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Mike Eisenberg: To Err is Human

Documentary filmmaker Mike Eisenberg profiles the Sheridan family, who have been devastated by multiple medical errors.

Mike Eisenberg Show Notes


Following father's footsteps


Mike was born in Philadelphia - childhood mostly in Maryland - but as a child was not interested in health care, even though his father was a patient safety advocate - as documentary filmmaker he wanted to tell stories otherwise not seen - fiction is harder and more expensive to make into film - the documentary path led down the path to make "To Err is Human


About 3.5 years ago it started with a short film on AHRQ: Agency for Health Research and Quality, the organization Mike's father started and was the Director until he passed away in 2002 - there was annual debates over AHRQ's budget and attempts to slash it - but AHRQ has far less money they should given their role


Started the documentary by driving to DC, pay out of pocket, and interview his father's old colleagues about AHRQ's role that the public knows nothing about - themes of medical error, patient safety and improving care emerged - it was evident to Mike that conversation was no longer being had - if felt to Mike it was his responsibility to carry on his father's work


We, including his production partners Matt Downe and Kailey Brackett try to stay positive in tone and show what happens when people take this seriously - focus on the process to make things better


Report in late '90s titled To Err is Human, Building a Safer System - a report that used research that determined how bad medical error was - the data was shocking - it said 44,000 to 98,000 died each year from medical error - that was brand new concept, made new headlines, President Clinton said it would be tackled


At the time, those numbers were questioned - but today one study, Marty Macquarrie out of John Hopkins that says 251,000 die each year - and John James's study that says between 240,000 and 440,000 die each year from medical error - hard to quantify because CDC (Centre for Disease Control) doesn't have a box to tick for 'death by medical error' - even conservative estimates have medical error as 3rd leading cause of death


We compare how many plane crashes, 7 or 8, would happen each day to equal medical error deaths each day - a staggering number, almost the same as the opioid epidemic - the important question is not accuracy of numbers, but how to get accurate numbers


The Sheridan family and medical errors


There is not a consensus around medical error death numbers - sometimes people die at home from hospital errors - part of the reason we've not seen more solutions is that the public, especially Americans, have been trained to treat the medical system: that physicians don't make mistakes, they are right all the time


The real reason we've not seen change in patient safety is because physicians have not embraced the patient in this process - some health care systems have, they visited over 250 health care systems - many of them doing interesting things to help curb error, but only a few have really engaged the patient


If a Hospital engages patients in a patient safety process, then the Hospital is admitting it makes mistakes, and that admission is considered guilt - but Med Star Health, especially out of Georgetown, show promise: they had a public facing explanation of an error that was prevented - great message that most of these errors are preventable 


It is easy to say to public we are humans too and make mistakes, and most are not egregious or intentional - most hospital surgeries have a practice called 'stop the line' and reasses if things are organized correctly, a bean counter will say it is not efficient and costs money, but it costs less then lawsuits


Regarding body cameras worn by physicians for patient safety, Mike considered including that aspect but thought it was too touchy subject - solutions for other societal problems can be embraced by health care - aviation is the most obvious, they interviewed Sully Sullenburger of the water landing in the Hudson River - vital health care takes a look outside its own walls


In Toronto we found a surgical team using video and other data to show when errors are most likely to occur and to use that data for better safety - 'hand offs' to other staff is obvious time things can go wrong


Improving patient safety is more than preventing law suits - the real 'bottom line' is about lives not profit - we expect health care to do what it is supposed to do and not cause new problems - what's important is communication with the patient


One of the stories in our film is about Sue Sheridan - her family experienced 2 medical errors - the 1st was her son Cal who has cerebral palsy and got that at 5 days old because of a small over sight by not performing an available and cheap test when he was born with jaundice - the other case is about the father Pat who was diagnosed with cancer - they thought it was benign but sent sample for pathology examination 


Aviation Culture vs Medical Culture


The results showed it was malignant, dangerous and needed to be removed - but those results didn't get through for 6 months because it was an over looked fax - so Pat didn't get treatment and died of cancer - but what doesn't go on the death certificate is that he lost 6 months of treatment


Organizations like the Society for Diagnostic Error in Medicine (SDIM) is leading the charge on diagnostic errors 


The biggest difference between airline industry culture and medical industry culture is the lack of transparency of the latter - recently an airplane window cracked and fell off and sucked a woman out the window, that was the 1st aviation accident that lead to a death in years - studies have found that most plane tragedies are not accidents


Recently Boeing had 2 large plane crashes and they've been open about determining what went wrong and how to fix it - the same thing should happen in health care


In aviation pilots have to re-take their test every 5 years to prove their competence - don't do that with driving cars, just give licenses when people are 17 and assume they'll good for the rest of their life - same thing with health care - we need to be honest about where health care is weak and where it can be improved


In aviation, airlines work together globally to improve safety for all airlines - but this is not the practice in most hospitals - but there are exceptions that share their research and date like Inter Mountain Heath Care in Utah, and some in Boston that have embraced imperfection - when an error happens they gather the team to learn how to prevent it in the future, as opposed to how avoid bad PR (public relations), or blaming someone and firing them - that's not how you fix the problem


In the documentary, Sue's family engaged in litigation, they 'won' in one instance of medical error, but not in the other - Mike chose not to focus on the litigation angle in the documentary - for the medical error to Sue's son, they did not get a resolution - Sue has turned her entire life into advocacy - one of her achievements is that the test her son should have received - bilirubin - is now a requirement


For Sue's husband's medical error - been about 18 years since her husband died, and the hospital recently had a screening of the documentary and a panel discussion afterward - the first time the hospital had openly discussed the case with its own staff - the pathologist had told Sue that it was not his responsibility to make sure the info he sent got through to the receiver


Physician have highest suicide rates


The US will have a shortage of physicians by 2024 often due to burnout - because they are also enterpreneurs - they have one of the most challenging jobs in the world 


Physicians have highest suicide rate of all professions - rampant in physician culture, especially clinicians - Mike's friends that are doctors are over worked and its scares him - they needed to be treated right - but its hard to expect humans to be perfect all the time when they are not treated that way - when things go wrong, the hospital worries more about its image then the people, its a systems vs people problem - it promotes volume and that is not conducive to reliability


Mike calls upon patients to be a voice, its not just a hospital problem - don't have to go to school for many years, just need to listen and look - can avoid a lot of these mistakes if they listened to patients, and patients felt empowered to engage 


Re physician suicide, it is an individual choice - wouldn't be surprised if financial problems are a factor - many start with 6 figure deaths, have families, and witness trauma every day, its a tough job - Mike has screened his film a lot in hospitals and he hears staff worried about losing job if point out errors - there is heirarchy in health care that is not healthy - old gaurd is not embracing new reality


One hospital claimed they had solved physician burnout by mandating that there was at least 6 hours between shifts - but that is still not reasonable - lessen to learn is suicide is individual, but common is that they feel their profession is not respected, appreciated - the message is that its been working for 70 years, why change now - but now is the time to change to take patient safety seriously


Fixing patient safety is about how care is delivered, and how we treat health care workers


In aviation, they do not permit pilots to fly if they haven't had a specific number of hourss of sleep, or if they've had even one drink of alcohol - some hospitals have similar standards, but why is that not a federal mandate? The Agency for Healthcare and Research Quality (AHRQ) is important to learn where to get better - but not much done with that info because they are underfunded but could cause huge change 


This is not new issue, its been around for 20 years - need to have discussions about access to care, about diversity and care - but they are only improved if thought from a patient safety perspective


Media and its messages


Aviation has done it well because they've collaborated globally, but in the US hospital are autonomous and its hard to develop a plan that all will follow - while aviation has an organization that investigates crashes, that doesn't exist in health care - why is that not happening in health care? Because one person dies at a time. 


In aviation, they 2 or 3 hundred at a time and those stories are on all the front pages - but when someone dies from communication breakdown there isn't the same collective impact or response - it boggles the mind


Since his documentary released, seen a documentary on HBO called Bleed Out, made by a comedian who tells about his family's experience with medical error over the years - also Bleeding Edge on Netflix about tthe FDA's lackadaisical approval of medical devices - 3 documentaries coming out in 1 year is progress - but how to make progress on the national stage? Mike working collaboratively on a project to put patient safety on the map 


Media has a responsibility in patient safety too - Mike says every day there are 4 or 5 stories on gun violence in Chicago, where he lives - and that problem persists despite local government action to fix it - in health care errors will always occur, but can learn from errors to prevent future harm - but to fix the problem requires engaging the public


Media is hugely responsible for what people care about - the media has all the power about what people care about - essentially telling the political atmosphere what it should care about - Americans choose what they want to protest about - we need a better way to show the scope and scale of medical error without blaming doctors and nurses - there is no villain in patient safety - malpractice is different from patient safety


We need a villain, somebody to blame - last year at Vanderbilt, a nurse was thrown under the bus for making an error that resulted in death, but it was actually a system failure that allowed her humanness to make an error, it was not her fault - instead of the hospital changing the system, they throw an employee under the bus, and she went to jail - then we wonder why people don't report errors when they see them


A culture shift in health care is needed, and it must come from the top - by working together we can send a message to 'the top' to make a change


Most patients want to be treated with honesty and transparency and will work together if something goes wrong - but that's not usually how it happens, it is usually a cover up, or denial, or this is how health care works and sucks to be you - but a culture of lawsuits has emerged as the way to get info out of hospitals - its not about money for most of these people


Less money, more transparency


In Sue's case, she sued for less money in exchange for greater transparency - we should get away from lawsuit culture and move toward working together


Mike has been fortunate to travel around the country to talk to people who knew his father {Founder of AHRQ} and sharing the film - a lot of people share the sentiment and passion he had still inspires them today - it is really cool as his son to hear that 17 years after passed away that he still has an impact on the health care system


Mike feels that a lot of the work that his father did - you can see clips of him on Youtube addressing Congress - is gone - don't why - was it because of his leadership, or because it was the right time? Mike thinks we need another leader who has the ability to bring people together - the way culture is set up, we need a celebrity - Dennis Quaid, famous actor, almost had his 2 sons die due to medical error and he made a short documentary and started a foundation


There are other examples, Serena Williams who nearly died due to preventable harm and racism - problem is 'medical error' is a very scary term and it is applied to all doctors, nurses, surgeons and it shouldn't be that way - there is resistance by the health care industry to embrace the terms 'patient safety' etc and not as an offensive term


Mike is proud of father's legacy, but worries that it has been forgotten by the people who spearheaded it in the first place - we need a superhero who can jump up and say these are issues we should be talking about


Mike is now balancing promoting To Err is Human and speaking at medical conferences and symposiums and screened the film hundreds of times - we need to go one person at a time, change one mind at a time 


There will be a screening of the film in Ottawa on World Patient Safety Day {Sept 17th} and for the first time there will a free online screening of the movie - to find link for free online screening check out his website and through twitter @ToErrIsHumanDoc


Website also lists other screenings in local areas - if you're interested in hosting a screening for your community, contact Mike - they tried to make the film so it is a conversation starter - but this issue is not solved, so we need to remind people where we are at, so we can continue in the right direction


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