When Routine Goes Wrong: Remembering Ryan Welch's Journey | Why Doctors Make Mistakes

foreign [Music] the battle is on to reduce the estimated 320 000 medical errors made in Britain each year to win that fight doctors and nurses must first openly admit their mistakes when they do it becomes clear that a combination of things are not simply the actions of a single doctor or nurse lies at the heart of most medical mistakes but for patients to benefit medicine must do more the caring profession must apply the hard-earned lessons of other hazardous Industries [Music] this film is about those attempting to build a better future [Music] foreign last year eight-year-old Ryan Welch went into the George Eliot Hospital in nuneaton for some tests to try and explain his bed wetting problem we never had to draw an art off him for quite a few years and at school it started to want to go to the toilet a lot at school as well so we knew he'd probably got a little problem three days after his admission to the hospital Ryan Welch was dead [Music] a series of mistakes following a routine catheterization led to the onset of septicemia which the hospital did not spot until it was too late simple bedwetting tests that's all it went in for having brainstem death just too shocking for words Ian and Denise's pain has been made worse by the fact that they have had no explanation of what happened from the hospital foreign contacted us to see how we cope in not not one of them up there have contacted us [Music] over the years since Ryan's death his parents have tried to arrange a meeting with the hospital we're 15 months down the line now and really it does seem an inordinate length of time for the hospital to actually get around to talking to the parents about the case right from the outset it seems to me that it would have been in their interests to accept the fact that something had gone badly wrong contact the family give them the support they were entitled to and just be completely honest with them about explanations I don't think anybody will ever really see how bad Denise has been affected there's some days that she just cannot deal with it she's in tears I find a crying in corners little things my spooker cheers flashbacks she sees Ryan with tubes coming out of him but don't see his face she has Dreams and Nightmares in the night and all this nobody sees and the hospital has got no idea what we're going through all too often this is the way that the medical profession in Britain leaves its victims the defensive position adopted by the medical professionals involved exacerbates the feelings of grief and Injustice [Music] we're in the Attic of Ryan's Grandma's at the moment um all his toys and his clothes had to be brought up here because his mother couldn't bear to look at them too many memories never really took much notice when I packed him obviously you should set this into the spare room just fight with it on his own hours obviously she can't look at these things can't go back to the house where we were living I could understand why must bring back so many memories and you just can't hold him anymore doctors and nurses are human they will make mistakes but regaining The public's trust depends on the profession changing the way it deals with these failures I think if they come forward when it all happened offered as an apology and an explanation may be telling us the procedures that they may have done to improve it so it doesn't happen to anybody else I think Denise could have coped a little bit better if we'd have had that [Music] another small boy another hospital a different world the way the Martin Memorial Hospital in Florida dealt with the case of seven-year-old Ben Kolb shows how far the profession has to go in the UK Ben had been admitted for an ear operation within minutes of receiving his anesthetic things had started to go wrong half an hour into the operation anesthetist George McLean was called to the operating room the child's vital signs were exceptional and that his heart rate was very high and his blood pressure was very high and we treated the heart rate and blood pressure and the child's Vital Signs we turn the normal and everything appeared to be just fine at that point uh we decided to continue the surgery and within about five minutes of that period of time his Vital Signs began to rapidly deteriorate this culminated in a cardiac arrest approximately 10 minutes after the initial episode we got the child resuscitated with stable Vital Signs and we sat down to talk to Mrs Kolb and explained to her that her son had had a problem during surgery and that he was now in a coma and we didn't know if he would wake up from it oh [Music] Donnie Haas is risk manager at Martin Memorial it is her job to deal with cases in which there are legal issues for the hospital she came to talk to Ben's mother and from the start she was completely open she didn't understand what had happened and I told her that we did not either but it was my job to look at this and to try to find out what those answers are and that I would share that information with her by now Ben's Father Tim had arrived at the hospital you could tell by the looks on everybody's faces that this was very serious and uh it was it was somewhat dreamlike you're there but you don't you're you don't feel like you're entirely there the following day it was made perfectly clear by a specialist that he was brain dead and at that time we offer to donate all his organs I went to the funeral viewing and that was one of the hardest things I'd ever had to do was go up to the coffin with the family and this little boy looked just like my little boy had looked at that age this is very hard for me still um just a beautiful little boy um and explained to family that how sorry I was when it happened and how I did not have an idea what had happened and just how genuinely upset I was and how sympathetic I was Donnie haas's investigation got underway Ben's problems had seemed to coincide with the injection of a local anesthetic lidocaine around his ear Donnie sent a sample of the drug that had been injected to the labs at the University of Georgia [Music] people wasn't big enough to do all the tests required all the lab could do was tell Donnie what it wasn't [Music] the test should have shown lidocaine it didn't so we knew at that point only that whatever we had given been was not what it should have been that's all we knew but the coroner seemed to have already made up his mind what had killed Ben saying that he had died of natural causes due to a bad reaction to the anesthetic such a verdict effectively cleared the hospital of any blame in some hospitals that might have been the end of the matter but Donnie Haas knew the coroner was wrong she pressed on with the investigation there was more of the drug left in the syringe itself Donnie sent it for a second analysis 24 hours later the lab phoned through the result [Music] it was probably the most devastating phone call I'd ever received in my career it was one of those things that you think is impossible but it happened and now you knew it happened and and how's the best way to deal with this we were having dinner and Donnie called and that she said that she had the information back and she would like to talk to us about it I believe it was the following day we went down to Fort Lauderdale and that's when she told us exactly what had happened what I recall seeing is that there are two medications that are used in the procedure that Ben had what we found by analyzing the syringes was somehow and we honestly do not know how those two medicines got mixed up and that we take full responsibility for that very very sorry my immediate response was how could how could such a simple thing cause cost someone's death it was a real shock when Ben had undergone his operation there had been two drugs involved one was the local anesthetic for injection around the ear the second was epinephrine or adrenaline and should only have been used to dab on any bleeding areas during the operation by mistake Ben had been injected with epinephrine it gave him a heart attack and killed him I think that's an in CH two layers watch on mobile devices or the big screen all for free no subscription or fire [Applause] foreign [Music] afterwards the kolb's lawyers told Ben's Father Tim that the sort of openness and honesty displayed by the hospital was almost unheard of and I'm thinking to myself why why isn't this normal procedure that that really surprised me that he assured me that this was so unusual that that it would be precedent setting from Ben's death to the meeting at which his parents were told the truth barely a month had passed the father stood up and said that he said we just really wanted to thank you we never would have known and we always would have wondered and excuse me that's a lesson it's a big lesson it's important as hard as it was it's the only thing that should be done I'm reasonably proud of the way we handled it we could handle it better I wish to God that this had never happened this case has been on my mind now for years it stays with you and it resurfaces things will set it off I think it's made me a better physician and I just hope to God it never happens again to be involved in something like that this is the box of things we saved from the Cold Case this is the actual box that we sent the items to the University of Georgia in and um this is the actual syringe that was used to inject Ben around his ear in the four quadrants of the ear and it was this solution that caused the problem but how had the mistake been made when the two drugs were placed in the operating area they were poured into small cups though these cups were different out of their vials the drugs themselves looked identical making it easy to give the wrong one a mistake waiting to happen the hospital didn't blame any of the individuals involved they knew their procedures were at fault and they changed them drugs are no longer drawn up from open containers but are taken direct from the bottle the mistake which killed Ben Kolb could not happen at Martin Memorial today Ben was a healthy seven-year-old little boy who would come to our hospital for his third elective ear operation he had passed since that time Donnie Haas and George McLean have told us many others as they can in the medical profession about their experience they even came to London recently and addressed the inaugural British medical journal conference on medical error in an attempt to spread the word decision to publicly discuss this case but the kolbs wanted us to do whatever we could to prevent this from happening to someone else this has been and his story is told to you in his memory and I hope that though telling the story of what happened to Ben is always painful for Donnie and George they know it's important how important one small girl owes her life to their evangelism viewing everything I received a call one day from a risk manager who had a little girl actually on the operating table in her hospital at that very moment who was having ear surgery the little girl had a cardiac arrest the risk manager had heard me speak at a conference and could not remember what had happened I told her briefly she hung up the phone and I never heard anything else for about a month and she called back to tell me that she had called the operating room and given that information to the staff right there in real time and they realized they had made the same mistake fortunately for this child the knowledge at that time allowed them to treat that child differently because they knew what had happened and the child lived and I just think that's the answer it's just got to tell you that that this is what we have to do in health care we have to be able to take air and hold it up to the light a day and say look what happened at our institution and here is why this happen so that you just don't make Martin Memorial better you make Health Care better and and you make it safer for all patients the hospital's honesty in investigating the events that led to Ben's death and then in talking so frankly about them are held up as an example of how it should be but sometimes George McLean wonders why their reaction should still be considered remarkable Five Years on if you look at how many thousands of mistakes are allegedly made in health care why are we still being held up as an example does that mean that the other sixty thousand mistakes were covered up and nobody came forward nobody tried to change anything nobody did it right it just amazes me that we're still held up on this I probably have a better term some sort of pedestal for having been open honest and dealt with this as decent human beings it scares me to know to think that if if we're exceptional my God what is going on out there three [Music] three with some in the medical community stubbornly refusing to lift their eyes above the Horizon many of the best ideas are coming from another world our whole cause is not to affixed blame it's we want to prevent this from ever happening again that's our job to make sure it never happens again throttling up three inches Challenger go and throttle up most medical errors are not the result of the recklessness or the incompetence of an individual doctor or nurse [Music] they're usually the result of a combination of factors in which the action of the medic is simply The Last Link in the chain simply identifying a guilty doctor or nurse is rarely the solution to the problem [Music] Jim Bajan has just returned to medicine from a world where they worked this out long ago we're dealing with people nothing with malevolent human beings that's not the problem in health care it's the problem of good people trying to do a good job and great things don't always happen after training as an engineer and then a doctor Jim Beijing joined the American Space Program NASA and spent several years as an astronaut Beijing is now one of the most influential men in America's growing patient safety movement the flow charting Post-its are invaluable he's spreading the patient safety gospel among the staff of the Veterans Affairs or VA hospitals where he is head of patient safety three and a half million U.S military veterans come through VA hospitals each year we're trying now to try to get people out of that fault fixation and realize that people don't come to work to make errors they don't come to work to hurt a patient that's the last thing anybody wants to do three space shuttle mission and it has cleared the tower Jim beijing's model is his old employer NASA being an astronaut for about 15 years you know we had the opportunity to take part in various investigations the Challenger investigation for example and people were there saying what happened how do we make it better our whole cause is not to affix blame it's we want to prevent this from ever happening again that's our job to make sure it never happens again [Music] pigeons throttling up three inches now at 104 Challenger go and throttle up [Music] even after an event as catastrophic as the Challenger crash the focus of NASA's investigation was preventing a repetition rather than blaming individuals the key to making medicine safer is to see it as a high risk industry like space flight or Aviation but the traditional view of medicine as a caring profession has enshrined the culture of blame setting it apart from other high-risk Industries this has robbed Medicine of the ability to avoid repeating its own mistakes to Dr Don Berwick a fellow patient safety thinker there is nothing unusual about the mistakes doctors make beyond their consequences most errors as they appear in medicine are just like the errors that human beings know they make in everyday life a human mind is imperfect we have trouble with memory we make mistakes in handling things and in communication so uh these aren't special to the medical environment one example maybe this stovetop the burners are arranged in a rectangular form but the controls happen to be linear and my wife and children and I are always by mistake turning on the wrong control because there's no natural relationship well the same happens in healthcare this is just a stove but if these were controls on a respirator machine on a young baby or in a pharmacy dispensing machine you can see the consequences of uh of error would would Mount up very very quickly we work in a high Hazard environment there are a lot of events in Medicine a lot of Technologies a lot of handoffs and humans are not perfect so errors that are normal in daily life of little consequence can accumulate into disasters in health care and we now have evidence that that happens all too often this deadly cocktail of a mundane era and terrible consequences characterizes the vast majority of errors in high-risk Industries medicine included if the doctors can acquire the humility to see themselves as workers in just another high-risk industry the sorts of solutions which are taken for granted in those Industries suddenly become accessible boston-based behavioral psychologist Dr Robert Simon has flown into Toledo Ohio on the latest leg of a remarkable patient safety Crusade the ideas of his Med teams organization demonstrate the effectiveness of borrowing solutions from industry he's bringing this insight to the emergency department of the Toledo Hospital where he will spend the day in the hospital's emergency department the doctors and nurses go about their work admitting and patching up patients referring them to other departments or sending them home as Robert Simon monitors their activity he's watching for areas in which communication might break down these breakdowns in communication might seem mundane but they are at the heart of many medical errors the med team's approach is borrowed from work Robert Simon did with another high-risk industry Cyrus you're sick today we're going to take care of you okay in the 1980s U.S army helicopters were dropping out of the sky in alarming numbers [Applause] more alarming many of these losses were not the result of enemy action or even mechanical failure [Music] we look back over five years of accident reports so from 1984 to 1989 we looked to see which of the heirs were crew coordination heirs now there was a failure to communicate or coordinate activities that led to a mishap what we saw was that the Army had lost 292 million dollars and 147 lives due to teamwork failures well this required some remedy sometimes helicopters would be flown into the sides of mountains or into lakes simply because though it was plain to all on board what was happening nobody liked to mention it Robert Simon put together a training program to maximize helicopter crew coordination and help prevent this sort of accident its foundation is a system of formalized communication between crew members which by the time recruits first get to sit in the flight simulator is already second nature Robert Simon encouraged the flight Crews to use a system of callbacks this involved a formal checking and rechecking of instructions and procedures to eliminate the sort of misunderstandings that might lead to disaster will ever fly as soon as check the effect of Robert Simon's changes was remarkable the Army realized precipitous drop of Class A accidents to the tune of about 50 percent we couldn't have put that all to the air crew coordination training but it certainly had a significant impact on the reduction in accident rate Robert Simon discovered the same sort of communication failures within medicine that he'd found among the helicopter Crews and often the results were just as catastrophic at one of the hospitals he's dealt with he came across the story of the attempted resuscitation of a one-year-old baby the doctor calls for calcium chloride the nurse turns around and she administers potassium chloride potassium chloride is a lethal injection and the baby dies and it costs the hospital more than two million dollars to settle that suit some train flight one or two the same call back system that has served the U.S military so well might have prevented the death of that baby gearbox oil level check tail pylon check cockpit area check and crew and pasture briefing check the nurse would have checked the order back with the doctor and put an end to any confusion in another hospital a doctor misdiagnosed a case of meningitis in an 18 year old patient in an episode reminiscent of those pilots who flew their helicopters unchallenged into the sides of mountains The Physician examines them and discharges and says I think you've got the flu if you like in a couple days you're not still if you're still not feeling well you know coming back and we'll uh take another look at you send them home a couple days later this 18 year old comes back via ambulance to the hospital and he's very sick well he has meningitis and within six hours of his rearrival to the hospital he dies [Music] when Robert Simon picked apart the event he found that when the boy first came in a nurse had suspected meningitis but said nothing she said she tells us well when I told him a couple weeks ago about something I was concerned about he just jumped down my throat and he just said I'm the doctor here I do the diagnosis and you know don't you know just stay out of to stay out of the way so she learned her lesson she doesn't tell this doctor what's on her mind and for want of that communication that youngster they will have lost his life [Music] Robert Simon's template obliges a nurse in this position to speak up and more importantly it requires a doctor to listen [Music] it's formalized structured communication system has transformed emergency departments all over the country the changes are subtle you don't see someone metamorphized into a med team's person it's in some ways a mental state it the actions are subtle but the behaviors are powerful some hospitals have reported a 90 reduction in clinical errors startling result from such an apparently simple idea one of the reasons that medicine needs to be treated as an industry rather than as a caring profession is that the Machinery now available to doctors demands great expertise [Music] in the early 1990s the emergence of laparoscopic or Keyhole surgery caught the imagination of the public and the profession it was very obvious not to me but to all my surgical colleagues that this is something that has had a major impact in in the patient's well-being and it's revolutionized some surgical procedures but the way Keyhole surgery was taken up exposed some patients to new dangers sure in a keyhole operation the surgeon makes tiny incisions through which are inserted the instruments and a miniature camera lens the surgeon operates watching the pictures on a television monitor okay head up please in the hands of men like aradasi from Saint Mary's it was a great Advance it removed the need to cut a patient open it reduced scarring pain and recovery time [Music] but not all surgeons had darzi's understanding of what the new industrial technology required of them there were major differences between laparoscopic or Keyhole surgery and the traditional open surgery that we've all been trained to do and these these led to a number of technical errors in the early days due to the lack of training and the familiarity with the procedure and the instrumentation and the equipment used general surgeon David rosin was in at the start of Keyhole surgery in this country he recognized that this technique was different and used a shoe box of all things to recreate the disorientation often experienced doing laparoscopic surgery what we try to do is simulate that by putting grapes and Smarties and things into the shoebox have the camera the telescope poking through the camera attached looking at a screen so we couldn't see what was in the box or I couldn't do it in the box and then poking the instruments through and trying to pick up grapes peel them cut them in half it was all very good technical exercise simulation and of course very cheap but in their desperation to embrace the way of the future some surgeons fail to realize that without acquiring new skills they'd risked damaging their patients people just went at it like a bullet in China you know in China shop they went out and said oh gosh I've I've done a one-day course or I I've watched such and such therefore I can I must do it a surgeon new to Keyhole techniques once arranged to come and watch David rosin perform a laparoscopic hernia repair operation he didn't arrive and he found me the next day and said I thought I didn't get your offering to watch the lapisol behind your repairs are you doing here today and I said no I said but I will be doing some next week and he said oh that'd be too late what do you mean to be too late and he said oh I've got a case book for tomorrow in effect in the early days of Keyhole surgery some surgeons were practicing on their patients in no other high-risk industry would such a thing be allowed but the very public failures of Keyhole surgery in the 1990s concentrated the mind of the profession and led to the development of a number of industrial type training programs where Pioneers like David rosin had had to rely on grapes and shoe boxes anybody starting down the road today has the benefit of the most advanced computer technology we are now able to assess surgeons we are able to identify areas of weakness and improve them we can identify those very gifted surgeons very early on and process them quicker so we've used this technology very successfully in training the future surgeon the profession insists that the lessons learned from the introduction of Keyhole surgery leave them better prepared for future technical advances but it's not just in Keyhole surgery this industrial approach is bearing fruit straw who's a 57 year old man and they're doing a repair at a right it's 10 30 in the morning in an operating theater at the Veterans Affairs Hospital in Palo Alto California what began as a routine hernia operation on a middle-aged man is quietly developing into a problem [Music] the patient's vital signs are giving the anesthetist cause for concern she has only moments to work out what has gone wrong in the operating theater at the Veterans Affairs Hospital in Palo Alto California a routine hernia repair has developed into a crisis the patient's vital signs are fluctuating wildly suddenly the anesthetist loses the pulse unsure of what to do the anesthetist calls for help [Music] a crash cart is brought in and the Team battles to get the patient's heart going again a routine medical procedure has somehow turned into a full-blown emergency okay here one two three watching from next door is California anesthetist Dr David Gabba that's a pretty weird rhythm it's like a real code yeah really should the worst happen Gaba has the power to bring the patient Back to Life by typing an instruction into his computer let's do it now because the patient on the operating table is made of plastic wires and computer chips the doctors are all anesthetists practicing on the simulated patient reacting to the rapidly changing symptoms that Dr Gabba and his team throw at them they take turns to be in charge of the patient's anesthesia requirements they feel appalled the technology is modeled on aviation's flight simulators which have long been Central to Pilot training [Music] we don't think you can eliminate air what we're really striving for is to better enable us to trap errors when they occur either if we make them or somebody else makes them and work together so that those errors don't cause a problem for the patient no industry has been more aware of the need to trap errors than the space industry the industry knows that building a safer system depends on knowing where that system is failing and that depends on a sound reporting system [Music] NASA employees who make mistakes step forward knowing that they will not be blamed and that any information will be put to good use former astronaut Jim Bajan is now head of patient safety at the VA hospitals it's also the most expensive better to learn from someone else's experience rather than have to learn by your own and who pays the tuition for our experience for our education primarily a patient and that's quite tragic and what we're trying to get people to do is saying by speaking up when there's a problem one if you speak up early maybe you can prevent the problem from really becoming a tragedy secondly if you have had the bad fortune to have one if you're the only one that learns anything from it you're not getting maximum utility from the price that's already been paid that's a sunk cost it's occurred you pay that tuition why should everybody else learn about it why should you keep it a secret the reason why medical errors are often kept a secret is simple in medicine unlike other high-risk Industries reporting systems have operated in an atmosphere of personal blame when I was a new nurse back in the early 70s in most places the um the theory was three strikes and you're out I knew that if I made three medication errors I could be terminated the first time I made a medication error I reported it like just like I was supposed to the next day I got a short but to The Point Counseling by my supervisor and was told that I was to go to take training for four hours on how to administer medications when Connie made a second error she reported that one as well but rather than four hours of medication administration class I got eight hours and a good warning to remember that a third error could very well result in termination depending on the seriousness of the medication error I made a third mistake I took care of the patient we got it all taken care of but I will tell you that I thought long and hard doing a third report and I did not report the third one and I felt bad for not reporting it I knew I should have reported it but I knew I could be fired and I talked to my colleagues I talked to other nurses well lo and behold I was not the only person who had made more than two medication errors in my career at that hospital nobody reported the third error and why was that because we knew we could be fired oh this approach to Medical error is highly dangerous to patient safety at the Veterans Affairs hospitals Jim Bajan has presided over what may be the single most important development in the battle to make medicine safer the introduction of a formal Anonymous Nationwide reporting system and significantly in designing this system Beijing has gone back to his roots VA doctors and nurses will send their reports not to their bosses but to a wholly independent body NASA people will report directly and ask it doesn't come through the VA so people do not have to be fearful that some big brother is watching they're saying aha so and so reported this therefore something bad must be going on there a bad person we I we wouldn't think that but people can be paranoid with good reason from past experience so we want to make sure there's no barrier there so that way we can get reports through it this other Avenue and see what else we learn a similar independent system will be attempted across the UK for the first time this year but this openness must go further traditionally the fear of expensive legal action has discouraged doctors and hospitals from being honest with patients but at the VA hospital in Lexington Kentucky they have discovered that if a hospital is proactive in dealing with patient victims an accident need not cost you the Earth [Music] when in 1987 Chief of Staff Dr Steve crayman appointed an in-house lawyer to help protect the hospital he was unconsciously adopting the adversarial stance that usually characterizes a Hospital's relationship with any patient alleging negligence foreign [Music] this was a pretty traditional way of thinking about risk management at the time we didn't know any better but then the hospital got involved in a case which was to change the way it looked at Medical error we hit on A case that uh clearly involved negligence in which patient had died and the patient's family had known nothing about it it had appeared that the patient had died of natural causes when later it was spotted that she'd been killed by a drug overdose the hospital knew it was to blame there were two estranged daughters and they we knew they had no way of knowing that they had lost their mother to a medical error and we really had not thought before that of what we would do in such a case we had a meeting about it and decided at that point that we would do the right thing and notify the relatives and we did that so they came in with an attorney I just told them exactly what happened they were surprised and somewhat shocked uh we told them that we accepted full responsibility for it and that they were probably due compensation and that we would help them get it we felt we were doing the right thing and continued that way for the subsequent 13 years until today we're still doing it part is just saying we made a mistake the easy way to do it is get it out Simply you know not carry on about it just just say it and people appreciate it on top of this Lexington's honesty means they pay out less in compensation than similar hospitals not more in our experience once you once you apologize and admit that it really did happen uh it's all downhill from there it's it's a patients basically want those two things monetary compensation I think is a distant third we've had a few patients here who've even refused monetary compensation once we acknowledged our own responsibility for their for their mishap oh remember eight-year-old Ryan Welch who died last year of septicemia after going into hospital for a simple test [Music] after more than a year of trying to get some answers from the hospital Ryan's parents Ian and Denise have at last been granted a meeting we're heading towards Georgia Hospital um we're eventually got a meeting with the hospital after losing our eight-year-old son some 15 months down the line after loads of pestering loads of telephone calls we hoped of an apology and we hope to have questions answered as to why our eight-year-old son died but even 15 months later the meeting is on the hospital's terms what to submit our own questions so they can have their answers ready they've told us that we can't take a solicitor with us because the meeting isn't in is an informal meeting though the hospital has agreed compensation for Ryan's mom and dad it's not about money somewhere along the line some Good's got to come from this tragedy we just don't want it to happen to anybody else when we first got in there they straight away apologized um they answered all our questions some that couldn't be dancers for and some they weren't aware of until we actually brought them up I was very very surprised I expected to get no answers whatsoever but um we got in there and I've apologized before we even sat down and then they've apologized several times during the meeting and I do think they're really really sincerely sorry I still think now if we hadn't pushed it and we'd still be waiting for it I don't think they would have given so easy I agree I don't think it's easy 15 months a long time why couldn't it have been 15 days for whatever answers quite quickly after his death it might have helped us and especially Denise as well as apologizing the hospital has stopped doing the procedure that Ryan underwent but why could this meeting not have taken place sooner all that's being asked of the medical profession is that they treat others as they would wish to be treated themselves it's extraordinary how hard this sometimes seems to be the fact is that each year an unacceptable number of us are injured or killed by those that should be there to make us well now the medical profession has the chance to heal itself to stop seeing medicine as some mystical vocation and take on board the solutions that other high-risk Industries embraced years ago but our willingness to understand the profession's failures depends in turn on its willingness to be honest and open with us this requires a revolution in thinking on both sides whether we have the imagination to grasp this chance remains to be seen [Music]

Channel: Only Human

Views: 11,512

Keywords: clinical practice, disease prevention, documentary films, documentary series, health outcomes, healthcare accuracy, healthcare teamwork, human nature, human qualities, inspiring documentaries, medical analysis, medical awareness, medical challenges, medical discoveries, medical information sharing, medical investigations, medical journey, medical professionalism, patient safety, treatment errors

Id: EUlx1ND27EE

Length: 50min 33sec (3033 seconds)

Published: Sat Sep 09 2023