Surfing the Healthcare Tsunami | |
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Also known as | Surfing the Healthcare Tsunami: Bring Your Best Board |
Genre | Documentary |
Written by | C Denham |
Directed by | C Denham |
Country of origin | United States |
Original language | English |
Production | |
Executive producer | C Denham |
Producers | Matthew Listiak, Elizabeth Gay Muzio, Collin Gabriel, Jonathan Lawhead |
Editor | Dan Steinmetz |
Running time | 53 minutes |
Production companies | TMIT, Summer Productions |
Original release | |
Network | Discovery Channel |
Release | April 12, 2012 |
Surfing the Healthcare Tsunami: Bring Your Best Board is a made for television documentary that explores medical errors and waste in healthcare. It was broadcast globally on the Discovery Channel in 2012. It references federally-funded studies in the United States and news footage to support the claim that healthcare workers are afraid to speak up when medical errors occur in hospitals. The documentary covers solutions to preventable system failures causing harm. [1] [2] It aired four times on the Discovery Channel commercial-free [3] [4] in North America, Germany, the U.K., France, and other Western European countries including Sweden. [5] It premiered at the National Press Club on April 27, 2012, after a short speech by Captain Sully Sullenberger who was featured in the film. [1] [6] [7] [8] [9] [10] [11] The film was screened at the Texas Health Care Quality Improvement Awards on May 3, 2012. [12]
The film uses examples of the high risk industries of auto racing, aviation, and manufacturing to illustrate dramatically improved safety through the application of best practices. [13] It challenges consumers, caregivers, and governance board members to act. News video footage of "The Miracle on the Hudson" flight of Captain Chesley Sullenberger, who landed US Airways Flight 1549 on the Hudson River saving 155 lives is shown, and Sullenberger describes a framework he used in dealing with the crisis that can be applied to healthcare. [14] One example explains that the Mayo Clinic in Jacksonville brought in a NASCAR pit crew chief to examine their operating room turnover and received "great suggestions" according to the Bob Brigham, COO at Mayo Clinic in Florida. [15] [16]
Surfing the Healthcare Tsunami includes appearances with actor and patient safety advocate Dennis Quaid who shares how his twins accidentally twice received 1,000 times the dosage of a dangerous blood thinner called Heparin. He reports that his twins are "doing fine," and he hopes to prevent medical errors like theirs by sharing their story. Quaid’s speech at a National Press Club event is presented in which he states that "the real sweet spot or safety envelope for high-performance care is the intersection of three systems: leadership, safe practices, and technology. When these support systems are functioning within the right organizational culture, we get great care and we get safe care." [1] [6] [7] National network news video of interviews of Quaid on CNN, MSNBC, and C-SPAN are included in the film.
The documentary references the made for television documentary also broadcast globally in the Discovery Channel, Chasing Zero: Winning the War on Healthcare Harm which used hospital accidents to focus a lens on leaders in healthcare reducing preventable medical error rates to zero. The documentary captures segments of Chasing Zero filmed around the globe at locations including Geneva, Switzerland; London, England; Hawaii; the Brigham and Women’s Hospital; the Cleveland Clinic; Vanderbilt University Medical Center; Johns Hopkins; and the Mayo Clinic. [11]
The film covers the death of a 2-year-old girl killed by a preventable and accidental lethal injection of a salt solution during cancer treatment. The father of the child who died, Christopher Jerry, sat with the pharmacist convicted of manslaughter in the death of Emily Jerry, and forgave him on camera. They pledged to work together to prevent this type of error from happening again. [8] [9] [17]
The documentary examines the difficulty the producers had in their efforts to bring attention to system errors in healthcare by showing a clip from their appearance on the MSNBC show Morning Joe on April 22, 2010. Joe Scarborough attempted to enforce the message that you can not trust healthcare providers by asking, "you've got to be very skeptical of every doctor and every nurse? You don't want to get in the way of what they're doing, but you just can't take their word for it anymore, can you?" But the data shows that systems errors are the cause of harm, not individuals. [18] [19]
Surfing the Healthcare Tsunami used the scene from the September 15, 1952, episode of I Love Lucy , "Job Switching", as a metaphor for how systems can cause well-meaning and competent caregivers to make errors. In the scene, Lucy and Ethel attempt to keep up with an unmanageable pace of chocolates coming off of an assembly line. When they do well, the manager increases the speed, forcing them to hide their errors. In turn, the manager thinks they can handle the increased speed and increases the speed again, leading to more failures in their work. As Dr. Thomas J. Lee notes, "Lucy and Ethel must feel the way that contemporary employees feel as they are constantly pushed to produce more and perform better without adequate or appropriate training, support, or understanding." [20] This scene has been used in healthcare to represent what happens to frontline healthcare workers, resulting in medical errors. [21]
The documentary recognized the global impact of medical errors by sharing that in hospitals across Western Europe, North America, and Australia, the chances of being subjected to a medical error in hospital is 1 in 10. The chances of dying from an error is 1 in 300, according to Sir Liam Donaldson of the World Health Organization. [1]
The documentary interviews several notable people in aviation including Chesley Sullenberger and John J. Nance. They recount that aviation saw that they had system errors that would doom the industry, the industry got together to fix the problems by forming the private-public joint task force, Commercial Aviation Safety Team (CAST). [22] [23] [24] [25] [26] [27]
The film introduces the concept of Story Power, using patient stories to engage the hearts and minds of medical professionals to change the way they deliver care for the better. [28] This concept is based on the Journal of Patient Safety article, Story Power: The Secret Weapon by Dennis Quaid, Julie Thao, and Dr. Charles Denham. This section features Patient Safety Advocate and Author, Regina Holliday who encourages patient advocates and healthcare providers to engage patients and their families in dialogue about solutions for healthcare. [10]
Dennis William Quaid is an American actor. He is known for his leading man roles in film and television. The Guardian named him one of the best actors never to have received an Academy Award nomination.
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care provider.
A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.
Mass General Brigham is a not-for-profit, integrated health care system that is a national leader in medical research, teaching, and patient care. It is the largest hospital-based research enterprise in the United States, with annual funding of more than $2 billion. The system's annual revenue was nearly $18 billion in 2022. It is also an educational institution, founded by Brigham and Women's Hospital and Massachusetts General Hospital. The system provides clinical care through two academic hospitals, three specialty hospitals, seven community hospitals, home care services, a health insurance plan, and a robust network of specialty practices, urgent care facilities, and outpatient clinics/surgical centers. It is the largest private employer in Massachusetts. In 2023, the system reported that from 2017–2021 its overall economic impact was $53.4 billion – more than the annual state budget.
Brigham and Women's Hospital (BWH) is the second largest teaching hospital of Harvard Medical School and the largest hospital in the Longwood Medical Area in Boston, Massachusetts. Along with Massachusetts General Hospital, it is one of the two founding members of Mass General Brigham, the largest healthcare provider in Massachusetts. Robert Higgins, MD, MSHA serves as the hospital's current president.
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.
A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery
John J. Nance is an American pilot, attorney, aviation and healthcare safety analyst, and author.
Fatal Care: Survive in the U.S. Health System is a book about preventable medical errors written by Sanjaya Kumar, president and chief medical officer of Quantros, Milpitas, California. Fatal Care was published in April 2008 by IGI Publishing, Minneapolis, Minnesota.
Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.
The National Patient Safety Foundation (NPSF) was an independent not-for-profit organization created in 1997 to advance the safety of health care workers and patients, and disseminate strategies to prevent harm. In May 2017, the Institute for Healthcare Improvement (IHI) and NPSF began working together as one organization.
Regina Holliday is a Grantsville, Maryland, resident, art teacher, artist, muralist, patient rights arts advocate, founder of the Walking Gallery and the Medical Advocacy Mural Project.
Blame in organizations may flow between management and staff, or laterally between professionals or partner organizations. In a blame culture, problem-solving is replaced by blame-avoidance. Blame shifting may exist between rival factions. Maintaining one's reputation may be a key factor explaining the relationship between accountability and blame avoidance. The blame culture is a serious issue in certain sectors such as safety-critical domains.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.
David Bates is an American-born physician, biomedical informatician, and professor, who is internationally renowned for his work regarding the use of health information technology (HIT) to improve the safety and quality of healthcare, in particular by using clinical decision support. Bates has done work in the area of medication safety. He began by describing the epidemiology of harm caused by medications, first in hospitalized patients and then in other settings such as the home and nursing homes. Subsequently, he demonstrated that by implementing computerized physician order entry (CPOE), medication safety could be dramatically improved in hospitals. This work led the Leapfrog Group to call CPOE one of the four changes that would most improve the safety of U.S. healthcare. It also helped hospitals to justify investing in electronic health records and in particular, CPOE. Throughout his career, Bates has published over 600 peer reviewed articles and is the most cited researcher in the fields of both patient safety and biomedical informatics, with an h-index of 115. In a 2013 analysis published by the European Journal of Clinical Investigation, he ranked among the top 400 living biomedical researchers of any type. He is currently editor of the Journal of Patient Safety.
Chasing Zero: Winning the War on Healthcare Harm is a made for television documentary about preventable medical errors in healthcare narrated by and featuring actor and patient safety advocate Dennis Quaid. The world premier was in Nice, France on April 22, 2010, It aired on the Discovery Channel in the U.S. and Western Europe on April 24, 2010, with repeated broadcasts through May 2010. It has been provided free to hospitals and caregivers both as a DVD and by streaming video.
Suzanne Gordon is an American journalist and author who writes about healthcare delivery and health care systems and patient safety and nursing. Gordon coined the term "Team Intelligence," to describe the constellation of skills and knowledge needed to build the kind of teams upon which patient safety depends. Her work includes, First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety, a collection of essays edited with Ross Koppel and Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork, written with commercial pilot Patrick Mendenhall and medical educator Bonnie Blair O’Connor, with a foreword by Captain Chesley "Sully" Sullenberger.
Nancy (Crane) Conrad is a teacher, author, publisher, entrepreneur, and public speaker. She is the wife of late astronaut Pete Conrad and Founder and Chair of the Conrad Foundation.
The Medical Tactical Certificate Training Program, also known as Med Tac, is a global bystander rescue care training program that focuses on life-saving actions that can be performed by non-medical bystanders for the eight leading preventable causes of death to children, youth, and adults. In urban areas in the United States, professional first responders arrive at the scene of an emergency after approximately 10 minutes. Immediate rescue care by bystanders is most effective within three minutes of an event. Treatment within this time has been found to have a significant effect on rates of survival and permanent harm. Created and expanded upon after the dramatic increase in active shooter and terrorism events, Med Tac integrates the American Heart Association Heartsaver CPR/AED Training Program, or the American Red Cross equivalent training, and the Stop the Bleed Program sponsored by the United States Department of Homeland Security and American College of Surgeons.