A horrific, fatal medical error.
How could this happen at a major medical center, and what can we learn to prevent errors in the future? How does this mistake differ from this one? Or this one made by a junior doctor in the UK? Can guidelines and safety processes help? Please check out the key excerpts from the CMS report on this incident below.
There’s a lot to unpack here, ZPac, and your input matters. Check out the original video here on Facebook and let us know what you think can be done to improve safety in these situations and others.
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Here are some key excerpts from the full CMS report of the incident:
The record revealed Patient #1 was transported to Radiology for a PET (Positron Emission Tomography) scan on 12/26/17 for a full body scan. The procedure was scheduled for 2:00 PM. There was no documentation in the medical record the time the patient arrived in Radiology. Patient #1 was alert and oriented. While in Radiology Patient #1 requested something for anxiety before the PET scan procedure due to being claustrophobic. Review of the medication order #60651186 dated 12/26/17 at 3:00 PM revealed the physician ordered Versed 2 milligrams (mgs) intravenously for the patient's anxiety during the PET scan procedure. Review of the Automatic Dispensing Cabinet (ADC) detail report revealed the order was entered on 12/26/17 at 2:47 PM. Pharmacy had verified the order at 2:49 PM. Review of the ADC detail report dated 12/26/17 revealed at 2:59 PM Registered Nurse (RN) #1 took the medication Vecuronium 10 mgs (a neuromuscular blocking agent which causes paralysis) from the ADC located in the Neuro Intensive Care Unit (ICU) using the override feature, instead of taking the Versed medication that was ordered for Patient #1. There was no physician order for Patient #1 to receive
Vecuronium. The override was not verified by Pharmacy. There was no documentation in the patient's medical record the RN had administered the Vecuronium to the patient. Review of a physician note dated 12/26/17 at 3:45 PM revealed the physician documented, "Called for code in PET scanner, patient was pulseless and unresponsive on arrival. patient was emergently intubated and retrieved ROSC [return of spontaneous circulation] after 2 - 3 rounds of chest compressions. Patient transferred to Neuro ICU". Review of the Nurse Practitioner's (NP) note dated 12/26/17 revealed the NP documented, "Patient was doing well and transferred to the stepdown unit. On 12/26/17, patient was readmitted to NCU [neuro critical care] after suffering cardiac arrest while while off the unit to undergo PET scan..." Review of the physician's note dated 12/27/17 revealed the physician documented, "I discussed the case with the neurology team and it is felt that these changes in exam likely represent progression towards but not complete brain death...very low likelihood of neurological recovery, we made the decision to pursue comfort care measures. [Patient #1] was made a DNR [do not resuscitate]..." The physician documented the patient was extubated (removed from mechanical ventilation) on 12/27/17 at 12:57 AM and expired on 12/27/17 at 1:07 AM. 3. Telephone interview with RN #1 on 11/5/18 beginning at 4:41 PM, RN #1 was asked to describe the circumstances leading up to Patient #1's death beginning on Tuesday 12/26/17. RN
#1 stated, "I was in a patient care role, I was the help-all nurse. A help-all nurse is a resource nurse and I had an Orientee" RN #1 stated that RN #2 had asked her to go downstairs to Radiology PET scan and administer the medication Versed to Patient #1 because the patient was not able to tolerate the PET scan procedure or they would have to send the patient back and reschedule it. RN #1 stated he/she searched for the Versed under her profile in the ADC and he/she couldn't find it. The RN stated he/she then chose the override setting on the ADC and searched for the Versed. RN #1 stated she was talking to the Orientee while he/she was searching the ADC for the Versed and had typed in the first 2 letters of Versed which are VE and chose the 1st medication on the list. RN #1 stated he/she took out the medication vial out of the ADC, and looked at the back of the vial at the directions for how much to reconstitute it with. RN #1 verified he/she did not re-check the name on the vial. RN #1 stated he/she grabbed a sticker from the patient's file, a handful of flushes, alcohol swabs, a blunt tip needle. RN #1 stated he/she put the medication vial in a baggie and wrote on the baggie, "PET scan, Versed 1-2 mg" and went to Radiology to administer the medication to Patient #1. RN #1 was asked how long it took her to get to the Radiology department PET scan, and RN #1 stated, "5 minutes or less, it was my first time to go to PET scan, I had to ask for directions". RN #1 stated, "I saw one patient [who was Patient #1] on one of our beds, I checked the patient for his/her identity, and told her I was there to give him/her something to help him/her relax".
RN #1 stated, "I reconstituted the medication and measured the amount I needed" The RN stated Radiology Technician #1 was there at the time he/she administered the medication IV to Patient #1. RN #1 stated he/she left the Radiology PET scan area after he/she had administered the medication to Patient #1. RN #1 was asked how much medication did he/she administer to Patient #1, and the RN stated, "I can't remember, I am pretty sure I gave [him/her] 1 milliliter. RN #1 was asked what was done with any left over medication, and the RN stated, "I put the left over in the baggie and gave it to [Named RN #2]..." RN #1 was asked what he/she did after administering the medication to Patient #1, and the RN stated he/she left Patient #1 in Radiology. RN #1 confirmed that he/she did not monitor Patient #1 after the medication was administered. RN #1 was asked what happened next and the RN stated, "Patient #1's family was standing outside in the hallway...we heard a rapid response call for PET scan. That was a red flag since the patient was ours, so [Named RN #2] called down there [to the PET scan] but there was no answer. The family looked at us and said "ours?" [Named RN #2] said "we are going to make sure." We tried to call PET scan again, we were being responsible to go to see if it was our patient". RN #1 stated that he/she and RN #2 went to PET scan and when they arrived Patient #1 was intubated and had regained a heart rate. The RN stated he/she, Physician #2, and the Charge Nurse moved Patient #1 back to the ICU. RN #1 stated, "I told [Named Physician #2] that I had given [Patient #1] Versed a few minutes ago...I reminded the Nurse Practitioner that Patient #1 was awake but unmonitored when I gave the Versed". RN #1 stated RN #2 approached him/her and asked, "Is this the med you gave [named Patient #1]?" and RN #1 responded "yes". RN #1 then stated RN #2 said, "This isn't Versed, It's Vecuronium." RN #1 stated, went into Patient #1's room and informed Physician #2, and the NP that he/she had made a mistake and administered Vecuronium to Patient #1 instead of Versed. RN #1 was asked if it was documented he/she had administered the Vecuronium in Patient #1's medical record. RN #1 stated, "I did not. I spoke with [Named Nurse Manager] and he/she told me the new system would capture it on the MAR [Medication Administration Record]. I asked and [the Nurse Manager] said it would show up in a special area in a different color." RN #1 was asked if he/she could remember how much Vecuronium she administered to Patient #1, and RN #1 stated, "I would have given 1 milligram." RN #1 was asked if he/she talked to anyone at the hospital in the days after the event, and the RN stated, "I did have some conversations with risk management. I don't remember all I said. It was on the phone. I came back on the 3rd [January] and saw [Named Nurse Manager]. That is when I was terminated. They sent me to an employee resource counsellor for my own personal wellbeing." RN #1 was asked about the "help-all nurse" role and was there documentation of what was done while working a shift, and the RN stated, "If you do something, you just chart it for that patient". The RN stated there was not an actual job description for the role of a "help-all nurse"
4. Interview with Radiology Technician (RT) #2 on 11/2/18 at 1:30 PM the RT was asked about the events surrounding [Named Patient #1's] medication error in December. RT #2 stated, "[Patient #1] was an inpatient brought down by Transport, and was dropped off in a hallway. Me and another girl went to get the patient and put in an injection room. [Patient #1] said he/she was claustrophobic so the other girl called the patient's nurse...a transporter walked by the patients room and noticed he/she was unresponsive. We were in the control room, we have cameras that we can view but not to the point of seeing if they are breathing." RT #2 was asked how long the patient was in the room by him/herself before the transporter noticed him/her. RT #2 stated, "If I was going to guess, maybe 30 minutes. I don't know specifically. I ran to call the code and [Named RT #1] started CPR..." Telephone interview on 11/5/18 at 9:29 AM with RN #2 (Patient #1's primary care nurse prior to the Event) the RN #2 was asked to describe the events surrounding Patient #1's death. RN #2 stated, "...[Patient #1] was scheduled for a PET scan and was nervous...PET scan called me and told me the doc [doctor] had ordered an IV med [medication] for anxiety...I relayed to the help all nurse and [Named RN #1] agreed to go and administer it. I don't remember the timing, I heard the code, they brought [Patient #1] back to an ICU room. I went over to ICU to give report to the nurse taking care of the patient and [Named RN #1] handed me a vial in a bag...I went back to my desk to do some charting and then I realized it [Vecuronium had been administered instead of Versed] I went and told my charge nurse and I gave the bag to him/her. That was the end of my
involvement." RN #2 was asked how long he had the bag with the vial in it before he/she realized it was the wrong medication. RN #2 stated, "It was less than 15 minutes..." Telephone interview with RT #1 on 11/5/18 beginning at 1:15 PM he/she was asked about the events that lead up to Patient #1's death, and RT #1 stated, "Transportation brought [Patient #1] in and I talked to [Patient #1] about the scan. He/She said he/she needed some medication for anxiety and he/she had gotten some when he/she had an MRI. I called [Patient #1's] nurse to let him/her know and the doctor that she could not go through the scan, so the doctor ordered Versed. We had a busy day that day, it was a full schedule. We were going to send [Patient #1] back if they couldn't come and give him/her the med. [Patient #1's] nurse asked if our nurses could give it, so I asked them and they said no because the patient would need to be monitored. I then asked [the patient's] nurse if he/she would need to be monitored and he/she said no and he/she would send another nurse. I injected the [radioactive] tracer for the scan knowing she was going to get the medication. We can't do the PET scan for an hour after the tracer is injected so it can circulate throughout the body. Two nurses came down and he/she asked if this was the patient that needed the med. [The nurse] gave the med and then we put [the patient] into our patient room. That is where they wait the hour. I went back into the scan room. Sometime later, the transporter was there to pick up [Named Patient #1], he found him/her unresponsive, we called the rapid response, I started chest compressions and [Named RT #2] got the crash cart..."
RT #1 was asked about how long Patient #1 was in the room after the nurse came and administered the medication, and RT #1 stated, "I had briefly 30 minutes of uptake time left. We could see him/her through the camera from where we were. He/She had her eyes closed the entire time, we thought it was a light issue with her eyes. The camera isn't sharp enough to pick up breathing. [rise and fall of the chest]" RT #1 was asked if Patient #1 was monitored after receiving the medication for anxiety, and RT #1 stated that the RN #1 did not stay and monitor the patient after he/she administered the medication.
Based on standard of practice, document review, review of hospital policies and procedures, interpretative guidances, Review of Tennessee Code Annotated, medical record review and interview, the hospital failed to ensure patients were free from all forms of abuse when a Critical Care Registered Nurse (RN) neglected to administer medication as ordered to 1 of 5 (Patient #1) sampled patients review for medication errors and failed to monitor for any untoward effects as the patient experienced respiratory/cardiac arrest. The hospital failed to report this incident to the Tennessee Department of Health as mandated.
medication as ordered and to ensure the patient was monitored for untoward effects resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of serious injuries and/or death. The findings included: 1. A review of the "Lippincott Manual of Nursing Practice 10th Edition" documented, "...Watch the patient's reaction to the drug during and after administration. Be alert for major adverse effects, such as...respiratory distress...NURSING ALERT...The nurse is ultimately accountable for the drug administered..." A review of the "ISMP List of High-Alert Medications in Acute Care Settings...ISMP 2018" documented, "...High-alert medications are drugs that bear a heightened risk of causing significant patient harm when they are used in error...Classes/Categories of Medications...moderate sedation agents, IV [Intravenous] (e.g.[for example]...midazolam [Versed]...neuromuscular blocking agents (e.g...rocuronium, vecuronium)..." 2. Review of "Paralyzed by Mistakes: Reassess the Safety of Neuromuscular Blockers in Your Facility" documented, "...Neuromuscular blocking agents are high-alert medications because of their well-documented history of causing catastrophic injuries or death when used in error...Because neuromuscular blockers paralyze the muscles that are necessary for breathing, some patients have died or sustained serious, permanent injuries if the paralysis was not witnessed by a practitioner who could intervene.
After a patient receives a neuromuscular blocker, progressive paralysis develops, initially affecting the small muscle groups such as the face and hands, then moving to larger muscle groups in the extremities and torso until all muscle groups are paralyzed and respiration ceases. However, full consciousness remains intact, and patients can experience intense fear when they can no longer breathe. They can also sense pain. The experience can be horrific for patients...The most common type of error with neuromuscular blockers appears to be administration of the wrong drug...Practitioners thought they were administering a different drug, so patients may not have been supported with mechanical ventilation..." 3. A review of the hospital's "High Alert Medications" policy documented, "...High Alert Medications - Medications that bear a heightened risk of causing significant patient harm when used in error...Medication orders are reviewed by a pharmacist prior to removal from floor stock or an automated dispensing cabinet unless...A delay would harm the patient (including sudden changes in a patient's clinical status...Additional strategies are followed for a specified list of High Alert Medications...Higher level decision support...Independent Double-Check where electronic clinical systems prompt dual signoff..." Vecuronium was listed as a high alert medication. There was no documentation in this policy detailing any procedure or guidance regarding the manner and frequency of monitoring patients during and after medications were administered. Review of the facility's "Medication Administration" documented, "[Named Hospital] staff validate the five rights of medication
administration to minimize medication errors...Right patient; Right medication; Right dose; Right route...Right time to adhere to the prescribed frequency and time of administration...Document medication administration in the electronic medical record to include, at a minimum, the following...Date and time of administration; Medication name and strength; Dosage of medication administered...Route of administration..." There was no documentation in this policy detailing any procedure or guidance regarding the manner and frequency of monitoring patients during and after medications were administered. Review of the hospital's "Interpretive Guidelines for Reportable Events" revised July 2009 revealed, "Effective May 27, 2009, the Health Data Reporting Act of 2002 was amended by Public Acts of 2009, Chapter 318. The new law provides that all licensed health care facilities...shall only report incidents of abuse, neglect, and misappropriation that occur at the facility to the Department. For state licensure purposes, the facility is required to make the report within seven (7) business days from the date that the facility identifies the incident... Definitions... 'Neglect' means the failure to provide goods and services necessary to avoid physical harm..." AGAIN please see the full report here.
– What is up Z Pac, it’s your boy ZDoggMD. I’m live and direct in my office. Okay, a lot of people have messaged me including a friend at Vanderbilt University Medical Center asking me to talk about this thing that had been in the local press in Tennessee about a horrible medical error that resulted in a patient death at Vanderbilt University Medical Center in December of last year, 2017 and they wanted me to weigh in on what I thought about this and initially I was very reluctant because I said well I kind of know what’s going on here and I don’t think it’s going to add a lot to the discussion.
And then I really kind of weighed it and said wait a minute actually I think talking about this is crucially important and my Z Pac was right and I was wrong about this. It does bear discussion. Let me back up and tell you what’s going on.
What’s up Vanessa, what’s up Suzy, I’m reading your comments today as well. So 2017 patient’s admitted with a subdural hematoma, bleeding on the brain. A couple days into the admission they decide to do a whole body scan. I read in one of the press articles it was a PET scan, now I don’t have inside information about this.
The patient’s name and the involved parties names are confidential so I’m relying on press and also reports from friends that are there that say it was as bad as reported. So what ended up happening was patient is going to get ready to have this scan. She’s expressed a concern about claustrophobia by report and the doctor orders a dose of Versed, which is an an anxiolytic, benzodiazepine drug, short acting, those of us in the know know and for those of us who don’t that’s what it is. The idea being take some of the edge off that claustrophobia, mild sedation, maybe not remember the procedure as well, those kinds of things which is all perfect.
Very much standard of care for this sort of scenario. Now the nurse who was managing this patient before going into the scanner went into what presumably the Pyxis, whatever her medication dispensing device was and couldn’t find Versed on the patient’s sort of ordered medications. Again this is my interpretation reading the press report. So at that point she triggered some overrides to override what was ordered and put in the drug herself. So she types in and we all kind of know how these machines work, she types in the first two letters of the drug name, V-E, Versed, trade name, right. Not the you know the generic name and a medication pops up, she hits okay, takes the medication.
Well it turns out what the device auto filled was a generic name which is vecuronium. And those of us who know what that drug does know that it is a neuromuscular paralytic agent. In other words it doesn’t sedate you, it doesn’t make you unconscious, it paralyzes your muscles, including your skeletal muscles, including your diaphragm and your muscles of respiration, your intercostal muscles that help you breathe.
Well, this was not a good thing because the nurse took the drug. Apparently didn’t look at exactly what it was because most people that I’ve talked to have said that vecuronium has a label on it, a warning label big that says warning paralytic agent. Gives the medication, administers it to the patient and they put her in the scanner. Now mistake number one.
Mistake number two purportedly, allegedly, is that at this point the nurse or whoever the staff was who were there after administrating the drug they did not watch the patient for signs of effect or relaxation or reaction, which you’re supposed to do. Instead they put her into the scanner and then probably left the room cause she’s gonna get a scan. The patient gets a long scan. When they go to take her out of the scanner she is pulseless and unresponsive and ended up being rushed to the ICU after I presume a code was run, rapid response and code, and she was, support was withdrawn a couple days later and she died.
Now let me just for the emotional significance of this, let me describe what this might have been like because what has effectively happened is she’s anxious about going into a scanner, she’s claustrophobic, she’s already scared. The nurse said I’m gonna give you something to relax, which is allegedly what she said, thinking it was Versed, and effectively gave her a drug used in executions where she was paralyzed increasingly in an ascending way and unable to speak, but completely conscious, able to feel pain and discomfort and fear but unable to move and progressively unable to breathe until she blacked out, lost consciousness, presumably suffered irreversible brain damage and later died. Let that sink in for a second. That is the tragedy in all of this.
This patient died under torturous conditions in a hospital, in a place where you put your trust in other people to take care of you safely. What happened? How did we betray her trust? And in the next couple of weeks I’m going to be doing a keynote at the Institute for Healthcare Improvement talking to specialists in hospital safety and I was thinking about this case more and more. The safety mechanisms that were in place to protect against this happening all failed, why? And we don’t know the exact details, but in a big picture sense it’s because a human being decided to override them and then decided that that other sort of standards of care were not going to happen, like monitoring the patient afterwards, checking on the patient, seeing how the effect was, even if you give Versed that can be a respiratory sedative, it can drop your blood pressure, things can happen. There should be careful followup and watching of this patient.
So on those levels catastrophic error, catastrophic failure. Now this actually put Vanderbilt’s entire Medicare status at risk according to the Tennesseean who was reporting on this and they almost lost the ability to bill Medicare, which would have been catastrophic because it’s one fifth of their revenue. So they put processes in place to improve systems after this including personnel changes, which I imagine was the nurse being fired. And again we don’t know the name of the nurse, I don’t want to know, this is the bottom line what is at fault here and how can we do better?
Well okay, I want you to weigh in. I want pharmacists to weigh in, what could have been done to prevent this dispensing of an incorrect medication? I want nurses to weigh in, I want rad techs to weigh in, I want everybody to weigh in and tell me what are you doing in your facilities to prevent this from happening. Then we want to think about what happened here. The thing wasn’t on the order, maybe she didn’t want to call the doctor, maybe she didn’t want to have to call IT, maybe she didn’t want to get into the HR, I don’t know what was going on. Maybe she was understaffed, maybe she was under stress, maybe something else was going on.
There’s a million reasons why the so called Swiss cheese model, all the air holes align and you get a straight shot to disaster. Whereas normally these situations are in place to prevent it from happening. We don’t know. Here’s the bottom line, there is no excuse for an error of this type happening in 2018 in a major medical center. There is no excuse.
And you can make all the reasons, you can say yeah this could have been different, we could have had a process for this, we could have not allowed an override, we could have done this, but the bottom line is we should never give this a pass on any level. We need to work diligently to figure out what went wrong. If it was pure human error that human needs to be adjusted and whether that means being fired, being sued, whatever that is we need to manage it. Understanding if there are extenuating circumstances, but still this patient died under torture effectively, all right, so that being said, let’s back up a second.
How was this different than the story I told about the nurse practitioner who, actually I have her thing here. I have a bag of pink wristbands for Remi Engler, her daughter, who she was, her routine was knocked off. We talked about this on the show, everything, every Swiss hole aligned where she forgot her beautiful daughter in her car when she went to the clinic and at 4:00 PM found her and they couldn’t save her. How is that different in terms of error than what happened here?
You know in many ways this gets to the heart of how human beings make mistakes, how we need systems in place, we need training, we need accountability, but we also need compassion when it’s necessary when it really was all the Swiss holes aligning and we need to do better.
Now in this case what can we do? Do we need some sort of better dispensing process, do we need a check whenever you’re giving something like Versed, should there be better protocols, do we need better staffing for the nurses, better support, there’s a million different things we can do. Let’s read some comments.
So Emily Dial says our Pyxis, which is the dispensing equipment, also has a pop up with this medication to warn that it’s a paralytic agent, back to basics five rights of mediation administration. So I want to learn more about these five rights from my nurses cause, when I say my nurses I mean my Z Pac. I want you to teach me about this because I don’t know about this as a doctor. And actually many doctors don’t understand the medication dispensing pathway and we would probably benefit from learning it.
In my facility says Stacy Lynn this would not have happened because vecuronium is only available in the surgical Pyxis and in the pharmacy. The hospital needs to have better policies. So sometimes they use, you know they can use vec in the ER, use it as a paralytic agent along with sedation and intubation to ventilate. So it’s not an inappropriate drug in certain settings. So I can understand why maybe it was available, but maybe, so Celeste says triple check, call an attending, if you’re unable to fulfill your duties that day take the day off, there’s so many things. So I think pretty exclusively people are saying there isn’t a human excuse for this and I think I have to agree that you cannot give somebody a pass for this. Now when we talked about Remi Engler and I spoke to Nickee Engler, Remi’s mom, I got the sense that this was a deeply good person for whom everything aligned and our foilable human brains failed us in the most crucial situation. And a lot of people disagreed with me, but I unequivocally believe this because there aren’t a ton of systems to keep us from forgetting our child in a car beyond repetition and routine and conscious awareness to the problem. But a lot of times we run on autopilot.
Now in the hospital, this nurse was not running on autopilot. She had to go out of her way to override the safety mechanisms. Without then taking the extra step of making sure it was the right medication, checking on the patient, doing those kind of things. So that’s initially why I didn’t want to talk about this because it’s like well it’s pretty clear, but you know what there is always nuance in these stories and even if talking about it today changes one workflow somewhere in the country where a life is saved or disability is prevented. There is this whole saying that like the third leading cause of death in the United States is preventable medical error. I’m not sure I believe the statistic, it doesn’t matter. It’s high, it’s too high. Any medical error that causes debility or death is too many and until we have to, guys like part of this whole movement of Health 3.0 is looking at ourselves, putting ourselves under a spotlight saying not everything the administration does, not everything the quality czars do, not everything the measurement industrial complex does is bad.
Sometimes we need to really focus on processes and realize that we make mistakes. So we need systems that help us avoid those mistakes. We need better training, but we also need fail safes. Pilots have them. There still could be human error, but it has drastically decreased and I think we can learn a lot. We don’t cookbook medicine things, but at the same time this was preventable.
Let’s read a few more comments. Let’s see April Peterson says I can’t tell you how many times I’ve seen nurses not scan the patient med, say they’re in a hurry and will document it later when they sit down to chart. Boo ya, that’s it. Doctors cut corners, nurses cut corners when we’re super busy we think you know what I’ve done this so many times nothing’s going to go wrong and then it does. And I’ve seen it happen with potassium orders. I’ve seen people die, I’ve seen this happen. And then the hospital does a root cause analysis and they go through the whole thing and always it’s a Swiss cheese. There are multiple errors. Rarely is it just one human making a single mistake. It’s usually a series of things, but again entirely preventable, entirely preventable.
Let’s see why was this drug even stocked in the radiology department. There’s a history at Vanderbilt of these sort of shortcuts, is there a history at Vanderbilt of these shortcuts occurring before? It sounds like a habitual behavior unfortunately, Marie Daniels. Well you do wonder if the override’s that easy. You know you do wonder. Again Vanderbilt’s a world class institution, but in our world class institutions we make big mistakes. The bigger the institution the bigger the mistakes. That’s what I’ve noticed across institutions which means we need better policies.
That being said if I’m gonna have a complex surgery I’m gonna go to a major academic institution. And again this is gonna piss off come community people, but you want people doing a procedure on you that does it a lot and has a good safety record, maybe takes harder cases so maybe more people die or have bad outcomes, but adjusting for that they’re doing really well. This actually matters. We did a show with Dr. Rifkin from MCG Health about care variation and saving lives and quality improvement and guidelines and things like that. I will share it soon again.
Let’s read some more comments. Yeah, a lot of, okay so this is what I’m gonna do. I’m gonna leave you guys with this, I want you to leave your comments. I want you to have civil discussions in this section about how we can do better. I don’t want to complain, I don’t want to victim shame, I don’t want to blame people, I don’t want to do any of that. I want to have real, actionable ideas of how we can prevent this, what you’re doing in your institution, what you do personally because remember this as hard as our jobs are and as busy as we are and sometimes we feel put upon on all sides, we have this really sacred responsibility to relieve human suffering. In this case that failed and so what can we do to live up to the meaning and the purpose of what we do, and sometimes that means doing mundane shit like coming up with safety protocols and processes and things like that, that seem boring but they save lives every single day. So let’s talk about it guys. Hit like, hit share and we out, peace.