Episode #325 APSF Podcast Takeover: The HSSIB with CEO Dr. Rosie Benneyworth From The Medical Safety Podcast

We are excited to introduce you all to a new podcast and I think it is fair to say that if you like this podcast then you will really enjoy our takeover show today. If you are new here, then welcome! This is the Anesthesia Patient Safety Podcast and I’m your host, Alli Bechtel. Today, we are collaborating with the Medical Safety Podcast with hosts, Amir and Adam. I’m so excited that they are joining me on the show in a few weeks to have a conversation about patient safety, but we couldn’t wait to share one of their podcast episodes with you. They are talking about big patient safety topic including communication, listening to patients, building safer systems, teamwork, and more in this epsiodes, so stay tuned.

Before we dive further into the episode today, we’d like to recognize Vertex, a major corporate supporter of APSF. Vertex has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Vertex, – we wouldn’t be able to do all that we do without you!”

Without further ado, here is The Medical Safety Podcast and their 10^th episode, “The HSSIB with CEO Dr. Rosie Benneyworth.”

[The Medical Safety Podcast Episode 10]

“SPEAKER_00 0:04

I find it a hugely important piece of my work. My team are all working with families and patients as well. But actually, for me to sit and listen, I think it’s so powerful what people have got to say. The people I meet, they’ve lost trust in the system, they feel that they haven’t been listened to. What they tell me is actually what we want most of all is for this not to happen to other people. We want the learning to be there so that other families don’t have to go through what we’ve gone through. And that’s such a powerful message.

SPEAKER_01 0:37

Welcome back to the Medical Safety Podcast. I’m Adam Shahada.

SPEAKER_02 0:40

And I’m Amir Hammond.

SPEAKER_01 0:42

The Medical Safety Podcast is a place where we discuss how to improve the safety of our healthcare system through the integration of human factors into system safety, including medical incident investigation and proactive safety measures. In previous episodes, we discussed the death of Elaine Bromley with her husband, UK airline pilot Martin Bromley. We also discussed aviation parallels to that case with Canadian airline captain Mike Schuster and the escalation of language of concern with Canadian Dr. Katie Lynn. We have other episodes, and in today’s episode, we are incredibly fortunate to have Dr. Rosie Bennyworth with us. She is the interim CEO of the UK’s Health Services Safety Investigations Branch. And Amir, I’m going to turn it over to you to give a bio here, but I have to say that we are incredibly fortunate to have her with us. I cannot believe we’re even doing this interview.

unknown 1:31

Yeah.

SPEAKER_02 1:31

Echoing Adam’s words.

Dr. Rosie Benneyworth, HSSIB CEO

SPEAKER_02 1:33

Dr. Bennyworth joined the Healthcare Safety Investigations Brand, HSIB, which is the previous iteration of the body we’re talking about today in August 2022, and is now the interim chief executive officer of the Health Services Safety Investigations Body, the HSSIB, or probably what we’ll refer to it as the H SIB going forward. She’s led the transition to this arm’s length body. She has a long-standing interest in improving the quality and safety of care that people receive and has held several senior leadership roles in health care. This has included Chief Inspector of Primary Medical Services and Integrated Care at the Care Quality Commission, Managing Director of the Southwest Academic Health Science Network, and as a clinical commissioner with the Somerset Primary Care Trust and Clinical Commissioning Group. Dr. Bennyworth has a background in primary care and has worked as a GP in Somerset for 15 years. Rosie, as she likes to be called, has a significant non-executive experience and is currently a non-executive director of the board of Somerset NHS Foundation Trust. She has also held roles as a non-executive director and vice chair of the National Institute for Health and Care Excellence, non-executive director on the board of University Hospitals Bristol and Weston NHS Foundation Trust, and a trustee of Nutfield Trust. Welcome, Dr. Benningworth. Welcome, Rosie. Thank you so much for joining us today.

SPEAKER_00 2:58

Thank you. I’m absolutely delighted to be here. Thank you.

SPEAKER_02 3:02

We always start very much the same way. So how did you get started in medicine?

SPEAKER_00 3:06

Well, I always wanted to be involved in healthcare. I come from a family of farmers, so no one in my family is in healthcare. So I’m not sure what prompted me, but initially I thought about pharmacy, but then very quickly thought actually medicine’s the career for me. And I’ve never looked back. I’d loved my career in medicine in every part. I think we’re very privileged to work as doctors and work in healthcare, and it’s been a fantastic experience for me.

SPEAKER_02 3:32

Amazing to hear that. So could you walk us through how you got started in patient and system safety from your initial role as EGP in the UK?

SPEAKER_00 3:41

Yeah, so I’ve always been interested in improving services. And I started that when I was a GP in my local practice. I think it’s fair to say my career has probably been shaped quite a lot by personal experience. I’ve had a son who’s had medical issues that have required multiple services, being involved in his care. And whilst the care he received was excellent, the clinical care, often actually as a patient, I find it quite hard to navigate quite a complex healthcare system. And I think that really drove me to really thinking about how I could improve that for other patients, especially as I was a GP. And you know, if anyone can navigate a system, it should be a primary care physician. And, you know, as a GP, I found it very, very confusing at times. And on occasion, you found that actually as a patient, you weren’t really listened to. It was very much you’ve been kind of disempowered as a patient rather than empowered as a patient. And I was quite keen to change that. I then developed in my management role as well as my general practice role in a variety of ways looking at actually how do you improve services. And I’ve tried that as a commissioner, as a regulator, in a body that looks at innovation in the NHS. So I’ve tried to improve healthcare in a very complex system, which is challenging, I think, for everyone. But I think my role currently with HSFIB gives the best opportunity I’ve had in terms of really looking at the system and thinking about how to improve things. I think also I’ve had an interest in patient safety for several years now, specifically. I was involved in an organisation called an Academic Health Science Network, and part of that role, I became a national lead for patient safety through that role and started to really understand much more about a systems approach to looking at issues and really thinking about how do we look at things in a different way. I actually think we should be doing much more to bring the innovation agenda and the safety agenda together. And then I was really fortunate to join HSIB and subsequently HSSIB. And I’m very lucky I work with an immense team of safety experts who’ve come from all sorts of backgrounds. Some of them have come from aviation backgrounds, from the military, from legal backgrounds, some clinicians, but all with a really deep understanding of human factors and safety science. And that’s really, I guess, helped drive my understanding and knowledge around patient safety, learning with them and from them as we’ve gone along. So I think it’s a really exciting field and delighted to have the role I do. I feel lucky every day about what I do.

SPEAKER_01 6:27

I have some understanding of what you might have gone through with your son. My wife is currently battling breast cancer and she’s received excellent, excellent care over here, but quite fragmented care. And I have to say, as you said, navigating the system, especially for a doctor who I work in the system, and also oftentimes I work at the various hospitals that she’s been treated at, or I have worked at them, it’s been probably the most challenge I’ve had of anything that I’ve ever done. And I think not only do we need to work on delivering the excellent care that we are, I think the idea of making it easier for people to navigate and the system doesn’t talk to each other, and that’s here in Canada. I’m sure it’s similar in many other places around the world. But I just wanted to say that it really touched something in me where I just realized that this must be an experience that so many people have, and I really only experienced it being that it was my partner that’s going through this. So I imagine if we were to talk to a number of people in a number of different parts of the world, that they would have the same thing. But I think clinicians often we don’t see this. We see our part, we don’t see how the whole thing fits together.

SPEAKER_00 7:30

Yes. One of the things I see consistently is that actually it’s often those gaps between services where safety issues occur, safety instance. And I think actually we’ve got to do much more to integrate services, to join up services to share information better and to communicate better across the system and to really empower people through that journey as they use different services. I think there hasn’t been the progress in that that we need to see at the moment. We’ve got a new strategy in England called the Tenure Plan, her NHS 10-year plan, and part of that is actually looking at how services move out into the community patients. And I think that will certainly help.

SPEAKER_01 8:11

It hits on a theme that Amir and I have been talking about this idea of system safety, which is this idea that very often we find as clinicians that people are told, well, you need to be vigilant, and individual nurses and physicians and allied health professionals need to be on the lookout for these cracks in the system. But the question that we’re hoping to get to is a bit of a more macro one, which is how do we make the system better and easier to use? And as Martin Bromley has put it, how do we make it easier for the people at the sharp end, the clinicians, the nurses, et cetera, to get it right and make it harder to get it wrong? And as you just said, how do we make the system, the pieces of the system fit in together? So I hope that we’ll explore a little bit of that today. And I think it’s the work that we’re all trying to do.

SPEAKER_00 8:57

Yes, absolutely. And you know, we see amazing frontline professionals working despite the system around them and despite the challenges. And I completely agree with yourselves and Martin. We’ve got to make the systems, the processes, the environment much better to really enable people to come to work and do the best job that they can.

SPEAKER_02 9:18

What does your day-to-day work look like?

SPEAKER_00 9:21

Okay, well, it’s it’s very variable actually, and there isn’t really a pattern to my day-to-day work. I spend a lot of time, I meet with families, I meet with people who’ve who have been harmed by healthcare, and I meet with bereaved families. And that’s a really important part of my work is listening to stories, listening to people’s experiences of care and making making sure that we put that at the centre of our work. I meet a lot with stakeholders, we have a complex system in the UK, as I think many healthcare systems are, and so I spend a lot of time trying to raise the profile of our work, really thinking about where the emerging risks are in healthcare and and how we can kind of how we need to look at those. And I spend time with policymakers as well and ministers and the Department of Health and Social Care, really thinking about how we can influence the national direction of travel. I work a lot with my team. I’m not an actual investigator, but they are a very skilled team of investigators, my team, and so they’re out in the environments in the hospitals or primary care settings and all the different settings that we investigate, really observing practice and looking at practice. And I sometimes go out with my investigators as well to have a look and see to follow them and learn from them and support what they’re doing. So I do a whole range of things, but it covered the whole country. So travel quite a bit across the country. And I also I’m really proud of the links we’ve got internationally. We have some great links. We’ve got an international network that we established called the International Patient Safety Organizations Network, and we really try and learn from lots of different parts of the world who are all struggling with the same patient safety issues by and large. So we we want to share and learn across the across the world as well.

SPEAKER_01 11:12

Rosie, I just wanted to say that I think it’s remarkable that you, as the CEO of the organization, are going out and meeting with families and Bare family members as opposed to leaving it to somebody else whose job it might be in the organization or to an investigator or somebody else. In my mind, we don’t see that enough. I mean, it really speaks to the core principles or what I think the core principles are of the HCB. And really that the most senior person in the organization is coming down to the level of the where the care is provided and to see the impact and the consequences of what may be medical error or system issues, and to really get that out there, that people truly care. I think it really goes to the core of healthcare, and I think it’s something that we don’t necessarily do enough in medicine writ large, which is we sometimes just go on to the next patient and so on, but we don’t sit with and understand what has happened when things don’t go the way we want them to go. So I just wanted to say that that I applaud you for that. And I think it is remarkable because my sense is that a lot of other CEOs may not do that. So thank you.

SPEAKER_00 12:14

I I find it a hugely important piece of my work. My team are all working with families and and patients as well. But actually, for me to sit and listen, I I think it’s so powerful what people have got to say. And often uh the people I meet, they’ve lost trust in the system. They they feel that they haven’t been listened to. What they tell me is actually what we want most of all is for this not to happen to other people. We want the learning to be there so that other families don’t have to go through what we’ve gone through. And that’s such a powerful message. And we need to, you know, we’re doing all we can as an organization to try and prevent that. I think there’s, you know, lots of barriers in terms of moving things forward, but I think we ought to put and continue to put the family voice in everything that we do because that’s why we’re here to serve the patients that we’re here to look after.

SPEAKER_02 13:09

I know it’s always difficult to discuss specific examples of patient safety, but if you’re able to, can you tell us if there are any examples of situations that you’ve been involved in that highlight the importance of the work that you do?

SPEAKER_00 13:21

Yes, and I can come on to lots of examples we’ve done as an organization in in a moment, but my understanding and my thinking of this started when I was a GP, and I remember, you know, like most of us, making errors and feeling terrible about it. I remember one specific medication error I made, and it it did result in thankfully minor harm, not more serious harm, but did result in minor harm to a patient. Um, but what happened afterwards, I had a very supportive team, and we did kind of really look at this incident in detail and take a systems approach as to why it happened. And when we looked at it, this was when I was quite a junior GP and I was feeling really terrible. I felt, you know, should I be carrying it really knocked my confidence? Should I be carrying on practicing? Should I be doing doing this if I’m going to make these mistakes? Thankfully, it was a very rare event or was a not a common event. But when we looked at it, we found that in this situation uh there was issues with the IT system not flagging it. It normally, the IT system prescribing system normally flagged with certain interactions and certain ages that you should prescribe things and it didn’t because this was a private prescription. This person had been seen in a clinic by a local nurse who wasn’t familiar with our systems. I’d just come back from maternity leave, I was pretty exhausted and fatigued. I was signing prescriptions. It was the days where we used to sign pieces of paper and I was on call, lots of distractions, I was in a very busy space. Pharmacists then dispensed the medication and didn’t pick this up either for a whole variety of reasons. And if you look at, I guess if you go to the Swiss cheese model of a whole series of things kind of lining up, why things go wrong, it was a classic example. And I guess what made me realise then is that, you know, actually that’s a prime example of where if we got the systems right to start off with, the risk of that error happening would have been far less. So my interest in this started when I was practicing as a GP. And I I think certainly in primary care in the UK, but I think probably more generally, we still have this culture of being worried about speaking up when things when things don’t go right. You know, you feel you have that kind of personal responsibility as a clinician, and you can be quite worried about what the implications of talking about these things when they go wrong. And I think that’s something we can learn from aviation because they’re well ahead in terms of talking about near misses and talking about incidents in a blame-free culture. But we’re certainly not there in healthcare at the moment, and I think the learning I had from that instant was was significant.

SPEAKER_02 16:03

I think that’s a great answer. I think it speaks both to something me and Adam have experienced with these systems areas that we personally feel accountable for. I commend you on the reflection and the motivation that you’ve had to address larger systems issues rather than just say it’s on me, I have to do better, et cetera, et cetera, and just move on. I think the work you have done now from that event has far surpassed the kind of change that we would have seen from an individual actor modifying their own personal practice. So I think that’s fantastic. It was kind of the impetus for me to get on this podcast with Adam and for us, I think, to change these things. I do have a couple of questions with regards to some definitions that we’d like to get out of the way if that’s okay. So we don’t work in the UK. Some of the terms use are a bit unfamiliar to us. Could you tell us what is meant by the term health care trust?

SPEAKER_00 16:49

Yeah, certainly. So this is the name given to a public sector organization that is legally established to provide healthcare services to the public. So it can be a hospital, a mental health service, an ambulance service. So it’s it’s a name for an organization, essentially, providing healthcare.

Health Services Safety Investigations Body (HSSIB)

SPEAKER_02 17:09

We were hoping to capture, in your own words, what the health services safety investigations body is. We’ve talked about it in previous episodes, but we would love to hear from you, as someone who lives and breeze this every day, what that organization is and what you guys do.

SPEAKER_00 17:26

So we’re a national organization covering England, and we’ve been set up as an arm’s length body of the Department in Health and Social Care. And our role is to investigate national patient safety concerns and national patient safety risks, and then make recommendations to national bodies as to what needs to change. So we can investigate any part of the healthcare system, we can investigate any of the sectors, so whether it’s an acute hospital, a mental health, or community hospital, primary care, and we can investigate all of the transitions between those parts. And we can actually also investigate anything else impacting on patient safety. So we can investigate the national system, the regulatory system, and any kind of we could look at industry as well, private, private industry, healthcare industries to think about technology that’s being produced. So we’ve got quite a broad remit in terms of our legislation. We’re set up in primary legislation, so we have some really uh interesting powers, and our powers allow us to compel people to talk to us as part of the investigations. We can go and seize equipment and enter premises. We tend to try and avoid that because we want to work with the system. Um, and importantly, we have our legislation has something called protected disclosure or safe space, which means that when people talk to us, the information that they tell us is protected by law. And that’s really important because actually it allows people to speak freely about things that have gone wrong without fear that they’re going to get in trouble from their line manager or their organization or like they’re going to lose their job or anything like that. And importantly, the underlying principle of our work is really to establish learning, is to kind of gain the learning from things that have gone wrong and share that and change the systemic factors that are creating these patient safety incidents. So, really taking a systems approach, a human factors and safety science underpinned approach, and importantly with a no-blame, no liability approach as well, because for us it’s really important that we’re not about blaming individuals when something goes wrong. We’re about what’s the learning, how do we improve the systems that is going to change patient safety?

SPEAKER_02 19:46

Can you give us some insights as to how the conditions came to be where initially HSIB, then the HSSIB was created? Was there an inciting or a number of inciting events? Were there factors that hastened or slowed the progress towards its creation? Can you give us like the overarching timeline of where this idea came to be and how it got to the place it is today?

SPEAKER_00 20:08

Yeah, certainly. So I think it probably started the thinking around the time of quite a national scandal we had in the UK relating to a hospital in mid-Staffordshire, where hundreds of patients sadly died from neglect and did not get the care they needed. And it was a big national scandal around, I think it was 2008, 9, 10 of those years that it was emerging. And then we had some brilliant academics in the country, someone called Carl McRae and someone called Charles Vincent, who are international patient safety experts. And they wrote some papers about the need to learn from other industries and the need to have a national patient safety investigation body. And that’s how we started. And we’re very much modeled on the air accident investigation branch and the learning there is from these other investigation bodies that exist in other industries and the learning from other safety critical industries.

SPEAKER_02 21:08

I get the inciting event and I get the motivation to do this, but was it just a group of physicians or clinicians who got together and then petitioned the government for the establishment of this national body?

SPEAKER_00 21:20

So essentially it was a collection of things coming together, actually. It was certainly informed by these academics writing these papers that were listened to. I think there was political will at the time. We had a Secretary of State called Jeremy Hunt, who was really interested in patient safety and still and still is very interested in patient safety. And he was very interested in what had been happening in other industries. And I think the system was really rocked by what happened at this hospital that no one had picked up for years and really kind of changed the thinking. We’d had a big public inquiry led by someone called. Robert Francis, who had made a lot of recommendations into the system about what needed to improve. And I think there was a general feeling in the country that we must never let this happen again. Things need to change. And at the same time, there was lots of questions about other public inquiries that were being considered. And it was felt that there wasn’t a body. The immediate kind of response to things when they went wrong was to organise a public inquiry. And actually, the thinking was why isn’t there a national investigation body that actually could be stood up at any particular time that has the skills and expertise to take on some of that inquiry work? And we know from, for example, I believe in the UK, the air accident investigation branch has been so successful that there hasn’t really been a public inquiry in aviation since the 70s. And likewise, there’s been there was the rail accident investigation branch set up in response to a very significant rail crash in the UK. I think that was in the 90s. And then since that time, there hasn’t been a public inquiry into rail industry. So there was precedent from other safety critical industries about what worked. And uh I think there was an attempt to really think about how do we how do we try and move that forward. I don’t think we got there yet in terms of reducing the number of public inquiries, but I think that’s certainly once we built with trust and confidence as an independent body, we’ve only been an independent body since 2023. I think that will grow as we get um get more established.

SPEAKER_01 23:34

Just from the law background in terms of public inquiries, public inquiries are a great tool to identify what happened and to make recommendations. But every time you have a public inquiry, you have to have, you have to stand it up. As you said, you have to have a commissioner, you have to get counsel, you have to get experts in the field, you have to interview people, and it becomes it’s sort of almost like a standalone organization that you have to create this body to then conduct the public inquiry and then wrap it up. And it becomes like you’re creating an organization for the sole purpose of investigating this one issue, as opposed to, as you said, Dr. Bennyworth, this idea that well, you have a standing committee with specialized expertise in those areas and in the various areas that you may need. So, for example, in the Transportation Safety Board of Canada, which is the air accident investigation branch here in Canada, you have already this committee, but that doesn’t mean that we don’t send things out. So often things are sent to the United States for analysis regarding very specific avionics, but at least you have the organization ready to go with what’s literally called a go team and things like that, so that they can go and investigate accidents when they happen. And I think because of the nature of aviation accidents, that’s probably why it came from there, where you have this very large public event that the evidence is going to quickly be destroyed if you don’t have a team that is ready to go to go and investigate those things and at least gather the evidence and then you can analyze it later on and so on. And of course, it now makes sense that we have something like that for healthcare, for medicine. And we’re still in that stage that you were in, you know, several years ago in the UK, which is we still occasionally run public inquiries. And to this point, there’s there’s consideration of a public inquiry in Alberta, one of the provinces here in Canada, because we’ve had at least two people recently die in emergency departments in the waiting rooms. And as we know, emergency medicine the world over is in a bit of a crisis point. But we’re still in that stage where there’s consideration of public inquiries rather than at a provincial level or a national level having one of these organizations. So we hope that we might be able to get something like what you have in the UK or in England specifically here. That would be that would be great for the for the same reasons.

SPEAKER_00 25:38

Yes, the other thing that we know about inquiries is that they take a long time. And actually, we need to often to start to make the changes on the ground long before they report, and sometimes they can take years to do their work, whereas our investigations take about a year or so to to undertake. And also the cost, public inquiries can go into many millions of pounds, our investigations much more cost-effectively. So there’s a a whole range of benefits.

SPEAKER_02 26:07

I was gonna say I’m very envious that you guys were able to put together a system like this. I think about the challenges that we might face in Canada, like we deliver our health care through our provinces, and so to come up with a national body, I foresee it being very difficult.

SPEAKER_00 26:21

Yes. And I can understand that. I guess the question is how is that learning shared? And are there things that need to be approached on a national level that need national solutions? And certainly in England, there are lots of examples of work we’ve done which need a national solution. It needs change in legislation, it needs change in national guidance, change in national policy, and that if we looked at a regional level, would not have the same impact, I think. So actually, I don’t know how much about the Canadian system, but the main thing is that it’s identifying those issues that happen in multiple hospitals, in multiple parts of your healthcare system. And are they experiencing issues that actually are out with their control that need the national system to respond to? And that’s the space we’re in.

SPEAKER_01 27:13

It’s interesting because it it may not necessarily need to be nationally. Our healthcare system started by a man named Tommy Douglas in Saskatchewan, one of the provinces, where he was the premier and said, We’re gonna try this experiment where we have socialized medicine. And the federal government at the time, which was a Prime Minister Diefenbaker, had said, Oh, that sounds like a great idea. We talk about a Canadian healthcare system. We don’t actually have a Canadian healthcare system. We have a system that the Canada Health Act that started out that basically said, well, if provinces come out with a similar system to what Saskatchewan had at the time, they have five principles. They cover, for example, what is medically necessary, that it is portable. Basically, what the Canada Health Act said was provinces that establish a similar medical system. So if Ontario, which it eventually did, establishes a similar medical system to what Saskatchewan had, the federal government, which has the tax dollars, will fund it. And initially it was a 50-50 sharing. And then they changed that when they decided that the province was spending 50 cent dollars and that became a bit of an issue. And then we have a different allocation of sharing, but we don’t have a national system in Canada. We have provinces that enact very, very similar systems. And then for the federal jurisdictions, including the territories, they have their own sort of healthcare system that way. We’re very proud of our healthcare system, and we think it’s uniquely Canadian. The reality is there are many other jurisdictions that have universal single-payer healthcare. And so when we look at something like this, there is no reason that any premier, whether it’s Manitoba or Ontario or whoever, couldn’t start up exactly what you do, but on a provincial level. It may not be as good as having something nationally, but at the same time, since 90% or so of healthcare is delivered provincially, it could absolutely be the case that British Columbia decides, well, we’re gonna we’re gonna try this and we’re gonna see what we can learn. And then even people that are not within the jurisdiction can then learn from the reports. So this is absolutely something that can be done on a provincial level. Would it be better if it was nationally? Sure, but we don’t let the perfect be the enemy of the good.

SPEAKER_00 29:07

I think the main thing is there is a mechanism for that systemic learning. So I can be in the southwest of England, in deepest Cornwall, and be in a hospital there, and I will see this here the same issues as I will up in the north of the country in Cumbria, and we’ve got to find mechanisms to really understand why that’s happening and to improve it. And just to give you an example of the things that in England need a national solution, we did a piece of work recently looking at care of people in mental health crisis in the emergency department, and we found that our current legislation doesn’t enable staff to manage people very well. It is quite ambiguous in terms of when people need to be detained, and we’re putting staff in really difficult positions, making decisions that actually are not lawful, and so that needs a national solution to be able to address. And it’s those type of things that actually where I think we come into our own, it’s not about local incidents that need to be locally investigated, it’s about those things that are happening in multiple places. And we’ve got to get better, not just not just in the UK. I think we’ve got to get better in the world at sharing that and learning from it. And I’m always struck that if there’s a problem on a certain type of aeroplane, there’s systems that actually manage that and get that message right across the world really quickly. And they ground airplanes, don’t they, right across the world in minutes if need be? In healthcare, it can take years for that learning to spread. And so, how do we get that better? How do we really start to think about sharing learning so that we can do this on a bigger scale rather than just kind of the learning within organizations?

The impact of the HSSIB

SPEAKER_02 30:49

In the work that you have done, have you found things that have been successful in sharing learnings? Have you found techniques or strategies or or groups of people like how do you actually push that forward?

SPEAKER_00 31:00

Yeah, so I can give you lots of examples of work where we’ve had significant impact. So, for example, we did a report around aortic dissection, which we made recommendations to the Royal College of Radiologists and the Royal College of Emergency Medicine in the UK. We recently were contacted by the Aortic Dissection Charity for the UK, who said to us that they’ve now got data to show that on the back of our recommendation, 300 people a year or more are being identified as having aortic dissection and getting the surgery they require. And the charity is confident that that is down solely to the recommendation that we made. So that’s a really lovely concrete example of where we’re having an impact from one of our recommendations. We’ve got lots of other examples. We investigated a very sad case of a child who came in for an outpatient appointment, had a translator in an outpatient appointment. Parents didn’t speak English, then went and came for their MRI scan, but the child wasn’t fasted, so ended up being sent away and sadly got lost to follow up. The parents couldn’t read the letter saying that they needed to be fasted because it was all in English. Child got lost to follow-up, sadly came back, and by the time they’d come back for their scan, the cancer that the child had had spread significantly and the child subsequently died. And as a result of that, we looked at translation services in hospitals and we found that despite the technology being there, most hospitals hadn’t switched on the translation services in rhythm of communication out to patients. And so we made a recommendation to NHS England, and they have now developed a new framework that’s being rolled out to all of the hospitals across the country to make sure that people get information in a language that they can understand. So lots and lots of examples like that, where we’ve actually had a national impact through our work, which we’re very proud of. But we’ve got a huge amount more to do. So we’ll keep going. We do have an international network, as I said, and we do share the learning from our reports through that international network. And we have been invited to speak at ministerial patient safety summits about our work. And I think actually it’s vital that we do work internationally because, particularly, we’re doing a lot of work at the moment around digital safety. So electronic patient records, electronic prescribing and administration systems. And you know, those are often multinational companies that are providing these systems that actually we might need a multinational response to work with those industries to improve safety. So I think there is a real place for us having that global connection in this space to really ensure we have a kind of united front to make care safer for patients.

SPEAKER_02 33:55

My parents came to Canada many years ago. They did not speak fluent English when they came. So that story about the kid who was lost of all-up in the MRI like speaks so uh profoundly to me, both as someone who can have foreseen myself being in that position and deals with a lot of patients that way. That one example speaks to me in ways that I find even difficult to articulate. So I commend you for that work that can be done, and it’s just prompted me to think about the things we do here. And I have to acknowledge that that is huge work and that is going to be saving countless lives. And I thank you for the work done on that directly. I

Mechanisms for improving healthcare systems

SPEAKER_02 34:27

was hoping you could comment as we start this podcast as we’re discovering what happens across the world. We’ve been doing some reading about the NCEPOD, the National Confidential Inquiry into Patient Outcomes and Death. And we’re not quite sure how that differs from the HSSIB. If you could just delineate maybe the differences, the similarities, anything to clarify that distinction.

SPEAKER_00 34:49

Yeah, certainly. So we work very closely with NCPOD, as we call them in the UK. Their work is really about auditing against standards. So they they have a different methodology than us, still looking at how to improve services, but it’s much much more audit-based approach. And they have the the hospital uh teams who undertake audits looking at data and looking at, I think, how certain standards are being used. Ours is quite a different methodology. We use a whole variety of methodologies, investigation methodologies, things like SEEPS and CRAM and bow tie methodologies. I’m not I’m not an investigator, but my team all tell me about these. And essentially, we often find ourselves following a trail of breadcrumbs that we would describe. So we sometimes don’t know where the investigation is going to end up. We have a risk raised with us, a concern raised with us, and that might be in a theme or it might be around a certain incident. And we kind of go and investigate and go with where that takes us because sometimes we don’t know where it’s going to take us until we’ve started. So quite a different methodology. I think the other thing we do is we go out and we observe practice a lot. My team are out observing practice, working with staff on the ground, looking to see what the difference is between workers done versus workers imagined. So what people think is happening compared to what is actually happening. And often there’s quite a big gap there. Um, often that’s where we find the safety risks emerging because people, you know, develop shortcuts, or they they don’t know about policies, or they don’t know about certain things they should be doing, and or there’s there’s barriers as to why people aren’t implementing what they should be. And, you know, recently we did a report around mental health and learning from deaths in mental health, and we found that despite the national guidance saying that actually if you work in mental health, you shouldn’t be using risk assessment tools to risk stratify people into a low, medium, or high risk for self-harm, we found that when we went out to have a look, that was being used in a really widespread way. And so we’ve explored why that was. And we found that, well, firstly, the IT systems were often set up so that actually people had to put in a risk before they could move on to the next page. And secondly, the coroners in our country were asking for these risk assessment tools when people were going to inquests. And so, despite the national guidance saying one thing, there were kind of barriers in the way for people to be able to kind of put that into place. And so those are the type of things we try to unblock both of those areas through our work. And, you know, it’s really important that we understand what is actually happening compared to what people think they’re happening, and we can only do that by going and observing practice.

SPEAKER_01 37:48

I really like how you, Rose, you were just talking about the system essentially, right? I mean, we look at this and say, well, national guidance says this, but the actual practice says this for the for the following reasons. And if we fix those issues, which is probably easier said than done, of course, but the only way that we can start to fix them is by identifying them. If we do fix them, then we get closer to what James Reeson and Martin Bromley have been saying about how we make it easier then for people to get it right and harder for them to get it wrong. I think it really speaks to the idea of yes, individual clinicians and people at the front end can be more vigilant and can improve their practice and so on, but really the system that they work in can be improved and we can really help a lot of people in that way. It also comes back to this idea that it’s not the system that keeps people safe, it’s the individual clinicians that make the system work. And I think that’s a big theme that that we’ll see.

The HSSIB’s mandate

SPEAKER_02 38:39

So, Rosie, on the website, the HSSIB does a really good job at showing that they gather information from either hospitals, patients reach out to them and and start, as you said, this trail of breadcrumbs. One example may lead you to look for others that are similar, may actually cause you to go back and review the records that you’ve done and start an investigation that has national implications. But I find it hard to delineate exactly which things you investigate and which things you don’t. You’ve given a number of examples of things you do investigate, but is there some that you could say the public perceives that you would investigate that you don’t actually do? Are there examples or things that you do not follow up because either they don’t meet your mandate or they don’t reach the threshold for you think them being a national problem?

SPEAKER_00 39:24

Yeah, so we have criteria that we use to prioritize our investigations that is agreed with the Secretary of State. And those are that firstly, it has to be an issue that’s causing significant harm. Secondly, it has to be something that is of significant scale. So happening in multiple parts of the country or happening in multiple different providers. Thirdly, we look at whether we can address inequalities and support improvement in health inequalities through our work, we know that there are significant health inequalities in patient that are associated with patient safety. And the last thing is can we add value to the investigation? So if there’s already a huge piece of work, improvement work going on, and there’s not much room for us to be able to add value, then we we don’t get involved. So we use those criteria to prioritize our work. We never have enough resource to do all of the areas that we want to because there’s so many different areas. In terms of areas we wouldn’t investigate, we wouldn’t investigate if it was individual, an individual provider. So it has to be something that’s happening in multiple places. We don’t investigate individual clinicians, that’s not our role. We’re not a regulatory body, so we don’t investigate from a regulatory perspective. And and also we would kind of think very carefully if there was criminal proceedings being undertaken. That’s not to say we wouldn’t necessarily look at the systemic reasons why uh, for example, that criminality hadn’t been addressed, what was speaking up listened to, and things, but we we would probably think very carefully about that.

SPEAKER_01 41:03

It’s interesting that you say that because I’ve heard very similar things from people here in Canada who their concern if we were to do this, and this was a few years ago, but these were people involved in patient safety at a government level or a ministerial level, had had said, well, we can’t necessarily have an aviation-style board. I mean, how could you possibly investigate everything that’s going on in healthcare and medicine and so on? And there seems to be this sort of broad pushback without getting into the specifics. And the first thing that I say to them is, well, even in aviation, they don’t investigate every single accident. They investigate uh, you know, accidents that cause death and they have a triage, and even a small aircraft that resulted in death may get a smaller investigation. A large aircraft, a large airliner, for example, that had a near miss might get even more of an investigation because of the severity of the issues that are involved in that. So there is a system where they have different categories, even in aviation in Canada and across the world, of which accidents are investigated, what the level of investigation is, and not all investigations take two years and cost millions of dollars. And so that’s the first thing. The second thing is we now have a model such as yours and in Norway and so on, where we can say, well, what are we doing in other jurisdictions? And how could we tailor it to a made-in-Canada solution, as we sort of like to say here? And it’s clear that there is a model that is working and something is better than nothing. And I’m sure that yours is a new organization. I’m sure things will evolve just as they do in any organization, because things will evolve over time. The nature of the issues will evolve, and people will have learned how best to make efficiencies and other things like that. So I appreciate the the answer, and I would just flip it back to the people in Canada that we would say, well, we can do things like that here. So, Dr. Minimumorth, we’ve heard that families, bereaved families, patients, et cetera, will refer cases to you and you’ll decide with the criteria that you just mentioned whether or not it reaches national importance, et cetera, and whether you’ll take on an investigation. My question is, do hospitals or individual trusts refer cases to you?

SPEAKER_00 43:01

Yes, very frequently, actually. And we’ve built a level of confidence in the system, mainly because of our legislation that protects individuals and protects organizations because we don’t name individuals, we don’t name trusts in our reports, don’t name any of the providers in our reports. And as a result of that, we will launch an investigation and we have organizations contacting us and saying, please come and see what’s happening here. So we have organizations reaching out to us about lots of different issues and encouraging us to go and investigate, which is a fantastic place to be because I think it demonstrates that trust we are building with the system.

SPEAKER_01 43:42

I was just going to say the same thing. It’s really heartwarming to see that you clearly your work speaks for itself and how that work is received by the healthcare profession clearly allows them to trust you enough to then refer cases to you, which is great because, in my view, in many places in North America, there is a concern. I think on the part of hospitals, especially given how litigious we tend to be overall, there is a concern that, well, we better not make this publicly known. If we decide to investigate, we might get back to the patient. But even then, I think oftentimes there’s a really big push to really hide things essentially because I think we still have very much this blame-centric model that we have. And I hope to ask you a little bit more about that sort of in the rest of the interview. But it is, it is really great to see. What we’re going to do from here is we’re going to take a quick break. And when we return, we’re going to talk to Dr. Rosie Bennyworth, the interim CEO of the Health Services Safety Investigations Body, about one of the reports that we recently did some episodes on. This is the Retained Surgical Swabs or what we call in North America retained surgical sponges following invasive procedures.

Unintentionally Retained Sponges Report

SPEAKER_01 44:45

Okay, and we’re back. And we’re talking with Dr. Rosie Bennyworth, who is the interim CEO of the Health Services Safety Investigations Body. And we’re talking now, we’re going to switch to, instead of a broad overview, we’re going to switch to talking about the Retained Surgical Sponges Report, or as they call it in the UK, swabs. These are things that we’ve talked about before on two previous episodes where we split it up into what the specific findings were and then their broad sort of systemic findings. And so just to give Dr. Benningworth a sense of sort of where we were in this, we did these episodes and please go, not for Dr. Benningworth, but for everyone, please go and check those out if you haven’t had a chance to listen to them because we were really impressed with the quality and the depth of investigation. We were just talking off-mic about how both Amir and I were really impressed about how the H SIB was actually set up because this could have been a whitewashing kind of organization or things that were glossed over or had an investigation for the sake of having an investigation. But with this report and with many of their other ones, but particularly with the one that we looked at here, it we were impressed by the fact that they looked at a broad variety of factors. And then they also went very in-depth. And then they also said, well, let’s look at what other industries are doing and apply some of those safety management principles to the concept of how we can try to lessen the risk of having unintentionally retained sponges left in patients after surgery. And so in particular, the HCB begins their reports with a reference event as an example, and then they tie in other types of similar investigations into a theme. But they begin with a reference event. They talk about the first name of a harmed patient, and they detail not only what happened to them, but the aftermath and the patient’s feelings as well. On the specific episodes, we talked about how we approve of this because we feel that it really brings to life the impact that those issues have on patients. And we’re all patients at some point, no matter who we are in the system. But also that we recognize that in an alternate world, the HCIP could have simply put out reports on various safety issues without these stories. And we heard a little bit of what you were saying, Dr. Bennyworth, in the beginning of this podcast, where you talk about even as the CEO of the organization, you are there talking to the families of harmed patients and talking to the individuals and so on. Was this a considered decision that was always part of the plan when the HCIB was deciding how to format its reports? I.e., was it a considered decision that you have this reference event, that you use the first name of the individual? Was it considered in that way?

SPEAKER_00 47:11

Well, we feel that actually really listening to patients in the public and listening particularly to families and patients who’ve been impacted by harm from healthcare is vital for our work. Now, in some of our reports, we use a reference event as we did in this report, and it looks at an individual case and investigates that. And we always get the patient consent to be able to release their name and the details, obviously, of their case. But that’s one method we use. Sometimes we hear from the system that they’re concerned about an area, but actually we haven’t got any specific incidents. In some areas, reporting of safety instance isn’t very strong. So actually, we can’t find reports of safety instance around a certain area, but we get the sense that there is a risk there. So we go out and we investigate looking at that theme, looking at that area. And in that case, what we might do is we might pull together a focus group of patients. We might work with voluntary and advocacy organizations that actually bring together patients in a certain area to really listen to their stories. So, whichever way we look at an investigation, what is vital for us is to be able to hear the voices of people who are using services and how they’re impacted by these incidents and the risks that they see. I think patients often will raise concerns. Sadly, I don’t think we’ve got a system, certainly in England, and I’m not sure what it’s like in Canada, but sometimes those voices are not heard and they’re they’re ignored and they’re dismissed. And we hear that quite frequently in our investigation. And I think we need to continue to shine that spotlight on where patients raise concerns so that to not listen to.

SPEAKER_02 48:52

You were saying something like this earlier about the value of connecting with patients directly. And I just wanted to mention it here. And for our more research-minded academic listeners, there’s a lot of evidence that’s showing that sitting down and actually listening to your patients, spending more time with them, connecting them on a human level really reduces the burnout physicians face. This will probably be cut for a time, but I just want to sit down and and at least make sure that this is acknowledged and heard that it isn’t just something you do to pay lip service to be a good physician. It actually makes you better at your job. Sitting down, connecting with people, having a real meaningful personal connection with them does improve the work you deliver and does improve the care you deliver. So that’s it. I just want to get it on mic just to say it for myself more than anything. Thank you.

SPEAKER_01 49:31

Well, no, just to double-click on that, Amir, I don’t know that we’ll cut it, but I think it not only improves the care that you provide, which helps the patient and of course it helps you do a good job. We have good evidence now that it’s a way to avoid burnout, meaning it takes care of the clinician themselves and it actually gives them more satisfaction in terms of their job and also prevents them from feeling depersonalized and all those other burnout symptoms and so on. And so it’s a way, if we talk about the physician as a resource for the community, it’s a way of maintaining that resource. And I think it’s a really important aspect to it. Yeah. In a similar way, we applaud the HT for working hard to provide healthcare providers voices. They could have also simply said, Well, we did a human factors analysis and we came out with the following things in a very clinical, dry sort of way. But the HT goes and says, Well, here’s what happened to the patient. Here’s what happened to healthcare providers. And we talk about moral injury after this, we talk about certain physicians having an outsized feeling of taking uh responsibility for errors that they may or may not have had total control over the outcome. And so when we look at the Sponges report, for example, I really thought it was great that you not only went out and, as you said, looked at how the working conditions were so that you could identify factors relating to workflow and so on that could then help prevent these, but you brought out quotes from individual practitioners about how they see the issue, how they see the workflow, and really, really giving them a voice as well. And we feel that this grounds the report and makes it far more likely for the recommendations to be accepted by the people who are doing the work, by the medical establishment, as opposed to being a report that’s seen as sort of an ivory tower process from a think tank that doesn’t understand the reality of the day-to-day work and healthcare. Can you shed some light on how this aspect of the report came into being, i.e., that you would not only go out and interview for the sake of the investigation, but that you would put those quotes into the actual reports?

SPEAKER_00 51:26

Yes, and and we feel that practitioners’ health and well-being is is kind of the other side of the coin to patient safety. You’re not going to get safe patient care unless you’ve got a really valued staff who work in cultures that actually enables them to do their job properly. And so we do hear a lot of issues about burnout, about moral injury, about the impact of that, that um both on the own their practitioners’ health and well-being, but also on the outcomes for patients. So we think it’s very important to shine a spotlight on that area. And we spend our investigators spend a lot of time out talking to staff, really understanding what’s working, what’s not working, really understanding things from their perspective and also observing how they work as well, because that’s really important, observing the kind of conditions in which they’re working. And we find that often the frustrations that staff are having to manage on a day-to-day basis are the things that actually ultimately lead to some of the gaps and some of the problems that increase the risk of the patients. We are fortunate as an organization to have this safe space provision, which in our legislation which really enables people to talk freely to us. And the staff we talk to tell us how important that is because they can talk to us about things that have gone wrong without being worried that they’re going to be told off by people or lose their job, and some of the things that we hear from whistleblowers across the system that the awful things that can happen if you start to raise concerns. And so staff feel very protected talking to us, and that’s important for us as well. But I I think we feel it’s very important to balance the staff voice and the patient voice. We’re not going to have a healthcare system if we don’t have well-motivated staff who feel valued and we need to listen to their voice and really make sure that the systems, the processes, the environments that they’re working in support the work that they do.

How systems changes can improve safety, efficiency, and reduce cost all at the same time

SPEAKER_01 53:26

And so finally, we feel that the strongest aspect of the report, we would talk specifically about the sponges report, was twofold. First, that it provides a clinically informed outsider’s view, and second, that all aspects of the healthcare system are considered, not just local working conditions. So, for example, in the MM rounds that are had across the world, only really the local hospital conditions and behaviors can realistically be considered because it’s a local investigation. Notably, in the sponges report, the HCB specifically resolves the tension between improving a process that already works relatively well, i.e., the count, the surgical count for sponges, and the need to be efficient with OR time by saying that redesigning sponges is A, more effective than changing practitioners’ behavior, and B, doesn’t have that trade-off. So just to be more clear, we saw that when you pulled out the quotes from individual practitioners, these are scrub nurses, circulating nurses, surgeons, et cetera, one of the tensions that they said was, well, how many cases do we not hear about because everything goes right? And it’s a small minority of cases, I’m paraphrasing here, that have these retained surgical sponges. And so if we really work really hard at improving the count, which is the primary method of protecting against unintentionally retained sponges, don’t we have a trade-off or we’re going to harm more people because we’re improving a process that perhaps really you’re getting marginal returns on? But you’re by doing so, by spending more time on the count, then you all of a sudden you’re harming patients because they don’t have access to the operating rooms because we’re not being so efficient. And the HCIP takes this larger view of the system and says, well, that’s not the only way. Yes, if we look at just local factors and working conditions and what the people in the operating room are doing, that appears to be the only way. But when we look at the system, what if we redesign the sponges? And one of the potential things that they see later in the report is what if we have RFID tag sponges, which is a different type of equipment that they use in some places in the United States, which provides stronger protection against unintentionally retained sponges. And as they have some studies, we don’t know what these studies are specifically, but there are some studies that suggest it actually makes more efficient use of OR time and potentially saves money as well. And so, you know, we see that we can resolve the tension at the sharp end by redesigning the system by redesigning the sponges. But also when we generally think of improving safety as costing time or money, this is an example potentially where this isn’t necessarily the case. We may be able to build a better system and save time and money. I just wonder what you think of this idea.

SPEAKER_00 55:49

Yeah, so I I’ve got several thoughts about this. Firstly, in all of our investigations, we see the huge opportunity to improve productivity and to improve processes through improving patient safety. They’re the same. If we improve patient safety, we see we see productivity improve and so and efficiency improves. So it’s not a standoff. Often the best performing organizations in terms of the productivity are often the safest ones because they’ve really thought about how their systems work. They’ve really thought about how all of the systems and the processes line up to actually really deliver good care. Um secondly, I think the argument about cost is a really interesting one. I get told all the time, well, patient safety costs too much money. But actually, if you look at the evidence, that it disputes it. And I really like a paper that the OECD put together, which shows that 13% of all healthcare spend in middle and high income countries goes on safety failure. And we know in England that we have an enormous amount of bed days used because of medication errors. I think five or six years ago they talked about 180,000 bed days a year just because of medication errors. We have the rework that happens across the system, people going back to theatre. You know, in this report, we talked about a lady having to go back to theatre twice. Now that’s not just awful from a patient’s perspective, but actually the costs associated with that are huge. So I think we’ve got to flip this argument around and really think actually it’s imperative that we look at safe patient care because actually the costs of not looking at safe patient care, even if you take out the litigation costs, the costs of the failure demand are enormous. And so I personally believe, and I’ve long believed, that actually the only way that we’re going to make healthcare cost effective and cost efficient is by improving quality and safety. I think the other thing I’d like to say is that actually, which this report talks about is the balance of risk. We’re never going to eliminate risk altogether in healthcare. We’re never going to get to a place where there is absolutely no risk. And so I think we have to have a much more mature approach to looking at risk and actually have a much more transparent discussion about what risks we’re going to accept and what risks we don’t accept. And I think we could learn a lot from other industries with their kind of approach to safety management, safety management systems that they have in place to look at how they understand risk and tie that into the decision making. So, you know, are we going to accept a one in a million risk or are we going to accept a one in a thousand risk? Where are we going to invest? And at the moment, decisions are often made on who shouts loudest rather than really that granular understanding of risk. And I think we have to learn from other industries to embed a better approach to that.

SPEAKER_01 58:46

But you don’t know this, but that answer is first of all amazing. But also a lot of the things that we’ve been talking about, and often Amir and I take sort of opposite sides of this with the tension of sort of what’s been going on. The sort of quick follow-up question that I had for you was when we see people, and I see this almost on a daily basis here in Canada, and these could be policymakers or clinicians or whoever, when we see people that have this mindset where they say, well, we could be safer, but we don’t have the money, or we’re not a private industry like aviation where they can just raise ticket prices. And we’ve talked to airline captains who say, well, that’s actually not how the airline industry works. You know, price is one of the most competitive aspects, and people choose which airline to fly with based up predominantly on price. So it doesn’t even work that way in aviation, but they have this idea that healthcare cannot be necessarily made safer without increasing cost or sacrificing efficiency or things like that. Is this just a mistaken mindset that is perhaps not supported by the evidence?

SPEAKER_00 59:38

I personally think it’s a mistaken mindset. And as I said, in every one of our investigations, we could give you lots of productivity improvements that would actually improve the use of public money. And we’re very, very conscious in our work that actually we’re working in a very financially challenged environment. Um, and very conscious that we need to be much, much better in a system of understanding the cost effectiveness of the interventions we’ve put in in place. But I have no doubt, looking at all of the evidence that we’ve gained from our investigations, that we would improve the financial position if we focused on cost. A recent example is looking at people who were discharged from hospital and what happens to their medication. And because of the lack of good information sharing, we saw numbers of examples where people had to be readmitted into hospital because there was poor information sharing about their medication and subsequent medication errors. And we see examples like that frequently. We did a report around prison healthcare recently and showed that I think it was about 100,000 hours of wasted ambulance time because ambulances were being called inappropriately for patients. And when patients did need an ambulance, they were not getting that urgent help for a variety of factors. So I truly believe that we’ve got to tie up the operational decision making, the financial decision making, and the safety and quality decision making much stronger together. Often they’re done in isolation. And if we do that, we will end up with better patient outcomes for less money.

SPEAKER_01 1:01:13

Thanks so much for that. Amir, I just wanted to turn over to you, just because you often have ideas that perhaps differ from mine on here. So please feel free to go ahead.

SPEAKER_02 1:01:21

I think I’m just coming around to understand the utility of having this set on an arm’s length body. So throughout this discussion, particularly in the concept of the finances, I can see why this is important. I can see why having an arm’s length body that just provides recommendations rather than being a regulator is very important because you can actually go do the work to say, hey, we’ve done the number crunching. This is not a biased perspective. We can show you either how much money it saves or you can say these are alternatives and we are aware of the systems at play to give an unbiased view. So you don’t know this, Rosie, but I’m oftentimes the one saying our healthcare systems are strapped for funds. You know, it’s very hard for a politician or a regulator or a legislature to say we are going to meaningfully either cut the services we deliver in this particular care to pay for this other preventative measure service because it’s a very real cost that either they experience or patient experience. And at the end of the day, if you’re an elected politician or a hospital administrator, your job is on the line. And so it’s a very unpopular position to take. But I really value the work that you’ve done, especially in the reports that you’ve put out, demonstrating that there could be a financial benefit. And I think it goes a long way because you are an unbiased arm’s length body as a specific cost-saving intervention to balance the books or balance the budget. It is truly coming from a place of care and concern for the system as a whole. And I think that that speaks very highly to the work you do and why it has such significant value.

SPEAKER_00 1:02:41

Yeah, I agree. Thank Key.

SPEAKER_02 1:02:43

Adam, I think you have some more questions that you want to get out of specifically.

SPEAKER_01 1:02:47

We’re on this journey together, Amir, when we do this podcast, and we like to look at the arguments not just from an academic point of view, but you know, what are the actual barriers to implementing a system like what they have in the UK here in Canada? And we see these arguments, and I think we would do ourselves a disservice and the public a disservice if we don’t actually address them. Because if we see this from people that are honestly safety conscious, then we need to address them. And I think one of the ways is to just provide the evidence and say exactly what we just said, but to have somebody like Dr. Bennyworth to come on to say, well, actually, in our experience, having implemented the intervention that we’re suggesting, we see that we can sort of have it all in many cases, where we can actually improve systemic safety and improve efficiency and lower costs. I mean, that is the sort of holy grail, so to speak, of what we’re looking to do, right? I think many of us would be happy to spend uh marginally more money to get significant safety improvements, but that’s a harder argument to make when you can say, well, what if we redesign the system and we actually get all three where we get improved efficiency, improved safety, and decreased costs? So it’s just an interesting idea that I think I’m still coming around to, and therefore I think many other people probably are as well. And it’s an interesting idea that, you know, sometimes the sale isn’t as hard as it needs

OR Black Box / Resuscitation Recorders

SPEAKER_01 1:03:59

to be. If I just move on to the unintentionally retained surgical swabs, part of the report was to look at the reference event, which was a woman named Helen that, as Dr. Bennyworth mentioned, had to go back to the OR twice more, have her chest opened up to retrieve not just one but two surgical sponges. But when they looked at the reference event, those three operating room events, the HCIP couldn’t actually determine what occurred, in large part because they were relying on what people remembered from the events. And they at several times in the report mentioned that the quality of evidence isn’t available to determine what specifically happened in those ORs. So what the HCIP did was they looked at other similar surgeries to get a sense of how the actual working conditions were. And these are coronary artery bypass grafts or cabbages, as they’re commonly called, and I think one was a lobectomy, for example, which was the removal of a portion of the lung, so that they could see how the work is actually performed and they went from there. My big issue with this is we’ve been here in other industries. And so, for example, I come from the aviation industry and they had this issue, you know, 50, 75 years ago, which was that, well, we don’t know what happened when this aircraft crashed, and they put cockpit voice recorders and flight data recorders, what we commonly call as the black boxes. And my question was given that a lot of people who are now working in this patient safety space come from other industries like aviation, and given that this is an aviation sort of style of inquiry, was there consideration on the HCB side of things, Dr. Bennyworth, that perhaps we could look into OR recorders, which are done in some circumstances? In other words, there is the idea that we could have recorders, audio video recording, so that solely for the purpose of safety investigation, privileged information that is kept out of the courtroom, which we can talk about whether or not there needs to be, and I think there does need to be specific legislation for that. But is there consideration for a recommendation that in order to have this information be available? That OR recorders are something that could be used. Is there consideration of that, or was that considered in this report, or how does that fit with you, Dr. Bennyworth?

SPEAKER_00 1:06:07

So it’s an interesting question. And I don’t think it was considered in terms of this report as a recommendation, but I have been thinking about it since you’ve asked this question. I think there’s a few things really. I mean, I think certainly we’ve got to get our culture better. So in in those situations where things are going wrong, we do need a culture where people can speak up and talk about things. And we do need a better culture of documenting that and making sure that that information is recorded. In terms of specifically black boxes in ORs, we’re probably not quite in the right place at the moment for that in England. And the reason I say that is I think firstly there’s been quite a debate about things like use of CCTV in different environments like care homes. And I think there’s a question about people’s privacy and how the data would be used. And when people are having surgery, it’s it’s kind of their most vulnerable time. So I think from a patient’s perspective, that would need to be tested. I think also we are working in a culture of fear and blame, really, as we talked about earlier. And I think there would be concerns from staff members again how that would be used. Now, I don’t think that’s to say it should never be considered going forward. I’ve seen how it’s used this data recording in aviation, and it’s very impressive to be able to give that real-time information. I think we need to make sure that it’s done very much in the culture and the spirit of learning. Um, and we would need a fair amount of reassurance, I think, for people working in those situations that it wasn’t going to be used to kind of point the finger at people when something did go wrong. Um, I also think given the kind of conversation about cost and the economic impact, I wonder if it would be fairly cost prohibitive, not just the equipment, but the kind of setup and the systems that would need to be put in place to actually monitor the data, the storage of data, all of those things. So I think there would be some arguments against it. That’s not to say I’m against the principle. I think it’s an interesting idea, and it will be good to see whether that’s something that develops in healthcare across the world in the future.

SPEAKER_01 1:08:15

I think it’s a completely fair answer, and I thank you for your candor. I have a number of different responses that I’m going to talk about in a second, but I’ve recently learned that there are some operating rooms in Canada that do have these with patient consent and so on. Do you know of any in the UK that are currently operating?

SPEAKER_00 1:08:28

It’s not something I personally come across. That doesn’t mean it’s not necessarily happening in places, but it’s not something I’ve I’ve come across myself.

SPEAKER_02 1:08:36

So just going back to something Adam mentioned about the sponges report, initially when I had read it, I was actually very frustrated that there wasn’t information provided as to why this happened in this case. However, in hindsight and reflection, I realized that that’s actually a temptation we as clinicians fall into very often to be like, well, what can I do differently? I again want to commend the HSIP for their work on saying, even if we found one given solution, this doesn’t absolve the system of the fact that there are other things that can be optimized.

SPEAKER_00 1:09:05

What I would say is I think there are other things that we need to be doing using technology. So for example, I think we need much better early warning systems with our data generally so that we can pick emerging themes, that we can pick emerging risks and see what’s happening. I think there’s a huge opportunity to start triangulating data across instance complaints, patient experienced staff surveys to actually start to really identify where things are going wrong and pick them up early. So I’d I’d love to see that progressing at pace. And I know that there are really great examples of using different technology that are emerging, things like use of AI picking up patient deterioration, for example, in real time, seeing some examples of that, thinking, you know, the Swabs example, thinking about actually how do we use technology to make the system easier for people to work in and make it less dependent on individuals. Maybe you’re thinking away from individual responsibility to actually how do you put a system in place. What I think was fascinating about the Swabs report or Sponges Report, as you call it, is actually when you’re in the middle of a busy OR and it’s the middle of the night and you’re tired and there’s huge distractions and you’ve got a row of patients waiting to come in, your memory of what the policy says or your your ability to kind of count properly in those situations when there’s so many distractions is really difficult. And it sounds something so simple, but actually, until we actually understand those influences on individual behaviour and individual performance and really start to think about how do we mitigate for those, I think we’ve really got to start to our thinking because a lot of the recommendations we see are you’ve got to kind of train individuals, you’ve got to policies, you’ve got to, you know, tell people to read the policies. And actually that’s all fine. But if you’re if you’ve got if you’re tired and it’s three o’clock in the morning, you’re not going to remember what the training says or what the policy says. You’ve got to put things in place that are actually going to make it easier for people to be able to do their job.

SPEAKER_01 1:11:14

I I think that exact point is what I wanted to pick up on, which is, I mean, I’m going to go through and make my pitch here just so that I have it sort of down. But I look at this coming from an aviation background, and I go, operating rooms do not get up and fly around and crash into mountains, and you don’t need the sonar that you can find them under the ocean and things like that. So I look at this and go, this is a relatively simple but not necessarily easy intervention to put forward. And the data that it would capture is exactly what you just alluded to, which is this idea that we need to see how the work is actually being performed in the moment with the reference event. So if we go back to aviation as an example, we only have the CRM, the crew resource management that we have that developed because we saw perfectly good airliners being crashed because of the interactions that they were having with the crew and the interface with that, with the technology, for example, the landing gear, et cetera. And so really, we wouldn’t have the system that we had in aviation if we didn’t have these things actually recorded. And it was a far more difficult task to do in aviation. And we can imagine that in Helen’s event or in any of these reference events, that it’s as you say, it’s one thing to have it, you know, during the day when we’re all well rested, et cetera, versus an emergency situation with fewer resources, when we’re tired, et cetera. And so I think that that’s the big thing from my end is I look at this and say, this will really show that you can’t leave things to the sharp end nearly as much as we do in medicine. We need to redesign the system. It really bolsters the evidence for an intervention like RFID tagged surgical sponges, et cetera. So I really wanted to just pick up on the last thing that you said there, Dr. Bennyworth. But then if I go back and I make my pitch for the OR recorders, I look at this, and first off, I look at this and say, from an investigative point of view, it’s clearly the sponges report, in my view, shows that it’s necessary because the report outlines the fact that we don’t know what happened in Helen’s case. And then the second major part of that report was they said we’ve done as good as we can a human factors analysis of how the count is being done, but we’re relying again on how people recall the work being done as opposed to being able to observe how the work has been done. And we may be missing factors because we don’t have access to that information. So, from an investigatory tool point of view, I think really the question is, is the intervention necessary? And in my view, it absolutely is. And then, and I’ve heard Amir say many of these things, a lot of the things that you said to me, Rosie, are not new to me because Amir has often articulated a lot of these. And I’ll just say that you said, from what I heard, four different things in terms of potential barriers. And I think it is important that we identify the potential barriers to this intervention so that they can be appropriately addressed. The first one was culture, sort of an are we there point of view in terms of medicine. Then the second one was privacy of the patients, the third was from the healthcare worker point of view, discipline and the concern that the footage would be used for a disciplinary process. The fourth was cost in terms of setup and then the monitoring and so on. If I just address them in turn, and by all means I’ll give you an opportunity to respond, and we don’t have to go back and forth in 10 rounds, but I just wanted to let you know where I come from here. In terms of the culture, Amir and I have talked about the fact that one of the things that changes culture, culture is not an immutable thing. I think the HSIB is doing a fantastic job of actually changing the culture in UK healthcare. And we’ve seen that because trusts and hospitals are referring cases to you. That is something that we don’t even have here in Canada. And I think it’s fair to say that the UK has a bit of a more mature safety attitude as a direct result of organizations like the HSIB being there and the good work that is being done there. So if I bring it back to OR recorders, one of the things is that, well, the culture will change as things are done appropriately with these recordings. So obviously the system has to be set up in the appropriate way, which means we need to deal with the other concerns. But I see the OR recorders as actually a tool to change the culture, and it’s a cart before the horse issue. It’s not that we need to wait for the culture to change and then put it in, it’s that we need these tools to change the culture. And that’s that’s one view that I have. If we go to privacy, Martin Bromley put out the point that the UK is one of the most heavily surveilled or has the most number of cameras per capita, etc., some kind of metric like that. And people, the public, generally assume that because they’re being recorded on traffic cameras and other things like that, that they assume that when they go into the hospital, that the people that he talks to assume that it’s being recorded and they say, well, what do you mean that this event that I had in the hospital is not being recorded? It’s public funds, we need to learn about these things. They assume that it’s all recorded, when of course it’s as we know, it’s it’s not. And you mentioned a good point, it has to be sort of tested. And I think if you ask patients that they would want these things. And from the people that we’ve talked to, it seems like that would be the case. Even if they didn’t, there are ways that we can anonymize these things and so on. So I think that privacy is a concern, it needs to be dealt with, but I think that there are ways in which we can deal with them. If we go on to discipline, this was a huge area of contention for pilots. Pilots are, unlike physicians in this country, pilots are employees, and they were very concerned when Cockpit voice recorders came in. And I used to work for the largest labor and employment firm in the country in Canada, and it is always a concern when you have employees that are being recorded, and to what use are those recordings being put? And this was a fight that happened in aviation, and the way that it was dealt with was very simply to have very specific legislation that clearly said that these things, these recordings, are to be used for the purposes of improving safety. And it’s not a one-time conversation, one-time piece of legislation. There is a dialogue that goes back and forth, as happens in every country with these, and I think that we can at least have the model of aviation to say these are the purposes that these recordings can be used for. It is something that needs to be addressed. And then the fourth is cost. I have very little to say about this because as I said before, it’s not like operating rooms, you know, get up and go into, you know, mountains and so on. But Amir brought a point up to me that I hadn’t considered, which is if done incorrectly, this could theoretically increase the workload for the people at the sharp end. He said to me off mic, essentially, this idea of, well, imagine a scenario where they say, okay, Adam, you know, you were involved in this incident. I want you to review your footage now and and self-correct and tell me where things went wrong and what you could do and so on. And that’s not what we do in aviation, so it’s not what was on my mind. In my mind, we have an iterative process in aviation where we started out with physical tapes that were about 20 minutes or half an hour or so. And then as the investigations happened, meaning as airplanes crashed and those boards then investigated, they then went back and said, Well, actually, we didn’t get the actual start of this incident because the tapes were only 30 minutes, and then we went to solid state, and then we went to an increased number of minutes of the recording, and then we went to various factors. Oh, we need to make some fireproof and under the ocean and all of these sorts of things. And so again, it doesn’t have to be perfect to start. I would envision this as very similar to what we do in aviation, where we have recorders in the operating rooms, and I’m sure there’s going to be cases where they don’t actually work as intended, right? Well, we don’t have the microphones in the following way and so on. And as the reference event were to then happen, and as whatever the variant of HCB would happen, they would then provide guidance to industry to then improve the technology as it would go forward. But really, other than making sure that the recorders are on, which still happens in aviation, I would see this as a very hands-off only to be touched by the investigatory body. And that’s how the law works in Canada. Nobody else is allowed to touch this data, right? And so that’s how I would see those four things. If we talk about culture and then privacy and then discipline and then cost, those are sort of my comments there. Again, don’t feel the need to justify anything here. I just wanted to put forward how I see this, but I wanted to give you sort of the last word on this issue. But it is my hope that the HCB considers this as something that could potentially be recommended for the improvement of patient safety.

SPEAKER_00 1:18:57

Yes, and it’s certainly something, I think we’re seeing AI being used in ambient voice technology, and you could see how that could be kind of rolled out in terms of thinking about how you get the audio recording. I guess going back to the patient privacy bit, I think there would be inequalities that we would need to consider around that. So, for example, patients with mental illness, we know that there’s been some technology tried in health hospitals, which sometimes can make things worse, which has been about recorders on the wall to look at patient-patient observations. And sometimes I think if you’re suffering from paranoia, for example, as a mental health patient, those type of things can escalate your symptoms. So I think there’s things like that that would need to be considered. And I suspect there’s kind of cultural considerations as well with different cultural groups and the impact that they would have on people with more audio display. And like I said, there has been quite a significant debate over the years around the use of CCTV in care homes where we know that there have been horrible cases of abuse in the country in terms of some care homes. And so that’s been quite a live and active debate. And there is very polarised views about use whether it should be used or not. So I suspect that would come up. I think the other consideration is I think that we would we would certainly get a lot of requests about how else that data was used. And I’m just thinking about employment tribunals, for example, where you know someone isn’t getting on with someone else and there’s about poor behavior and how that’s used by professional regulators or by tribunals looking at employment claims when someone raises a grievance. So, like I said, I don’t have a strong view myself about whether there should be OR recorders, but I think there would be a huge amount of detail to understand how they were used effectively and in the context of healthcare. So it’s a really interesting conversation, though. Really interesting.

SPEAKER_01 1:20:57

Your points are well taken, Dr. Benny, with this idea that, well, it could the intervention potentially cause harm if we’re talking about recording, which is already done in the secure mental health areas and so on. But that’s why I restrict the conversation essentially to resuscitation areas, whether it’s the resuscitation bay of an emergency department or the OR or ICU beds, for example, to start with. And then, like I say, it doesn’t have to be perfect. I think we can kind of go forward. And we talked about how in aviation it wasn’t a one-time issue in terms of, well, the pilots are concerned about discipline. This was battles that were fought over decades, and you know, potentially we could learn from those and shorten that time and so on. So I I appreciate you having the discussion with us.

Extended version available on Patreon

SPEAKER_01 1:21:36

If you’ve enjoyed this conversation, we’ve actually got another 22 minutes of our interview with CEO of HSIB, Dr. Rosie Bennyworth. That’s available exclusively on Patreon. For just five Canadian dollars a month, you’ll get access to the extended version and all of the extended versions of our previous episodes while helping keep the medical safety podcast going. We don’t receive any outside funding, so your support goes directly towards producing future episodes. In this exclusive conversation, Dr. Bennyworth talks with us about the HCIB’s follow-up powers after an investigation, the need for independence of the HCB, what is not within the HCIB’s mandate, other countries’ bodies that are similar to the HCIB, emerging issues, and proactive safety measures in medicine. You can find the link to our Patreon in the show notes or just go to patreon.com slash medical safety podcast. Thanks for helping us keep these important conversations going. And now for the rest of our free content.

Outro: safety intervention worth mentioning and random recommendations

SPEAKER_02 1:22:54

I’d be more than happy to. So as we approach the end of the episode, uh, Dr. Bennyworth, we do have one question that we like to ask our guests, especially those who have the expertise you do. So if there’s one intervention you could implement, if there’s one change you could see to your healthcare system or healthcare systems more globally that would address the issues we’ve been talking about today, what one intervention would you recommend or hope to achieve?

SPEAKER_00 1:23:16

So I think we should be looking at how we implement effective safety management across the healthcare system. So I think we should be learning from other safety critical industries and have much more structured processes to manage safety safety in a way that we don’t at the moment.

SPEAKER_01 1:23:33

Fantastic. And the other thing I wanted to ask you, Dr. Bennyworth, was you mentioned at the beginning of the podcast that we needed to do more to bring innovation and safety agendas together.

SPEAKER_00 1:23:40

Often innovation and safety have two different languages. We know that innovation is absolutely fundamental if we’re going to have a sustainable healthcare system going forward. And it’s vital that we embrace innovation in all its forms, whether it’s digital technologies or medical device technologies, or whether it’s service innovation, different workforce models, different ways of designing pathways. But we’ve got to design safety into that in a way that we don’t at the moment. Often safety is seen as an afterthought. It’s not seen as the kind of sexy thing to be thinking about when you’re looking at innovation. And then you end up in problems that actually mean that often these innovations are stalled or don’t progress as quickly as possible. Um, so I think if we could get patient safety really at the heart of the spread and adoption of innovation, you would start to enable that much quicker. You would start to really kind of understand the risks and manage those risks during the implementation. So I would love to bring those agendas closer together.

SPEAKER_01 1:24:45

Spectacular. And then something that we do at the end of all of our episodes is this safety intervention worth mentioning. We’re gonna just highlight, as you just did a little bit earlier ago, the HSIB reports. They’re just a gold mine for patient safety information from everyone to practitioners for individual practice management to policymakers, etc. And so that’s the safety intervention worth mentioning. In terms of who can do what tomorrow, at a policy or government level, we talked about in this podcast how federal and provincial governments in Canada could consider enacting a similar body to the HCB and then could also consider passing legislation to protect recording devices. So individual hospitals that are interested in conducting similar reviews locally have the ability to do so. At a regulatory level, the regulatory bodies can read these HCIB reports as well with a view to how to improve the regulation of various professions. At a hospital CEO level, we’ve seen that some hospitals in Canada do have OR black box recorders, and of course, that could be considered for individual hospitals. At a department level, the department heads could read the various HCB reports with a view to improving local resources and considering changing their local investigations. And of course, at a practitioner level, we talked about the fact that these are just gold mines for everyone, but including practitioners, about how we could read these reports with a view to changing individual practice. And so from here we go on to sort of random recommendations. And these are just sort of fun little suggestions that we have. And is there anything that you’ve been sort of reading or listening to, or movies, or anything that you have, Dr. Bennyworth, that you might want to recommend just on a sort of a fun idea that you think that listeners might be interested? It could be something that’s even local to you that if we’re in your neck of the woods, maybe we go check out.

SPEAKER_00 1:26:23

Oh, in terms of patient safety and the kind of similarities, there was something I watched, I think it was on Disney Plus recently, which was actually quite a very tragic story of someone called Jean-Charles Meners. It was all related to the seven, seven bombings in London that happened 20 years ago. It’s a fascinating kind of story about how not to do patient safety, really. There was the whole human factors about what happened when this gentleman was misidentified as a potential suspect in the bombings, you know, communication failures, lack of cultural competency, people using new protocols, all sorts of things that actually really resonate with kind of a lot of the failures we see now. But then after the event, what was really interesting and what is very relevant to our work is how the family had to fight for answers. There was cover-ups, whistleblowers were sacked. It was like a masterclass in how not to manage an incident. And it ended up in a public inquiry because people weren’t listened to. So not really a fun fact, but a fascinating watch, actually, in terms of our agenda and what we’re trying to do and what we’re trying not to do. How not to do it.

SPEAKER_01 1:27:34

I think you struck the tone completely right. And I remember the 777 bar, and I I thought to myself, no, it can’t be 20 years ago, but apparently I’m getting older. I’ll try and find a link to that and put that out. So my random recommendation is to be inspired by this is a bit ephemeral, but to be inspired by the expertise and passion that people have in a field that perhaps is other than your own. So, for example, I’ve long been dismayed at the state of politics and policy in the United States, but the headlines just don’t The whole story. I was reminded of this by a US author, a lawyer, and happiness guru that people may be familiar with. She has a very excellent podcast. Her name is Gretchen Rubin. And I subscribed to her newsletter and I have for years. And in it, she recently told the story of a colleague of hers, and she linked to a C Spence panel that she was on that had former United States Supreme Court clerks, because she used to be a United States Supreme Court clerk. And I intended only to watch that one story, which was from a colleague of hers, but I ended up watching far more. And let me tell you, hearing, articulate, passionate, reasoned people trying to make the US a better place really touched something deep within me. And it was just so nice to be reminded that there are good people working hard to make a difference, you know, in different fields, but also much in the way that Dr. Bennywith and her team at the HSIB are working to make healthcare safer in the UK. I’ll put a link to Gretchen Rubin’s work and to the C SPAN video, and people can check it out if they if they feel so inclined.

SPEAKER_02 1:28:53

Uh Amir is a series of YouTube videos put out by a professor who works at the University of Toronto. He is the director of the Cognitive Sciences program. His name is John Vervake. He has a YouTube series called Awakening from the Meaning Crisis. There’s about 50 episodes on there. You don’t have to watch them all. They’re quite long, they’re about an hour or so. But it is a cognitive science-based perspective on identifying meaning and the value of finding meaning in your life and how it improves your behavior, how it can lead to actual benefits in your life. There are some people who have found great meaning in their life, but as someone who’s not particularly spiritual and as someone fairly young, I found this series tax to be very, very powerful in re-examining the reason why I do things and has helped me find some meaning. And beyond that, just help me look at the value of meaning in my life and how I pursue it. I listen to them when I work out sometimes because his voice is quite soothing. So if people want to check it out, we can certainly post a link to the first episode or at least the playlist in our show notes.

SPEAKER_01 1:29:51

Okay, I feel bad because I should have coordinated with you, Amir, because those are two very heavy sort of philosophical kind of things and far beyond what we normally do. We’re only just like, hey, this this bakery is pretty cool. We should check this out.

SPEAKER_02 1:30:01

Okay, that’s it for this episode of the Medical Safety Podcast. I’m Amir Hammid. And I’m Adam Shahada. On behalf of our guest Dr. Rosie Bennyworth, we thank you for listening to us today. As one TV doctor said, What? You have to say it. It’s a beautiful day to say five. Please consider following us on social media. We are still looking for an intern or someone to help us do research and make show notes for the show, as well as a producer to help with the technical aspects such as mixing and editing. As this podcast currently receives no outside finding, these would start as volunteer positions. But if enough people are interested and donate, it may become a funded position. This would be a great opportunity for a medical student or resident that is interested in patient safety, critical care, anesthesia, or aviation. If you are a fan of the show, please consider going to wherever you got this podcast and leaving us a positive review. It really helps other people find the show and everyone can learn from your comments. If you are interested in becoming a support of the show, please consider going to medical safetypodcast.com where you can either make a donation or connect with us. Even if it’s just a dollar or two, it makes a big difference, and we really appreciate it. We also appreciate the feedback and we’d like to send along a big, big, big thank you to all those who are really supported. Remember, lives are not just saved in the resuscitation bay. Countless more lives are saved by the diseases and errors that are prevented and by the work done by scientists, labs, clinicians, and professionals like you who are working to make every day safer than the last. Thank you.

SPEAKER_01 1:31:24

And now for our outtakes.

SPEAKER_02 1:31:26

Just a quick question, Adam, do you think we need to summarize? Like there’s been a lot of different topics. I can try my best, but I don’t.

SPEAKER_01 1:31:31

No, I I don’t think I think the summary is gonna take us too long. I’ve been more I’ve been trying to just respond to because this has gone in so many, as I knew it would, it’s gone in so many. It was everything I could do not to just pounce on the oh my goodness, you have this Martha’s rule, critical care outreach. Like, I mean, I could spend so much time on that, so I don’t think we’re gonna summarize it.”

[Bechtel] Wow, what a great conversation and episode. Check out the show notes for all the information that they talked about today and we hope that you will subscribe to their show and add their episodes to your queue along with the anesthesia patient safety podcast. We’ll be back next week with all new episode from the APSF and we hope that you will tune in.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.

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