00:10:11 - 05:10:11
Dr. Stephanie Sanderson 00:06
I know that as a nurse, I've made multiple, multiple mistakes. I've I've made medication errors, I've made treatment errors. I've, I've done the wrong thing to the wrong page. I've done that. I know that I have. And I bet that I'm going to make more. And I know that my nurses are going to make mistakes. And when they do make a mistake, what I tried to do is is to coach them, everybody needs a coach, it doesn't matter how long you've been doing something, how can we do this better? How did this happen? Tell me how this happened. Because maybe I can intervene. And this is a system problem. I try to look at it that way. I try to these are not bad people. This might be a bad process. But if they're not telling me, okay, I made this error, but it so if I can share a recent situation to kind of drive this point home. I had a nurse make a very, very egregious heparin error and giving heparin is could be life threatening because an overdose of heparin can cause the hemorrhage it can cause strokes, head bleeds, it can cause all kinds of problems. And when I found out about the mistake, what I did is went back to find out what was happening, what what was the what were they doing before the mistake happened. And what happened was that there were two nurses taking care of a critically ill COVID patient who was just put on ECMO. And they were in room in a room in an isolation room. That was a, you know, a negative pressure room, there was lots of noise, they were in full PPE wearing peppers. Someone was outside the door, telling them to give heparin he the person outside the room because they tried really hard not to open the doors. And once you were in a room, they tried to stay in the room until they didn't need to be in there anymore. So there's a nurse outside the door mouthing to give 2000 units of heparin, the nurses in the room thought he said 10,000 you Oh, my goodness heparin. They didn't double check that they didn't verify that they didn't wait for an order that said that, because they trusted the nurse giving them right directive. And two and 10 behind a glass door looks the same. If you're reading Yes, it does. And if you're wearing a PAPR, and you're Yeah, hot, and the situation was very stressful. And so when I found out what was happening, I really, really sat down with myself to rehearse how I was going to address this because I was afraid that these nurses would deteriorate pretty rapidly if they knew that they had made this big error. And that, and that it could have caused this horrible harm in this patient who was already so incredibly sick. And so we sat down, and we had a very open dialogue about it. And I did not see it as like negligence, they they could have done a few things differently. But in that moment, I gave them that grace, which they deserved, because they were in a very, very difficult situation. Now we talked about the all the things they could have done to have avoided that. But neither one of those nurses quit. Neither one of those nurses called in sick for the next month because they felt so bad about what had happened. And I believe that that was because we really worked hard to preserve their integrity over all of this.
Jerrod Bailey 04:19
But I imagine that if there's a lawsuit five years from now, like we got to produce something right, in right, what do we have to produce? From from the AI? Like, what do you what do you think we should be thinking about now like table stakes, where do we have to produce
Matt Keris 04:34
story? What should we be producing? It's, it's going to be very similar now. But more complex what healthcare professionals professionals are dealing with in terms of the audit trail discovery. A lot of times we all know this standard practice, pointless law firms are seeking the audit trail to find the aha moment where there's a records alteration after the fact. The audit trail was so that it And part of the problem with a lot of healthcare systems is that you're, they're buying a product that's that's created for them. And they can either, you know, it's an evolving system, and no one really has their arms around it, they really don't know how to get some information, you know, people will internally move on. And then you may even, for example, get a new product. And the old EMR vendor doesn't want anything to do with the health care provider, they don't want to get involved in the litigation, if there's a real issue, they don't want to have to turn over their proprietary information, all those types of things, you could see that with AI, if it's truly an AI error, you can see similar to the audit trail, expensive discovery, I want to go in, I want to, I want to production of the of the audit trail, I want to, I want to know all versions that you use, I want to know the upgrades and amendments. And you may not be able to do that as a health care provider, because it's not yours. It's someone else's property. So and you may want to try to bring them in. But good luck on that. Why would they why would they voluntarily try to get back in to talk about if it's truly a proprietary issue or or their error? Why would they want to actively get involved in litigation to basically talk or expose one of their problems with their products. So I can definitely see as thorough a discovery into the AI when it was adopted, who the vendor is retrospective analysis, as we're seeing right now with audit trail.
Josh Silverman 06:33
If that happens, and people, let's say 73% Think lawyers spend too much time finding technicalities to get criminals released. I think they do that that's what they're paid to do. And lawyers are more interested in making money than in serving their clients and 69% of the public say that I disagree with that statement. Well, we have we've got an adversarial system. So lawyers, lawyers aren't hired just to come up with the best outcome they're hired to win for whoever they hire whoever hires them. Yeah. And what that tends to lead to is people fighting hard. And outcomes aren't necessarily what everybody would like. I mean, I remember when I was in law school, the big trial was the OJ Simpson trial. And everybody knew in their mind what the outcome should be. So they were mad at the lawyers, if lawyers have helped obtain an outcome that they didn't think was right, they thought your trial should have just been a rubber rubber stamp on their sense of justice, and people were angry. So yeah, it's a shame, though. i My experience is on both the plaintiff side defense side, most lawyers are just like everybody else. They want to work hard. They want to do well for their clients. They've got integrity. But yeah, we are competitive. And we do you want to win, there's no way around that. You know,
Jerrod Bailey 08:03
I, I deal a lot with folks in the med mal industry on both sides. And in there's plenty of folks on the defense side that say those plaintiff side law firms, they're, you know, they're, they're terrible, and they're, they're evil. And then you find the ones that really get it and they go thank God for them. Thank God for the plaintiff side firms, because what would we do if we didn't have a system that was advocating for, for the patient? And in I think that's it's an average federal system. But we hope then, in the middle of that, of that combat, that justice does find a way to get done. Right. Yeah.
Josh Silverman 08:39
I mean, and that's the theory. And I think in general, it works, where people are paid to bring out all sides of something.
Jerrod Bailey 08:45
Medical malpractice space, among others. And, you know, we talked about like the sort of push and pull between insurers and patients, things like that. Where do you where do you guys sit named, there's other sort of advocates and other sort of in this cloud of stakeholders in that process? And just curious where you guys sit in that? And right, how do you influence that? Yeah,
Dr. Christopher Landrigan 09:13
I think it's a it's a great question. It's a complicated space. And, you know, part of the challenge here is, as I'm sure you know, living in this world, is that you have all these different constituencies that look at the world a little bit differently, and have different interests and trying to tackle the patient safety or malpractice problem or what have you. And so, you know, we realized probably five years ago now that that we were all clinicians, right, we were kind of coming at this from a clinical space, we didn't really know the malpractice world at all, but But it occurred to us that it was important and we ought to be doing something to try to look at it through that lens as well. And so we did a study a couple of years ago, looking at well, you know, from malpractice database standpoint, what do we know about the role of miscommunications in malpractice claims? Same data set and and you know, it's really powerful data set and they had actually done some preliminary work themselves. demonstrating that communications looked like they were a big part of claims when you sort of start looking at things across specialty silos rather than just silo by silo. And we got access to that data set and did a random sampling of 500 of those claims and took a deep dive into them. And we found that that about 50% of claims 49% had miscommunication as one of the key root causes of what had happened, um, just an absolutely huge proportion. And of those, you know, about 40%, were directly we could, we could see they were their handoff problems that were in there. And of those more than 75% potentially could have been averted with something like IBS, you sort of boil all that down. And it looked to us like just about 20%, just shy of 20% of all the claims in the dataset potentially could have been averted with a tool like this.
Jerrod Bailey 10:47
I don't know if there's advice that you give folks or advice that's generally just sort of good practices right now, for those in the risk industry that are thinking about this slaw, is there anything that that we should be thinking of doing next, or monitoring or
Scott Buchholz 11:00
healthcare providers billing? Should we be doing their risk programs? I think they need to be attentive to incidents on the unit. I think they need to follow up. I think they need to bolster and make their risk programs more robust, and that's also medical groups to attack these things early on. And frankly, from a defense side, the sooner we can avoid a patient going out and seeking the services of an attorney. We can talk to that person and try to resolve it rightfully
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