy for me to say, right?
- 31:20There's like 400 compliance
- 31:21agencies that you need to keep
- 31:23up with just to stay in business.
- 31:24Now I know AP and CPR separate at Yale,
- 31:28but you know, even if you just count
- 31:30cap and Joint Commission which you
- 31:32which you have to do, it's still.
- 31:35It's still like 400 checklist items, right?
- 31:37So I don't want to minimize that.
- 31:38I know it's hard to to keep up with.
- 31:41The other thing that's different,
- 31:43I think, is.
- 31:44People at the hospital level think of
- 31:46us as like the smaller labs in AP.
- 31:48You know, they think it's like lower volume.
- 31:51It's like a bunch of people
- 31:52and sometimes in the basement,
- 31:54sometimes in that window.
- 31:55What are they doing down there?
- 31:57But what's interesting about it?
- 31:58When you look at at risk the the
- 32:02proportion of error or of risk
- 32:04in anatomic pathology is way way
- 32:07way higher than in CP.
- 32:09And that's not because we're stupid, right?
- 32:12It's because everything we do is manual.
- 32:15Right, and so you know,
- 32:17if you put a thing in a machine and
- 32:19it sort of gets gives you a result,
- 32:21it's gonna fail at a very reliable rate,
- 32:24right?
- 32:24But humans,
- 32:25you know it's a combination
- 32:26of patient related factors,
- 32:28tissue diagnostics and everything.
- 32:30We just delete.
- 32:31Our job is hard and and I think
- 32:34people need to accept that so.
- 32:35I'm going to shift gears in the
- 32:37second half of my talk and speak
- 32:39a little bit about some of the
- 32:41tools we've used around culture.
- 32:43If that's OK and high reliability
- 32:45is something that the Trump
- 32:46Commission and others have written
- 32:48about in terms of there,
- 32:49are there are principles of high reliability
- 32:52which and here are the principles?
- 32:57So interestingly,
- 32:57the first one is the toughest for labs.
- 33:00The preoccupation with failure.
- 33:02You know. People think of us
- 33:04as the gold standard, right?
- 33:06They think of us as like the result,
- 33:08the answer and for us to focus instead
- 33:11on what we do poorly is really tough
- 33:13culturally and from a moral perspective,
- 33:16and certainly again in this after COVID.
- 33:19You know, the labs were just like you know,
- 33:21murdered during COVID from a you
- 33:23know everyone was between being
- 33:25sick and out the lab shortage.
- 33:27And just like you know,
- 33:28the actual testing platforms,
- 33:30it's been a terrible people say, oh,
- 33:32it's great people know what we do now,
- 33:34which is like a nice like
- 33:35it's a silver lining I guess,
- 33:37but everyone is exhausted, right?
- 33:38People are exhausted and in AP we had
- 33:41major financial hits because of shutdown
- 33:43of elective surgeries and things like that.
- 33:45So it's been tough.
- 33:49I think you know thinking about the
- 33:51bandwidth to make things better is really
- 33:52hard when you're just trying to survive,
- 33:54you know.
- 33:55So I just wanna put in a note about
- 33:56that and just make sure that you
- 33:58take that with a grain of salt while
- 34:00we're discussing this or reluctance
- 34:02to simplify interpretations is
- 34:03really hard when you're busy.
- 34:05So for you to say, oh, I know what happened.
- 34:07It got switched.
- 34:08The microtone like Susie Q was like
- 34:09talking and it's she takes all the
- 34:11stuff at the same time. And that's why.
- 34:13So that's not curious, right?
- 34:15That's like you just wanting
- 34:17to be done with it so.
- 34:19I think figuring out usually there's a lot
- 34:21of different reasons why something happens,
- 34:24and understanding the complexity
- 34:25of the reasons helps you be
- 34:27successful in solving the problem.
- 34:29Resilience is like your capacity
- 34:31to fail and then get up again.
- 34:33So that is to me that's a more valuable
- 34:38and more honorable and more successful
- 34:41trait than existing excellence, right?
- 34:44Which is really tough for
- 34:45an organization like mass,
- 34:47general or Harvard Medical School.
- 34:49To say,
- 34:49yeah,
- 34:49we actually fall down and we're
- 34:51going to share with you how we
- 34:52fall down and how we get better as
- 34:54opposed to like we're the best.
- 34:55You know people who are the best are not
- 34:57going to tell you how they messed up, right?
- 34:59But everyone messes up.
- 35:01And so if we can do it and we can
- 35:02share what we learned, isn't that?
- 35:04Isn't that valuable?
- 35:05You know?
- 35:06And the other thing that's useful.
- 35:07I think the deference to expertise
- 35:09has to do with deferring to
- 35:11the frontline order meaning,
- 35:12so I'll give you an example we had.
- 35:14We had a case where a patient died because
- 35:17they didn't get blood products in time.
- 35:20The pneumatic tube system failed,
- 35:23and so you know,
- 35:24we went through many different iterations
- 35:25where we couldn't figure out why it failed.
- 35:27We sent the blood,
- 35:28they never received it.
- 35:29We sent it again.
- 35:30They never received it,
- 35:30so we ended up having the
- 35:32buildings and grounds guys
- 35:33come through M&M.
- 35:34Turns out that one wing of the
- 35:36hospital where this patient was
- 35:38was built at a different time,
- 35:40and the pneumatic tube system
- 35:42was like 3 millimeter smaller
- 35:44than the rest of the hospital,
- 35:45and the lab techs were sort of
- 35:47overstuffing the pneumatic tube
- 35:49containers because the patient was
- 35:50crashing and needed massive amounts
- 35:52of blood and they were getting
- 35:53stuck and we actually had them
- 35:55present like a map of the different
- 35:57pneumatic tubes of the hospital,
- 35:58and they're different diameters which
- 36:00like talk about different expertise.
- 36:02There's no way anyone in the pathology
- 36:03department would ever know that, and.
- 36:04The the The Blood bank texts were
- 36:06blaming the nurses the nurses
- 36:07were going to the blood bank
- 36:09text and it turns out there was
- 36:10like a total system explanation.
- 36:11So that was really interesting for
- 36:14us and sort of reaching out to those
- 36:16buildings and grounds guys who normally
- 36:17don't get involved in anything clinical.
- 36:19Certainly not an Eminem
- 36:20was really interesting.
- 36:23So I was thinking about telling you
- 36:26about a couple of things we've done to
- 36:28try and address some of these things.
- 36:30One of them is create and implement
- 36:32pathology, Eminem Realms and the
- 36:33other is a new thing we're doing
- 36:35called diagnostic error or diagnostic
- 36:37learning opportunity grounds,
- 36:38and I hope we'll have time for another day.
- 36:42I can and I think I spoke with with
- 36:44some team members this morning,
- 36:47including Andrea and Carla to talk
- 36:49about some of our performance dashboards
- 36:51and patient safety dashboards.
- 36:54So and Chi in process redesign.
- 36:56But today we're going to talk
- 36:57more about M&M rounds and these
- 36:59other rounds we're doing.
- 37:00So if you think back on our cases that
- 37:02I showed you one was preanalytic,
- 37:05one was post analytic and one was
- 37:07this like it legislative problem.
- 37:09So you can tell I made a real effort not
- 37:11to focus on something that was like,
- 37:13oh look at this Melanoma that was missed,
- 37:15right?
- 37:15'cause that's something that
- 37:16you get a lot of.
- 37:18So I really think we have to extend beyond
- 37:21worrying about what we're taught to worry
- 37:23about and and develop some new tools.
- 37:26So we developed these Eminem rounds.
- 37:28It was partially in response.
- 37:30We were already doing it,
- 37:31but we integrated residents because of
- 37:33new AC GME guidelines and pathologists,
- 37:36you know,
- 37:38we love to go to other people's
- 37:39M&M's and like shame them.
- 37:41You know, like this is the answer,
- 37:43this is what you missed but we
- 37:45frequently don't have our own EMS right,
- 37:46do you?
- 37:47I should say I should pause and
- 37:48if I were there in person I would
- 37:50ask if you have your own eminems.
- 37:53We currently do not have.
- 37:55Departmental Eminem it's in the works of
- 37:58being developed and and we're you know,
- 38:00we're tasked by the hospital to develop
- 38:02such a program in our department.
- 38:04Awesome, and I really looking
- 38:06forward to the next few slides. Oh
- 38:08well, this is a very very.
- 38:09This is like headlines only so I'm happy to.
- 38:13I think I was telling you earlier.
- 38:14We have like an 8 to 10 year experience.
- 38:16That's about to come out and
- 38:18we're going to publish all the
- 38:19templates and tools so people can
- 38:21just download them and use them.
- 38:22I see Marcelo there.
- 38:23I don't want to call out Marcelo,
- 38:25but Marcelo participated in
- 38:26more than one M&M.
- 38:28He did a great job.
- 38:29He's not
- 38:30now that I know that I'm going
- 38:31to have to go after Marcelo
- 38:33to get his experience. He's
- 38:35like I'm done with that,
- 38:37but I don't know where. I'm happy to help.
- 38:40Yeah, I mean you were there when we
- 38:42when we did that for many years.
- 38:44And it it was a total game changer.
- 38:46I mean, I don't want to overstate
- 38:48people were really nervous about it,
- 38:50like they didn't want to do it,
- 38:51and we invited like the we invited
- 38:53everyone like the secretaries
- 38:54were there or the assistants,
- 38:56the transcriptionist, the residents,
- 38:59the technicians, the chairman.
- 39:01And it. It, it was.
- 39:03Really, I don't know. I didn't.
- 39:04I don't think I realized how unique
- 39:06it was at the time until I started
- 39:07working in a different organization,
- 39:09and I realized that it's just not
- 39:10the culture, right? I don't know.
- 39:12Marcello, if you have any,
- 39:12I'm sorry to call on you.
- 39:13But if you had any.
- 39:14Memories of it.
- 39:16Actually I I would point
- 39:17out that it it was it.
- 39:19It was great 'cause it didn't.
- 39:21It didn't feel putative and
- 39:23it didn't feel like you know.
- 39:26You know people were looking
- 39:27to assign blame, blame.
- 39:29It was really a clear exploration
- 39:32of system related factors.
- 39:35I I as a resident,
- 39:36I found it to be really.
- 39:38A good a great learning experience
- 39:40and like a confidence builder.
- 39:41Honestly I thought it was great.
- 39:44OK, not a planted comment.
- 39:46Thank you, Sir.
- 39:47Thank you so much. I think it was.
- 39:49We tried very very hard to have
- 39:52curiosity be our focus and to select
- 39:54cases that had the biggest capacity
- 39:57for systems learning and to really
- 39:59open things up like to take away the
- 40:01safety net review behind closed doors
- 40:03and among leadership and make it more open.
- 40:06And we found that also increased
- 40:08reporting events 'cause people felt like
- 40:09oh this is this would be a good Eminem right?
- 40:11So we openly and honestly looked at cases.
- 40:15Figured out what happened and tried to
- 40:17fix them and promoted open discussion
- 40:19and transparent culture.
- 40:21We had a model where how we identified
- 40:23cases very standardized.
- 40:25We did RCA's and as I said we have
- 40:28a whole conference guide.
- 40:30We had like a slide deck template which
- 40:32we're going to get out there and I'd
- 40:34be happy to share two and then we just
- 40:36did it the same way every time so it
- 40:38never felt sort of like a witch hunt.
- 40:40It always felt like this is what we're doing.
- 40:42This is our system and it
- 40:45became totally normalized.
- 40:46And we shifted things.
- 40:47I know in pathology we never
- 40:48had our traditional Eminem,
- 40:49but for those of you who who did
- 40:52grow up in clinical medicine
- 40:53and in pathology in Canada,
- 40:55you have to do a surgical and
- 40:57medical residency internship.
- 40:58So I remember like standing at the
- 41:01front of those amphitheatres and just
- 41:03feeling like completely grilled,
- 41:06right like it wasn't a friendly
- 41:09place and we really only looked
- 41:11at harmful events in.
- 41:12In our case,
- 41:13we really were trying to look
- 41:14at near misses or close calls.
- 41:16With the capacity for learning,
- 41:17I've been talking about.
- 41:19In the traditional Eminem,
- 41:20the case information is presented by
- 41:22a person for the new pathology ones
- 41:24it was like gathered from all stakeholders.
- 41:27More systems.
- 41:27You'll see.
- 41:28It's really just from like person
- 41:31to systems and the top down punitive
- 41:33goes from the bottom up curious right?
- 41:36Like where you have frontline
- 41:37people who are like yeah,
- 41:38we don't understand what happened
- 41:39or here's how we normally do it.
- 41:41That kind of thing.
- 41:43And so again shifting the
- 41:44culture from frustration,
- 41:46anxiety to learning the denied
- 41:48offensive to transparent just.
- 41:50Culture,
- 41:50which is a balance between
- 41:53accountability and systems and
- 41:54then the top down like go.
- 41:57Figure out what happened and get
- 41:58back to us to you know engagement
- 42:00and ownership from the bottom up.
- 42:02These are real fish bones from
- 42:04real eminems we showed we had
- 42:06a breast you're going to think
- 42:07we never got a case right?
- 42:09Ever this was a breast
- 42:11biopsy diagnosis mix up.
- 42:12I think we did catch it though so
- 42:14was a mere mess and you can see
- 42:16this was a very like our most senior
- 42:18breast pathologist at the bye.
- 42:20Who had probably done millions of
- 42:22cases over his career and look how
- 42:25many contributing factors there were.
- 42:27I mean,
- 42:27it just goes to show how
- 42:29complicated things are, right?
- 42:32And we tried to make the ones
- 42:34bigger that were, you know, more.
- 42:36And everyone knows don't put
- 42:37different flags on the same tray,
- 42:39but I don't know about you.
- 42:40But our Histology lab is
- 42:41always running out of trays.
- 42:43We had another case really
- 42:45unfortunate and all explain it to you.
- 42:47We had looking at the time we
- 42:50have time we had a case where
- 42:53there was a patient who went.
- 42:55It was a frozen,
- 42:56busy frozen day, lung cancer,
- 42:58lung adenocarcinoma and there was a
- 43:00junior resident learning how to do
- 43:01frozen so they were in the frozen lab.
- 43:03Just cutting all kinds of Frozen's
- 43:05to get it right onto blank slides and
- 43:08putting them on top of the cryostat.
- 43:10Then they stained one,
- 43:11finish the frozen whatever and they got
- 43:13called away to the OR for another emergency.
- 43:16So there was a neuro patient and
- 43:18our neuro workflow with separate.
- 43:20We had different neuropathologists
- 43:21covered their own cases who was called
- 43:24rule out metastatic lung cancer.
- 43:26So already you can see what's
- 43:27going to happen right?
- 43:28So another Rep trainee gets called
- 43:31in starts picking up what they think
- 43:33are blank slides off the top of the cryostat.
- 43:35But of course.
- 43:36They're unstained lung cancer
- 43:38slides and cuts.
- 43:39Little pieces of brain onto them stains.
- 43:42It looks under the microscope and says
- 43:43it's metastatic lung adenocarcinoma,
- 43:45and they do a pretty big resection of
- 43:47the patient's brain and they find out
- 43:50that actually it's not in the block
- 43:51and it was reactive gliosis and that
- 43:53tissue was from the previous patient
- 43:55and it was a different resident,
- 43:56different attending,
- 43:57different patients,
- 43:58same day and just 'cause they didn't
- 44:00label the slide right and look at.
- 44:02There were so many issues that led
- 44:03to that this is a real real story.
- 44:06All true stories.
- 44:08So we actually got the the Eminem
- 44:11conference at crowded at VHS.
- 44:15And we awarded risk management credits
- 44:17which improved attendance in the days when
- 44:20people could come in person and really
- 44:23thought carefully about how we moderated it.
- 44:27Encouragement of frontline workers
- 44:28and trainees and the other thing
- 44:30we did once we were comfortable is
- 44:32we started inviting guests.
- 44:33So let's say we had a case
- 44:36that like affected.
- 44:38You know the OB guy in team?
- 44:39We would have the OB guide people come
- 44:41and that really at the beginning people
- 44:43stress people out like they did not want.
- 44:46It was like inviting guests to
- 44:47the family dinner table and then
- 44:49talking about family problems.
- 44:50You know, like they didn't,
- 44:51they didn't.
- 44:51They like can we just talk about
- 44:53it and then tell them later?
- 44:55And they were worried like they were
- 44:57worried that our treating clinicians would
- 44:58think like we don't know what we're doing.
- 45:01I would say from our surveys and
- 45:03from feedback from those people
- 45:04over like a decade long period.
- 45:06It did just the opposite,
- 45:08like they were actually able to help
- 45:09us bake into our proposed solutions or
- 45:11poke holes in some of our pro solutions.
- 45:14Like, well,
- 45:14if you do that then when we order it,
- 45:15we're not gonna be able to
- 45:17see this or you know,
- 45:18and they were also able to just have
- 45:20empathy for how complicated our work
- 45:22is and feel like they were a team.
- 45:24So it really changed things
- 45:25for us having folks.
- 45:27Fair, so we created this guide which we sort
- 45:31of tweaked every time we had an Eminem.
- 45:34Which I'm happy to share,
- 45:35and that's kind of a.
- 45:36That's a very like 40,000 foot
- 45:38view of like a 10 year experience.
- 45:40So there was a lot of work that went
- 45:42into it and it was really transformative.
- 45:45So since I got to MGH,
- 45:47I'll shift for my final little story
- 45:50about what we've done differently.
- 45:52To be quite honest,
- 45:53I didn't feel like MGH was
- 45:55ready for an M&M just yet.
- 45:56Culturally,
- 45:57that takes kind of a big feeling of
- 46:00psychological safety to get everyone
- 46:01in a room and start talking about that.
- 46:03So we started doing something different,
- 46:06which is we called the diagnostic
- 46:08Learning Opportunity Conference.
- 46:09And what we did was we took
- 46:11very senior people,
- 46:12full professors who were very
- 46:14well regarded in their fields
- 46:15and we went to them and we said,
- 46:17tell us about a time you missed a
- 46:19diagnosis and the interesting thing
- 46:20was these are like people in there.
- 46:2260s seventies, sometimes greater.
- 46:25Who literally were like in 1992.
- 46:28I had this case, you know,
- 46:30like it was like 2 seconds.
- 46:32They could remember exactly the case
- 46:34right and everything that happened.
- 46:36Which is kind of amazing and it
- 46:38goes to how powerfully emotional
- 46:39like you know how you remember
- 46:41things when they're traumatic.
- 46:42So we would have people come and talk
- 46:45about their mistakes and this was
- 46:48partially to strengthen safety culture,
- 46:50but also to teach trainees it was made.
- 46:52It's for trainees about what
- 46:54to do when this happens to you,
- 46:56'cause it's inevitably gonna happen to you.
- 46:58Maybe not in such a dramatic way,
- 47:00but like you're gonna miss something.
- 47:01How do you document it?
- 47:02How you disclose it? You know?
- 47:04How do you do in RCA?
- 47:05And we built it on this New England
- 47:07Journal article that came from Joe
- 47:08Shapiro where those of you who know
- 47:10did a lot of work on the second victim.
- 47:12She was a Brigham surgeon who
- 47:14basically invented peer support.
- 47:16Which is dumb.
- 47:18You know, I think clinicians do where
- 47:21they help each other after they've
- 47:23been involved in a harmful medical
- 47:24error and support one another and
- 47:26they call that the second victim.
- 47:28So this is the sort of circle app
- 47:30framework from that New England Journal
- 47:32that basically is a very fancy,
- 47:33sophisticated way of saying like you
- 47:35should talk about things after they
- 47:37go wrong and support one another
- 47:38like it's that's their whole like.
- 47:40I wish I could write a New England
- 47:42Journal paper that had that obvious tagline.
- 47:43Anyone who's ever been in therapy
- 47:45knows that's like obvious, but anyway,
- 47:46they they created this whole framework.
- 47:48It was great around speaking up teamwork,
- 47:50making things better and supporting each
- 47:52other, and also empowering people right?
- 47:54So letting people say this was
- 47:56a disaster and I'm going to
- 47:58be empowered to make change,
- 47:59and that happened during the pandemic.
- 48:02I think the interesting thing coming back
- 48:04to MGH for me as a Canadian who like didn't,
- 48:07I did a fellowship there for a year,
- 48:08but I didn't grow up there is I
- 48:10was looking back and there was a
- 48:12case records for those of you who
- 48:13read the CPC's and then we England
- 48:15Journal where they basically said
- 48:17you know this is a really famous.
- 48:20These are where they show
- 48:21famous case reports right?
- 48:22Like a 38 year old woman with renal
- 48:24failure and thrombocytopenia or
- 48:26whatever and incredibly famous.
- 48:28And then it took them 100 years.
- 48:32To present their first case of a mistake,
- 48:36and it's the most downloaded CPC
- 48:38in the history of the CPC's,
- 48:40and they haven't had one since,
- 48:43and I find that super interesting,
- 48:44it was a wrong site surgery.
- 48:46Greg Meyer came and he he was the
- 48:48discussant for this wrong site surgery
- 48:50and it's amazing to me that this is.
- 48:52It's just that that we haven't
- 48:53had more of those,
- 48:54but I'm thrilled they did and it
- 48:56sort of followed on the heels of
- 48:58many people quote the sort of to
- 49:00air is human and the patient safety.
- 49:02Kind of movement and it's our turn,
- 49:04which was a call to action for
- 49:06pathologists that I described to you
- 49:08earlier around diagnostic error.
- 49:10So I think as I said before and I
- 49:13might skip some of these slides is,
- 49:16I think in places like Yale and
- 49:18Harvard and others where we have
- 49:19this like idea of what we should be,
- 49:21it's almost harder for us to admit
- 49:24when we're wrong.
- 49:25I took I took a screenshot of my I do the
- 49:27New York Times crossword puzzle and it said,
- 49:30Boston flagship Medical Center
- 49:31and the answer was mass general.
- 49:33And I was like it didn't like that's hard
- 49:35when you think you're more the flagship,
- 49:37like really, so it's hard like.
- 49:40How do you then say,
- 49:41hey I missed this right?
- 49:43Like this is Harvard Medical School,
- 49:44it's Yale. It's whatever it is and
- 49:46I think in the end pathologists are
- 49:48that to treating clinicians right.
- 49:50You're like the answer giver.
- 49:52So how do you then admit that
- 49:53you made a mistake, right?
- 49:55Like when we're the gold standard and
- 49:56you're using, you're giving an opinion,
- 49:58you're not like an instrument or a machine.
- 50:01So we use the dlow terminology which
- 50:03we took from the Pediatrics literature,
- 50:06which we thought would be like more
- 50:08friendly than saying diagnostic error.
- 50:10I don't know if that worked.
- 50:11I have to ask people and and
- 50:12we really wanted to train our
- 50:14trainees on disclosure of events.
- 50:16So we have simulations.
- 50:19Think I'm gonna come.
- 50:20Looking at the time, no.
- 50:22I think I'll continue.
- 50:23So this was a case where we lost a part
- 50:26of a specimen and basically we couldn't.
- 50:29You know,
- 50:30we the clinicians sent it to us,
- 50:33not in formalin.
- 50:35We got to generate it and we couldn't do it,
- 50:37so it was a joint event.
- 50:38You know we didn't know how
- 50:40to investigate it.
- 50:40We didn't know what to people often call me.
- 50:42What should I put in the report
- 50:43like I need to finalize the report?
- 50:45What do I put it in and they want to sort of?
- 50:47They either don't want to write anything
- 50:49or they want to write like a 12 page
- 50:51summary of the root cause analysis right?
- 50:54Which is really tough and we don't
- 50:55train our trainees or pathologists
- 50:56on what to do in these situations.
- 50:58So that's what we.
- 51:01Aimed this deal.
- 51:02Oh conference,
- 51:03as creating more training around
- 51:04how to deal with these problems,
- 51:06which are inevitable and Susie and I
- 51:08wrote a paper about how to disclose in 2018.
- 51:11If you're interested,
- 51:12we created an algorithm of when to disclose.
- 51:17Which had to do a little bit with harm,
- 51:19but as you can see,
- 51:20even when there was no harm in
- 51:22a probable or possible error,
- 51:23we still wanted to capture
- 51:25opportunities for improvement, right?
- 51:27Root cause analysis or discussion
- 51:28with the patient.
- 51:29Even if there was no harm.
- 51:31And it's not just because we
- 51:33are sort of like open, honest,
- 51:34Kumbaya, it's kind of practical,
- 51:36like for example, a patient gets a biopsy,
- 51:38you realize something is wrong and
- 51:39it takes you three weeks to sign up
- 51:41the report 'cause you need to do
- 51:42fish in molecular and figure out if
- 51:43there's a mix up like in that case
- 51:45somebody's gonna have to tell the patient.
- 51:46Like why is it taking three
- 51:48weeks to sign out your GI biopsy?
- 51:49You might not have harmed them,
- 51:50but you know you might want to consider
- 51:54a conversation. OK, someone says I
- 51:55hope there's enough time for QA,
- 51:57so maybe I'll skip forward a little.
- 52:00Oh look takehomes perfect.
- 52:03So we I think we have to redefine quality and
- 52:06safety and join the patient safety movement.
- 52:08Better expanding our responsibility
- 52:10to involve all phases of testing and
- 52:13collaborate with those outside of the labs.
- 52:16We need standardized tools.
- 52:18Really bad beyond what's required
- 52:20for regulatory compliance,
- 52:21so much unexplored risk and opportunity.
- 52:26Especially challenging with
- 52:27events with joint ownership,
- 52:29which is very frequent in the labs.
- 52:31We need to figure out how to work up,
- 52:33document and communicate error and and
- 52:35we need to be trained on how to oversee,
- 52:37teach and publish in this area.
- 52:40And so this is kind of a wheel
- 52:42we create with like you know,
- 52:43pathology, quality and safety.
- 52:45It's all these things, right?
- 52:46It's it's compliance, it's AC health.
- 52:49It's patient safety,
- 52:50but there's also a scholarship
- 52:52and education piece.
- 52:53Lots of people on my team over the year,
- 52:55so I'm grateful to.
- 52:58And I will take questions now
- 53:00and hoping for the spring soon.
- 53:04Wow, thank you, that was fantastic.
- 53:07I I can tell that people are excited
- 53:10for questions so I will hold off on
- 53:13mine and open it up to to folks I
- 53:15and this is sort of file a I.
- 53:17I am at a pediatric pathologist but I
- 53:20am also associate director of autopsy.
- 53:22I want to clarify that what Joanna say
- 53:26actually is incorrect. We do have an
- 53:29M&M's. We do have
- 53:31M&M's for pediatric mainly but also
- 53:33in the past we have used autopsy.
- 53:36That being a. Hospital autopsy are
- 53:41the baseline for quality assurance.
- 53:44We have used this in the past
- 53:46and in very distinctive way.
- 53:48Contacting the Medicine Department
- 53:51or whatever to senior with
- 53:54possible error to be discussed.
- 53:56Unfortunately, the feedback was,
- 53:59you know, our resident are not interested
- 54:02anymore to participate in into this,
- 54:05molecular informatics is more interesting,
- 54:08so there is a little bit of pushback.
- 54:11Inviso older way to do quality
- 54:15assurance that you should be
- 54:17reinstated and we still use.
- 54:19Actually
- 54:19Raphael. I can I just thank
- 54:20you for the double check.
- 54:21I I was referring specifically to
- 54:24an Eminem within pathology only to
- 54:26discuss some of the types of errors
- 54:28that Doctor Hager just presented.
- 54:31Yes, we do have Eminem's and
- 54:33other departments for traditional
- 54:35sort of presentations.
- 54:36Let's let's ask Doctor.
- 54:38Lu raised his hand very politely so.
- 54:41Will will let him take the
- 54:43next comment about that.
- 54:45Yeah, yeah yeah, this is a fantastic lecture.
- 54:48I think this is, you know,
- 54:50I think it's right. You know this
- 54:52is exactly what we want to hear.
- 54:55You know, as a department store where you
- 54:57know we are thinking about this all along.
- 55:00But I think that you know we really
- 55:02want as Joanna is now taking the
- 55:04leadership role for the you know
- 55:06quality and safety in our department.
- 55:07Certainly there will be a lot
- 55:09of things we wanted to you know
- 55:11to do and this is really great.
- 55:12So I really like the concept.
- 55:14You know you were talking about them.
- 55:16Within the department,
- 55:17pathology literally is openly discussed.
- 55:19You know the the errors,
- 55:21and I mean as we know is you know you
- 55:24mentioned the word is not just the culture.
- 55:25Lots of things that you know error happen
- 55:28is not really individuals personal failure.
- 55:31It's a lot of time.
- 55:32It's a systemic failure, right?
- 55:33It's just the the way how you do this.
- 55:35So in your experience,
- 55:37in my question to you is.
- 55:39And when you do this,
- 55:40how what's your experience so far?
- 55:42For example, how open your faculty staff?
- 55:46Actually talking about the errors,
- 55:49I mean, you know, in a way,
- 55:50it's they themselves.
- 55:51We always want to try to find a
- 55:53way how people can be so she ate.
- 55:55Yeah people, person,
- 55:57that person versus event right?
- 55:59Because you know The thing is,
- 56:01you know,
- 56:02have you thought about developing develop
- 56:05like rewarding system to the people
- 56:08who actually openly talk about error?
- 56:11And mistakes, right?
- 56:12But that's hard.
- 56:13You know, I'm saying we are living
- 56:14in a very peer review system,
- 56:16and you know,
- 56:17people promotion people's
- 56:18reputation is dependent on.
- 56:20We always say how great a pathology,
- 56:22how great staff member is in the
- 56:24in the you know in this department,
- 56:26but we rarely talk about say how
- 56:28open how actually sharing those
- 56:30kind of mistakes actually probably
- 56:32more important than people going
- 56:34around and say how great I'm
- 56:36doing one thing or another.
- 56:37I just want to hear your perspective.
- 56:39I.
- 56:39Well, first of all the thing you need is an.
- 56:41Openly supportive leader,
- 56:43so already you're like that comment alone
- 56:46your you know or at least benevolent neglect.
- 56:49Like if you weren't here but
- 56:50you weren't obstructionist,
- 56:51that would be good too.
- 56:52But the fact that you're open,
- 56:54I would say so.
- 56:54I'll give you an example.
- 56:55People are a little nervous
- 56:57about talking about it.
- 56:58We started over the first two years of
- 57:00the 10 years of day identifying it,
- 57:02and I actually presented
- 57:03all the cases to begin with.
- 57:05And at the beginning people were nervous.
- 57:07But then when they saw the tone of the
- 57:09conference and they became more and more
- 57:11relaxed and they saw we were really.
- 57:13What our goal was.
- 57:14People started self identifying
- 57:15like they were like.
- 57:17Actually that was my case and
- 57:18can I tell you what happened?
- 57:19What actually you know?
- 57:20I mean so it's. But it took years.
- 57:23You know people had to see that it was.
- 57:25They had to see how the
- 57:27conference was moderated.
- 57:28They had to see what happened.
- 57:29They had to see what the culture
- 57:31was and they had to feel trust
- 57:32and they had to feel safe.
- 57:33So around your comment about promotions,
- 57:36I mean no one's more familiar
- 57:37with the pain of promotions than
- 57:39Harvard Medical School faculty, so.
- 57:43You know there's a.
- 57:44There's actually a promotion path for
- 57:46quality and safety now even at Harvard,
- 57:48so if that's your academic interest,
- 57:50you could potentially actually
- 57:51publish on changes in safety,
- 57:53culture or numbers of diagnostic
- 57:55error and that kind of thing.
- 57:57So that's a huge shift like that's
- 57:59not just we're going to talk about it,
- 58:01but in private,
- 58:02that's we're going to actually reward it.
- 58:03Now.
- 58:04When you say you couldn't reward it,
- 58:05you can be sort of glib and give,
- 58:07like you know, good catch ords or whatever.
- 58:09But I actually think that's not.
- 58:11I mean, we're professionals and.
- 58:13That kind of thing can be glib if,
- 58:15like the rest of your system doesn't
- 58:17take it seriously, you know.
- 58:19So I think the answer to rewarding
- 58:20it is making people feel like it's
- 58:22valuable and like it's making a difference.
- 58:24And then if you have people who where,
- 58:26it's their scholarly interest,
- 58:27promoting them on that track.
- 58:30But otherwise I think it just
- 58:31needs to be baked into the culture
- 58:33and people need to feel like part
- 58:35of our job as respected.
- 58:39As respected, you know leaders
- 58:42is to is to do this work.
- 58:45Doctor Prasad Prasad says
- 58:47you still have to publish.
- 58:48We promoted that's 100% correct and
- 58:50you can publish in this area and I'm
- 58:53working with multiple journals to
- 58:55sort of create new tracks and new
- 58:57areas to publish quality and safety.
- 58:59Jeez your hand up.
- 59:00Did you want to say something?
- 59:01Yeah I did wanna share a couple of thoughts.
- 59:05One is I really like your.
- 59:09You talk about moving it from blame.
- 59:12We do focus on the analytical factors and
- 59:16when we discuss quality QC conferences,
- 59:19we talk about who missed a carcinoma
- 59:23in frozen section,
- 59:24or a Melanoma and stuff like that.
- 59:26And it's it's very hard to separate
- 59:29blame from just curiosity and that
- 59:32would be on Joanne's plate to
- 59:35make sure we move and we are
- 59:37curious about how it happened.
- 59:39And how we can figure
- 59:41out how not to let it happen? I also like
- 59:46like what you presented about the deal.
- 59:49Sorry for one second, it's actually
- 59:50on everyones plate to do that right?
- 59:52Like it's a joint family decision
- 59:54to to sort of feel safe. Of course,
- 59:57it's up to the leaders to make to hold
- 59:59people accountable to that safety,
- 01:00:00but it's everyone, I'm sorry, go on.
- 01:00:03And also the pathology
- 01:00:05M&M. It seems
- 01:00:06like you decided to call
- 01:00:08it the. Or conference and
- 01:00:11invite the senior most people to
- 01:00:13talk about their mistakes or
- 01:00:15misses. And I was invited to
- 01:00:18and ask App Companion Society
- 01:00:22meeting where the entire head
- 01:00:23and neck platform was dedicated
- 01:00:26to things that you missed.
- 01:00:29And then I realized I was the only
- 01:00:32one who talked about something I
- 01:00:34really did miss and I started with.
- 01:00:37I'm really embarrassed about this case.
- 01:00:39But anyway, that's the topic I
- 01:00:41will share all the other speakers,
- 01:00:43talked about cases that someone
- 01:00:45else best and they got it.
- 01:00:47So that's just my generation
- 01:00:50where they would.
- 01:00:53They are used to
- 01:00:54catching other peoples missing stuff.
- 01:00:56Yeah, I want to just make 2.
- 01:00:58Thank you so much for that comment.
- 01:00:592 slight adjustments to your second comment.
- 01:01:02One is the M&M is different than the DLO.
- 01:01:05The Eminem was a systems based
- 01:01:0710 year experience where we went
- 01:01:09methodically through systems issues.
- 01:01:10In all parts of the lab,
- 01:01:11including transcription
- 01:01:12that like transport error,
- 01:01:14I told you about Dlo is a totally
- 01:01:16different conference that is
- 01:01:18focused on diagnostic error.
- 01:01:19But what's different about it than
- 01:01:21what you're describing is we focus on
- 01:01:22the management of the error rather
- 01:01:24than just preventing the error,
- 01:01:25so we don't focus on like what
- 01:01:27is it about a decimal plastic
- 01:01:29Melanoma that makes it hard?
- 01:01:30Or was it about Signet ring cell
- 01:01:31that you can do to avoid it?
- 01:01:33What we focus on is this is going to happen
- 01:01:36to you and when it happens, what do you do?
- 01:01:38How do you write up the report?
- 01:01:40How do you have a conversation
- 01:01:41with your clinician?
- 01:01:42How do you file safety report?
- 01:01:43What are the reporting
- 01:01:45requirements to DPH form?
- 01:01:47You know?
- 01:01:47How do you document it?
- 01:01:49What are the legal implications?
- 01:01:50So we focus on managing an error which
- 01:01:53no one gets any training on, right?
- 01:01:55And I I doubt that was
- 01:01:57discussed at the USCAP platform.
- 01:01:59We're really people focus more on on
- 01:02:01like preventing the diagnostic error,
- 01:02:02which is super important
- 01:02:03and we should all do that.
- 01:02:05But we're great on that training
- 01:02:07like that's what we do.
- 01:02:08So I just want to make a slight adjustment.
- 01:02:10It's a little bit different.
- 01:02:12Thank you.
- 01:02:18Any other we have?
- 01:02:20We have had some comments.
- 01:02:22I don't know if everybody saw Doctor Robert,
- 01:02:24Gary mentioned psychological safety
- 01:02:26in her comment and says that I think
- 01:02:29the benefits of such a culture are
- 01:02:30important and extent well beyond
- 01:02:32the realm of quality and safety
- 01:02:33to be beneficial for a larger
- 01:02:35educational training environment.
- 01:02:38And you know, we we have a another
- 01:02:43question came up from Doctor M.
- 01:02:44I'll let you go ahead. Terrific talk,
- 01:02:49I want to follow up a little
- 01:02:50bit on what Rafiella said.
- 01:02:52That is. How do you compete for interest
- 01:02:54with the residents when they
- 01:02:56want to do molecular analysis
- 01:02:57or next Gen sequencing
- 01:02:58or something like that?
- 01:02:59And do you have some pointers for us
- 01:03:01to how to sort of make it more sexy?
- 01:03:03Yeah, so the first of all,
- 01:03:05I just want to take a minute.
- 01:03:07Rafael mentioned.
- 01:03:07I think she was mentioning
- 01:03:09fetal autopsies basically,
- 01:03:10which in itself is incredibly difficult
- 01:03:14from a root cause analysis perspective.
- 01:03:16Like there's the patient who's brave.
- 01:03:18That social worker.
- 01:03:19The the the the legal weight cut offs
- 01:03:21at age cut offs like it's basically
- 01:03:22like an accident waiting for happen
- 01:03:24to happen in terms of safety events
- 01:03:26and autopsy is like on the other end
- 01:03:28of the spectrum from like molecular
- 01:03:30and all these like amazingly like
- 01:03:32and cool things like as a mass
- 01:03:34general person I get that right.
- 01:03:36What I would say about residents in
- 01:03:38general trainees is they're really
- 01:03:40frontline workers and as much as they're
- 01:03:43interested in that kind of work for research,
- 01:03:45they're pretty good at calling out problems
- 01:03:48like that's like part of their culture.
- 01:03:50Is like being frustrated with operational
- 01:03:52things or with cultural things,
- 01:03:55right?
- 01:03:55So how do you somehow like leverage
- 01:03:58that into learning and change for the
- 01:04:00system 'cause they're they're like?
- 01:04:02They get sort of a toxic dose of where the
- 01:04:05dysfunctions are in the workflow, right?
- 01:04:06'cause they're constantly trying
- 01:04:07to manage it, especially in AP.
- 01:04:09And so the Eminem was good
- 01:04:10for us in that regard,
- 01:04:12'cause they were able to have a
- 01:04:13place where they called that out.
- 01:04:15You know where they were like?
- 01:04:16Listen, I was on call and like XYZ
- 01:04:18happened and it was a disaster,
- 01:04:19you know or?
- 01:04:20I went to go do this thing and
- 01:04:22there was no X and it was a patient
- 01:04:25safety issue like they're actually
- 01:04:27pretty good at at doing that and so
- 01:04:29involving them in the root cause and
- 01:04:31involving them in the solution and
- 01:04:33actually making it easy for them to
- 01:04:34call it events like I was talking to.
- 01:04:37Some of your folks before about like
- 01:04:40creating a distribution list instead of
- 01:04:42having residents file reports 'cause it just,
- 01:04:44it's like prohibitive.
- 01:04:47So they can just sort of
- 01:04:48email someone and say,
- 01:04:48hey,
- 01:04:49we notice this like we notice this
- 01:04:51risk and then having like an Eminem
- 01:04:54platform or or or something like
- 01:04:55that where they can be involved in
- 01:04:57the solution I think can be really
- 01:05:00transformative for them and quite healing.
- 01:05:01'cause it's it's a difficult
- 01:05:03period of your life.
- 01:05:03And remember you're only a couple
- 01:05:05years away from being a faculty member.
- 01:05:07So many of those folks as I was
- 01:05:08saying to some people earlier are
- 01:05:10like very very thoughtful and
- 01:05:11mature and and and allowing them
- 01:05:13to participate instead of sort
- 01:05:14of paternal ising or them can be.
- 01:05:17Really great for everyone and
- 01:05:18then the ones who do really well.
- 01:05:19Of course then you wanna recruit right so?
- 01:05:23I think it's about it's not just
- 01:05:26about making it sexy for them to
- 01:05:27use your term, it's about
- 01:05:28making it sexy for everyone.
- 01:05:29It's about making it so that you wanna
- 01:05:31do it because it actually results
- 01:05:33in change as opposed to like you
- 01:05:35just checking a box or you just like
- 01:05:37complaining into the ether, you know.
- 01:05:40Autopsies also, like you know,
- 01:05:42we could have a whole other
- 01:05:44conversation about autopsies.
- 01:05:44Maybe I won't, 'cause it's 137,
- 01:05:46but I have time.
- 01:05:49Let's say you've got 66 people
- 01:05:51still on and listening intently.
- 01:05:53We got what, let's take one last
- 01:05:55question from Doctor Shelburne,
- 01:05:56who raised his hand
- 01:05:57time. I can stay on like
- 01:05:58if I were with you guys.
- 01:05:59I would be at the podium hanging
- 01:06:01around like sipping coffee,
- 01:06:03so I may be driving an hour and a half home.
- 01:06:06So I'm my day is for you if
- 01:06:08you wanna hang on, hang on.
- 01:06:10Thank you very much for
- 01:06:11talking that I'm one question,
- 01:06:13you know that I have that I think
- 01:06:14ultimately it's all about priority.
- 01:06:16You know there's so
- 01:06:17many competing things that.
- 01:06:19That residents and faculty
- 01:06:20we don't know where to go.
- 01:06:21We have to prioritize.
- 01:06:23Do you have a a system or metric
- 01:06:26or how you can evaluate the impact
- 01:06:29of all everything you're doing
- 01:06:30so that you know we can make
- 01:06:32a claim and raise the priority
- 01:06:34and and and show real impact. So
- 01:06:35how are you evaluating
- 01:06:37the impact of all this?
- 01:06:39That's a great question,
- 01:06:40so there's different ways
- 01:06:41you can evaluate the impact,
- 01:06:43and I think you can't like boil the.
- 01:06:44That's a really insightful question,
- 01:06:46by the way, so I think you need to.
- 01:06:48Pick something like you can't when
- 01:06:50you say everything you're doing,
- 01:06:51I just I just shared with you like
- 01:06:53a 10 to 15 year experience, right?
- 01:06:55Like we didn't do that like overnight
- 01:06:57we did one thing at a time.
- 01:06:58Very slowly.
- 01:06:59First of all, second of all,
- 01:07:01we measured things like safety culture,
- 01:07:03but we also measured safety event reporting.
- 01:07:05We measured number of safety events in
- 01:07:07different areas and then we also even
- 01:07:09looked at things like financial metrics.
- 01:07:11So like,
- 01:07:12let's say we're looking at efficiency.
- 01:07:13I didn't talk about any of the projects,
- 01:07:15but we we looked at things.
- 01:07:17You know you have to think about.
- 01:07:19What's your outcome is?
- 01:07:20And then what you're measuring.
- 01:07:22I think that's exactly right,
- 01:07:23and you don't probably need to do that for
- 01:07:25everything like some things are no brainers,
- 01:07:27right?
- 01:07:28Like you know,
- 01:07:28you don't have to measure every single thing.
- 01:07:31If something is obviously better.
- 01:07:33But if you want to publish it,
- 01:07:34you probably do, and if you're not sure,
- 01:07:37you should baseline before you make an
- 01:07:39implementation and and and measure again.
- 01:07:41So I think you're absolutely right that you
- 01:07:44do need to create some kind of measurement.
- 01:07:46We usually we use the smart goals
- 01:07:49or the smart framework, which is.
- 01:07:51Specific, measurable, attainable?
- 01:07:53I forget what are is relevant and time bound,
- 01:07:56and that's widely published.
- 01:07:58I didn't. We didn't make that up.
- 01:07:59It's it's a very again motherhood and
- 01:08:01apple pie approach to like it's like
- 01:08:03when people say oh the answer to that
- 01:08:05is getting beaker and you're like OK
- 01:08:06great but that's like not gonna happen.
- 01:08:08You know you know what I mean.
- 01:08:09So that's like the you know,
- 01:08:11attainable section.
- 01:08:12It fails the attainable thing.
- 01:08:14Specific is like when you say
- 01:08:16we're going to reduce, you know,
- 01:08:18frozen section discrepancies
- 01:08:19by 10% over a one year period.
- 01:08:22Bubba,
- 01:08:22and then you make like an intervention
- 01:08:24and you measure before and after.
- 01:08:25So I think you're right that
- 01:08:27you should do that.
- 01:08:28The cultural pieces are a
- 01:08:29little tougher to measure,
- 01:08:30but there are safety culture surveys
- 01:08:32and you can get in RM&M package.
- 01:08:35We actually have a survey that we
- 01:08:37use for CMAS where we measured rates
- 01:08:39of like how comfortable people felt,
- 01:08:41how much they felt that they
- 01:08:43changed their practice and then
- 01:08:44we had a narrative comment.
- 01:08:45So we were measuring how
- 01:08:46we were doing overtime.
- 01:08:47It's a little qualitative research.
- 01:08:48It's like a little more tricky,
- 01:08:50but there are still
- 01:08:51validated tools that exist.
- 01:08:54Thank you, it's hard though. Alright,
- 01:08:58well in the interest of people needing
- 01:09:01to move on with the rest of their day,
- 01:09:04I would like to just give a very sincere
- 01:09:07thank you doctor here for coming to us and.
- 01:09:11Bringing an introduction to safety culture
- 01:09:14to us in such a understandable and clear way,
- 01:09:18and I thank everybody who asked questions and
- 01:09:22so I'll you know if people want to log off.
- 01:09:27That's fine, but if anybody wants
- 01:09:28to stay behind for a few more
- 01:09:31minutes and ask some more questions.
- 01:09:33Doctor Hager said she'd stay
- 01:09:34so thank you so much,
- 01:09:38really really appreciate this session.
- 01:09:41Megan honor I hope that we
- 01:09:42can do it in person one day.
- 01:09:45I hope so too.
- 01:09:48I actually would be really interested
- 01:09:51in getting that slide deck template that
- 01:09:54you mentioned for your M&M conference.
- 01:09:57No problem. I think it.
- 01:10:00I you know it is something that the
- 01:10:03hospital has cost us with to do,
- 01:10:05and I've been talking to the other
- 01:10:07departments at Yale to kind of gauge of
- 01:10:09what they're doing for their peer review.
- 01:10:11M&M conferences and.
- 01:10:15You know it's it's kind of a new concept.
- 01:10:18You know the traditional eminems are still,
- 01:10:20you know, obviously, how a place.
- 01:10:24For for doing this stuff,
- 01:10:25but this is something that's a little
- 01:10:27bit more introspective and looking,
- 01:10:30you know, internally into our own
- 01:10:33practices and discussing these things.
- 01:10:37So any remaining people
- 01:10:40have any other questions?
- 01:10:42But it looks like people ran it.
- 01:10:44Oh, there's Christine.
- 01:10:45Hi no, I'm I just wanted to
- 01:10:48say thank you again. I really
- 01:10:49have to get going because
- 01:10:50I'm severely behind.
- 01:10:51But thank you so much for this morning
- 01:10:54and for the great lecture today.
- 01:10:56So and then Joanne and I need to
- 01:10:58catch up because we haven't started.
- 01:11:01But it it really is.
- 01:11:02There is some great
- 01:11:03ideas in this
- 01:11:05that I think so.
- 01:11:07OK, take care. Thanks, Christine.
- 01:11:13No one has a question. I'm going
- 01:11:15to end with a story.
- 01:11:17It's not an error,
- 01:11:18but I just wanted to share.
- 01:11:19I forgot to tell I forgot to tell you.
- 01:11:21I love this. When we were
- 01:11:23talking earlier that it's
- 01:11:24really a problem coming to Yale and
- 01:11:27knowing Yale because my iPhone just
- 01:11:30can't get that straight.
- 01:11:32And every time I would tell someone
- 01:11:33by Yale, it would come up gaelle
- 01:11:36and I had to retrain my iPhone.
- 01:11:40Problem because people every
- 01:11:42time someone needs they're like,
- 01:11:44oh, Yale at Harvard. Haha, I'm like,
- 01:11:47yeah good one like never before.
- 01:11:49Also my name blood GAIL.
- 01:11:50Like every single time for like 30 years.
- 01:11:53Yeah well tell Apple that you because
- 01:11:55according to them your name is Yale.
- 01:11:58Perfect, I know.
- 01:11:59I named my kids like really boring
- 01:12:01things because like my husband like how
- 01:12:03about this day and I'm like no no no.
- 01:12:05It needs to be like the most obvious name
- 01:12:07possible and needs to be pronounceable
- 01:12:09in every language. He's like.
- 01:12:11Why do you care so much about this?
- 01:12:13Like because my whole life like
- 01:12:15what is it like? Yeah exactly.
- 01:12:17Joanna Joseph, that's a good one
- 01:12:19that can't go wrong with Joseph.
- 01:12:21Good biblical name. Pardon,
- 01:12:25yeah, no. I I got lucky 'cause you know,
- 01:12:27being Polish born at least Joana
- 01:12:30translates easily to English.
- 01:12:33Enough is that Polish
- 01:12:35it's pronounced you on now.
- 01:12:37But it's. It also lends itself to
- 01:12:43lots of good nicknames like Joe.
- 01:12:47Well, thanks so much. I was
- 01:12:49lovely seeing you and be well.
- 01:12:52Yeah, same to you all, be well,
- 01:12:54I'll definitely hound you with
- 01:12:57some emails for some details. I'll
- 01:13:00send you whatever templates
- 01:13:01I'm always happy to share.
- 01:13:03I'll, I'll send you like a
- 01:13:04like a downloadable package
- 01:13:06that would be wonderful.
- 01:13:07Thank you so much.
- 01:13:09So take care and have a
- 01:13:11safe rest of your February.
- 01:13:13Hopefully spring is coming.
- 01:13:18Bye bye bye.