So imagine you are in a hospital waiting room while your loved one is undergoing an

invasive medical procedure and something goes terribly wrong. And she does not
survive. But no doctor and no nurse comes to apologise or fully explain to you what
happened. You're in the dark and alone and devastated, grief stricken and scared
behind the hospital's wall of silence. I am a physician and an attorney, and I've
lived at the intersection of medicine and law for the last 26 years. I want to take
you to that intersection. Despite extraordinary advances in medicine over the last
several decades, the New England Journal of Medicine just published an article that
predicts over the course of the next hour. 70 patients, hospitalized patients. Will
die or suffer serious injuries due to medical errors. And over the course of the
next year, 600,000 hospitalized patients will die or suffer those injuries due to
medical errors and mistakes. The economic burden associated with medical errors
exceeds billions of dollars every year in the US alone. But compounding those
tragedies when words and actions matter most, those who suffer from medical errors
will suffer a second harm. Most will not get the information they need or an
apology, and many will be outright lied to and information will be withheld. They
will be forced to suffer behind that proverbial wall of silence. And you may know
patients or families who describe these tragedies in their lives like car crashes.
But when it's silenced, it follows. They feel like victims of a health care hit and
run. Years ago as a leader in a major health system. I was complicit. I was
complicit in many of these hit and runs. And there's one in particular that
continues to haunt me to this very day, for we had a prominent health care
executive come to our organization. Now, this is a health care executive, came to
our organization to undergo an elective surgical procedure. And during the course
of her workup. Her blood tests indicated she had cancer in her blood, and that
should have caused us to postpone or cancel that surgical procedure. But due to
communication errors, the right people never got that information. Our system
failed her. She underwent the surgery and she was discharged from our organization
not knowing the diagnosis. Six weeks later, she died from a treatable leukemia.
Never knowing the diagnosis. And when I learned of this tragic, terrible event, I
wanted to reach out to the family, explain what had happened and to apologize. But
I was told by lawyers and the insurance company to stay silent. Behind the wall.
And sadly, and to my regret. I did not have the courage to reach out to that
family. And what ensued were four years of scorched earth delay, deny and defend,
spending hundreds of thousands of dollars defending the indefensible. Until we
settled for millions on the courtroom steps. And we learned little. And those of us
who are pressured to stay silent also suffered when we recognized that we had
violated our sacred oath to first. Do no harm. By withholding the truth. Shame by
this tragedy and many other tragedies. And frustrated by the lack of improvement in
health care, a small group of bold innovators chose to shatter the wall of silence
with extreme honesty to pursue healing and learning after harm in health care. And
with a change of leadership and our organization, I was allowed to join that group.
And we put our team together That developed a comprehensive and principled approach
to harm that included a promise, a promise to provide open and honest communication
to all patients and families after serious harm events. And if it turns out our
care was inappropriate, we would reconcile those cases without the need for
litigation. We'd learn from the events and we would support all members of the care
team who never intended for harm to happen in the first place. And we called our
program the Seven Pillars. And we published manuscripts demonstrating the benefits
of transparency. And then something happened. That doesn't always happen in life.
We got a second chance. I got a chance at redemption. For when Michelle came to our
organization. She was a 39 year old mother of two children undergoing an outpatient
GI procedure. And during that procedure, she suffered a cardiac arrest due to
excessive sedation and our failure to properly monitor her and rescue her. In that
waiting room. Her loved ones overheard the code blue. But this time the facts known
to that case were those of us who had responded to that event. But fortunately this
time. With our hearts connected to our head. We were prepared to be extremely
honest. We were empowered. Unlike years ago when we suffered in our own silence, we
were empowered to be honest with this family. And we were. And we apologize. And we
reconciled in financial and non-financial ways. And we fixed what was broken that
caused Michelle's death. And we provided peer support to every member of that care
team who was also suffering, having witnessed that harm. And we invited Bob and
Barb Michel's parents to join our patient safety efforts. And they did. And with
them, we also published further research indicating amazingly. Doing the right
thing to do is also the smart thing to do. We published our lessons learned that
included transparency improves care. Clinicians feel a lot less a lot less moral
injury when they're allowed to be honest with their patients. And lawsuits and the
cost of litigation went down. So with that data, with that information, Bob and
Barb and I traveled to Washington, D.C. We were able to convince the US federal
government. To fund the creation of a Healing after Harm empathic communication
toolkit that became known as candor. Communication and optimal resolution, a
toolkit all organizations can use. To pursue this paradigm shift in health care.
And my next stop was right here in Southern California, where I began to work with
some incredible innovators. And one in particular is the largest professional
liability company for hospitals on the West Coast. The first company of its kind to
incentivize their insured members. To hardwire this holistic and empathic approach
to harm. And beautifully and brilliantly, they call their approach. Beat a heart
where heart stands for healing, empathy, accountability, resolution, and trust.
Another innovator here in San Diego is the University of California, San Diego
Health, where they are incubating their candor approach with software solutions
that drive the reliable approach to harm. That includes communication. And
empathically supporting all members of the care team and learning from these events
and leveraging their data to prevent harm before it ever happens. We made a lot of
progress over the last few years with more than 800 organizations pursuing this
holistic and empathic approach. But we have a long way to go because there are
thousands of organizations, hospitals and long term care facilities that we need to
motivate and inspire. And to that end, I'm so excited that I can share that. We
have partnered with an incredible organization that's called Patients for Patient
Safety Us. An affiliate of the World Health Organization whose mission is to
advocate for transparency in health care and healing and learning after these harm
events. I am confident. Confident with all of us working together. Pushing and
spreading this innovation that we will be able to shatter that wall of silence once
and for all. Thank you. (Applause)