Transparency, Compassion, and Truth in Medical Errors: Leilani Schweitzer at TEDxUniversityofNevada
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Transparency, Compassion, and Truth in Medical Errors: Leilani Schweitzer at TEDxUniversityofNevada

Translator: Yaffa Kurzweil
Reviewer: Peter van de Ven The nurse grabbed the recliner
and jerked me awake. I heard “Code Blue”
and the room filled with people. In that instant, I knew he was gone. The doctors’ words attempted optimism,
but their faces betrayed them. The next hours were awful. My sweet boy had become
a corpse hooked to machines. I sat next to him,
begging him to come back to me. But really, I wanted to flee. I didn’t want any of this to be happening. I wanted to wake up
stiff and uncomfortable in that ugly blue chair and realize it all was just
a very bad dream. But this was far worse than a nightmare. My 20-month-old son had just died
in one of the country’s leading hospitals. On Thursday he was sick
and on Tuesday he was dead. That night when he had been
admitted to the hospital, white circles with wires were stuck
onto Gabriel’s bare little chest to monitor his breathing and heartbeat. Every time he made the slightest
little wiggle, the alarms would go off. And they’re loud. Every time we would almost be asleep, the racket and worry
would start all over again. We’d already spent sleepless
days and nights in my local hospital, where he had been misdiagnosed
again and again. But now, we were in a university
hospital for children. Finally, here,
I felt safe and very tired. And I’m sure the nurse
could see how tired I was, and she wanted to take care of me too. So she did the logical thing, she turned off the alarms
on the machine next to his bed. And I thanked her when she did it. I was so grateful for the prospect
of silence and sleep. Later, doctors and administrators
from the hospital would explain that actually, unknowingly,
she had done a lot more. She hadn’t just turned
the racket off in the room, she turned off all
of the alarms everywhere: in his room, at the nurses’ station
and on her pager. Later, the manufacturers
of the monitors would explain they didn’t think anyone would
go through the trouble of seven screens
to turn off all of the alarms. So, they didn’t include
a fail-safe to stop her. They were wrong. So, when Gabriel’s heart stopped beating,
there was no sound, just quiet. Nothing woke me until
several minutes had passed, and I was being jerked awake,
and the room filled with people and panic. Imagine if you were that nurse,
if you had done what she had done. You’re doing your job,
a demanding job, an important job, and you do something
that causes someone to die. A beautiful child dies because you think
you’re doing a good thing. Then your shift is over, and you have to look his mother
in the eye and tell her good-bye. And the next day, you’re expected
to go back to your job, carry on, go about your business, all the while hoping and trusting
that nothing else terrible happens. I could never do that job.
I’m not that brave. My response to what happened
to Gabriel is not unique. Like most people who have
experienced errors in medical care, we want three things: we want an honest, transparent
explanation of what has happened; we want a full apology; and we want to know and see
that changes have been made to ensure that what has happened to us,
never happens to anyone else. Unlike what we can see nightly
in television courtroom dramas, people don’t immediately seek lawyers. We want answers, not money. People hire lawyers because they
feel deceived and abandoned. It is a very emotionally
and financially expensive last resort that none of us want to do. And the thing is,
we all make mistakes. It’s just that for most of us,
the consequences are pretty small. I don’t hit the submit button
in my online banking account, and the power company gets paid late
and I get a little fee. Or I forget that on Wednesdays
school gets out early, and my daughter is annoyed
when I’m late to pick her up. I’m annoying, so,
pretty used to that. We all know that the power company
doesn’t expect a whole lot from me. And I hope my daughter knows
that though I may be late, she also knows I’m
always going to be there. But we expect so much more
from people in medicine. We trust them with what
we value the most, our lives and our loved ones. And then expect impossible perfection. We want the human element
when it means kindness and compassion, like the nurse trying to get us
a couple hours of sleep, but we deny it when it means
possible failure. We’re never going to have it both ways. The day after he died, Gabriel’s nurse
left that hospital for good. I hope she was not fired. Legally, I cannot be told, but I know she never returned
to that children’s hospital. And I get it. I wouldn’t be able
to go back there either. And one of the pediatric neurosurgeons
who took care of Gabriel, he later quit practicing
medicine altogether. All of their expertise
and wisdom and experience is no longer helping children. That is another tragedy
and another very expensive system failure. Unfortunately, hospital adminstrators
don’t tend to respond to medical errors with openness and transparency. They react with a legal version
of fight or flight. “Deny and Defend.” This means, keep your head down, shut up,
and let the lawyers handle everything. This is a very dangerous
and expensive response, that we all should be
concerned about. It would have been easy
for the university hospital administrators to blame the nurse, fire her,
and assume the problem had been solved because the bad apple was gone. It would have been typical
deny-and-defend behavior for them to ignore my questions, to go silent, and hope I couldn’t gather
my thoughts enough to file a law suit. It would have been a safe bet. But they didn’t do that. They didn’t prey on my vulnerability. Instead, they investigated,
they explained, took responsibility, and apologized. Then they asked me
what else they could do. It made all of the difference. Transparency in medicine
can help heal our medical system, and we all know that it
needs a lot of help. By being open and honest
when the unexpected happens, we can learn from our mistakes. We can find the deadly system failures,
and we can act to fix them. After the university hospital
investigated Gabriel’s death and the weakness
in the monitors was discovered, all other hospitals
using the same equipment were alerted to the vulnerability. Maybe, that helped someone else, I will never know. But it still comforts me now. After he died, the little plastic ID band
that was around his tiny wrist, should have been slipped onto mine. There was nothing more
that could have been done for him, but there was plenty
that needed to be done for me. I needed an infusion
of truth and compassion. And the nurses and doctors
who took care of him, they needed it too. We all should have been given
ID bands and become patients that day. Death is a full stop
for the patient in the hospital bed, but it is only just a very
terrible beginning for the survivors left in the room. Hospitals should extend
their care to these people because the impact
of these kind of experiences is slow, painfull and toxic. This is how transparency
can help the survivors. And these kind of experiences, they demand that we relive them,
over and over again. And those memories become
dense and strong, like thick black coffee. And just like too much caffeine, that reliving keeps us up at night
and can make us a bit sick. And the parts of these visions
and memories that we have, the parts that don’t
make sense and are unclear, they become void, so we fill them in. This phenomenon is translated
directly from Latin as “making shit up.” We wonder if things could
have been different. We feel guilty. Maybe we place blame
where it doesn’t belong. This is how transparency is healing. It finds truth, and it can take away
the infection of guilt and doubt. Gabriel was treated
at two different hospitals. He died because of mistakes
made at both of them. Accidents that no one
wanted to have happened. But how I was treated
after he died was no accident. How they responded to those mistakes
was very deliberate. Both had the opportunity
to learn from my son’s death and be transparent. But only one did. So, though I really wish I didn’t, I know both sides
of the transparency coin. The university hospital didn’t hide
behind legal maneuvers and dismiss me. They learned, they explained and they
changed the procedures in their hospital to ensure that all of the children
who were patients there were safer. Now, they encourage me
to share my ideas, they seek out my opinions, and they value what I
have learned from Gabriel dying. They give me the opportunity
to help people. And that makes his life bigger. But the local hospital ignored me. By going silent,
they didn’t just humiliate me, they denied Gabriel his dignity. And after more than eight years, that wound is very far from healing. I wish the story
I just told you was rare, but it is not. Errors in healthcare are common. The exact numbers are hard to determine – this is another side effect
of deny and defend. But a shocking accepted number is that 100,000 people
will die in the US this year because of preventable mistakes. This means, this year, there will be
100,000 opportunities to learn. 100,000 lives we should honor, 100,000 opportunities to choose
truth and compassion over deny and defend. I know what I’m asking for is big. I want a culture change. Maybe I’m talking about a revolution. And I know what the opponents say, that transparency in medicine
would just be a field day for the lawyers, insurance companies will never play along, and the already busy hospitals
would just be distracted by it. But case after case, study after study
proves the opponents wrong. Transparency in medicine will
save us money and make us all safer. Those are both good and nobel pursuits, but it’s not why we should do it. We should do it because eventually, we all are going to need
to wear one of those plastic ID bands. Eventually, we all are going to need
the good, healing medicine of truth and compassion. Thank you. (Applause)

About Bill McCormick

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47 thoughts on “Transparency, Compassion, and Truth in Medical Errors: Leilani Schweitzer at TEDxUniversityofNevada

  1. Leilani, your statement is among the most humane and cogent I have heard in response to medical error — and as a harmed patient-family member, soon to join you as a fellow TEDx speaker, I've heard and read quite a number. Exquisitely concise.

    On the off-chance this may interest you, please consider joining a group of citizen activist/advocates in our work. One ringleader, so to speak, is Regina Holliday of DC. The works are The Walking Gallery and Partnership With Patients.

  2. Wow! What a fabulously human response to something that has been known to destroy other humans – the loss of a child. Wow! What awareness & compassion, exquisitely organized and expressed. Leilani, I'm so glad you did this! May it inspire a whole bunch more humans. I am truly inspired.

  3. …when wrong are right ? … Economics saying the cliche " NO WANT MONEY " tell the fact to look back in compassion are not to EGO say … mean a lot to me to have matter ." SOMETHING " Death as to be see as part of life like dust that was swiped out and clean our path … let's stat up for EUTHANASIA … and evolution to better economics !

  4. Leilani, you honor Gabriel and all patients so very much. You tell his story with so much dignity, love, caring and compassion!! Everyone should hear his story! May he never be forgotten, and may you continue to educate our hospitals, institutions and care givers.

  5. Finally got to see this. I hope what she spoke about comes to pass but I doubt it. Nobody admits their mistakes in our society. It's not just the medical people. My heart goes out to Leilani. I hope she finds peace. I can't imagine losing one of my children. If it happened and somebody stonewalled me, they'd regret it. I'd make sure of that.

  6. Every nurse, doctor, health care worker, administrator and health ministers for the NHS should watch listen and learn.

  7. Sometimes people dare not admit our mistakes, especially when they are sure it is wrong and it hurts others. They don't have the courage to face the consequences of their mistakes. It is time for us to take responsibility of our own mistakes and get relieved from guilty. I think we should rethink the punishment in our education. Does the punishment teach us the right way to face our mistakes?

  8. First, I am so very sorry for your loss of Gabriel. Your testimony is extremely powerful, articulate and gracious in the face of such profound tragedy. Your compassion for the 'second victims' is compelling & hope the nurse & pediatrician have seen this. Please consider watching and sharing these youtubes: "Medication Errors-Really Smart People Make Really Mistakes"
    "Medical Improv: Exploring Learning Experiences…."
    "Interruption Awareness…"
    You ARE changing the culture. Beth

  9. I am so very sorry for the sad loss of Gabriel. Your presentation was moving, informative and echoes my personal views and that of many others. My son, Robbie, died as a consequence of medical negligence in April 1990. However, almost 24 years on the medical cover up continues in the UK. This is what the ECtHR ruled regarding my deceased son's case in may 2000:

    "Whilst it was arguable that doctors had a duty not to falsify medical records under the common law (Sir Donaldson MR’s “duty of candour”), before Powell v Boladz there was no binding decision of the courts as to the existence of such a duty. As the law stands now, however, doctors have no duty to give the parents of a child who died as a result of their negligence a truthful account of the circumstances of the death, nor even to refrain from deliberately falsifying records."

    The UK Government is refusing to introduce a free standing Duty of Candour for all Healthcare Professionals.

    A 20 minute documentary broadcast in January 2013 exposed the on-going cover up. You can access the documentary at:

    The sooner the medical profession is honest and accepts responsibility for adverse clinical incidents the sooner the bereaved families can move on.

    Will Powell 13th January 2014

  10. Thank you for your sharing. I will share with other nurses to spread your message. God bless you and your child

  11. The same thing happened to me in February. My son Anthony passed away because of a medical error. The md admited immediately! He was quite transparent and contacted me later on and we are awaiting the medical autopsy !still it does not excuse them from liability"! They were directly responsible for his death and all the alarms sounded OFF they just took six minutes to realize the oxygen tube was not hooked up! 12people in a state of the art room! When the code was called I knew like you that Anthony had passed! I also was a nurse with 23 years of experience! A.E

  12. Yes YES YES! I was very seriously injured (brain, eyes, throat, neck, muscles, nerves, abdomen, skin etc.), lied to by countless doctors, hospitals and ALL I turned to for info, help and remedial care.

    My GP (and others) were fed lies that 'nothing went wrong', my medical records taken off site and fiddled with/adjusted by the doctors' medical defence union (insurers) long before I was allowed access to my notes.

    Almost 10 years later I have STILL had no info, truth, remedial care or help with my disability (acquired brain injury+). I've lost my job (which I loved), my friends, family, possessions, my home, my retirement, my health = my LIFE.

    It all could have been SO different: they could have answered my questions openly, honestly and completely but no, every person at my every attempt lied, denied, delayed and betrayed my trust in them.

    Today I have cried most of the day and so desperate for compassion had to ring helplines. So many things doctors and other healthcare professionals (including Chief Executive of hospital) said, wrote, did – and DIDN'T do replay, year after year. I'm given drugs to try to deal with it all and my terrible anxiety, insomnia, fears, self-loathing and now (this year) massive [panic attacks.

    All this ON TOP of my original injuries = too much to bear but too afraid to kill myself = suffocating and paralysed in op theatre and 'dying' that time was enough so ON TOP I'm now TERRIFIED of the dying process.

    No help with any of it, huge walls that protect doctors/them and me pleading BEGGING for help year after year but passed on, fobbed off and dumped by ALL.

    And a bit before this op which destroyed my life (and totally unnecessary) the UK's NHS had published their Being Open guidance – not rules, voluntary. And this proclaimed patients do better and NEED (obviously) to know when injured by our healthcare.

    It didn't work then, was re-published (made out to be 'new') a few years later but it STILL doesn't work because doctors/hospitals have experts (and lawyers) to help them lie, cover up and deny things which threaten THEM.

    How can it be that patients and considered a threat when it is WE who pay their wages – plus (no consent to this but never asked or allowed to opt out) we also pay for THEIR legal protection AGAINST OURSELVES. Bad strange world.

  13. A Vascular Neurosurgeon was Operating on My Wife for a large hernia at L4/L5 (right side). During the DAY SURGERY there was an incident where Her vitals dropped during which time She actually woke.
    Later in recovery as She woke it was apparent She was in tremendous pain but in Her left groin area. Though the Dr. was given this information, nothing was done. (My Wife realized that She was in trouble and they just kept giving Her pain medication even though She asked them not to. She asked them to call me but they refused. A few short hours later the pain was worsening and now She was in serious trouble yet the Dr. still did not examine Her. During which time Her abdomen began to swell and She was involuntarily soiling Her self. Surgery was at 08:00 first report of problems (by Patient and Nurse) at 09:30 at 12:44 She code Blue and it took them until 2:45 to stabilize Her. THEY STILL DID NOT CALL ME. Until 5 minutes before I was due to pick Her up at 4:30. They told Me She was NOT going to make it and that I had to come say good bye but didn't know why. When I saw Her I immediately noticed that Her abdomen had gone from a very flat, toned tummy to what I thought was a Woman giving Birth. They said they gave Her lots of blood and I asked where the leak was. It was My insistence that they get Her back into Surgery that got Her back into Surgery. It took them 11-12 hours and She was put on life support. This Dr. Had severed Her Internal Iliac Artery (75% of it) during the a.m.. discectomy (which is why Her vital dropped) He even noted an unusual amount of bleeding but glued it and it slowed.
    The Dr. that saved Her described that Surgery as a ,"Living Autopsy". All Her organs, bowels got crushed and damaged. But mush to everyone surprise (Including some Scientists), She's alive today. Not with out a lot of problems. She's in constant pain, things are always going wrong and new things popping up but She's a fighter. There are so many other errors that happened that day. Many people hear about this and compare it to a King Novel, that can't happen here. Well it did and We all honestly believe that the only reason they refused Her care and to call Me that day was for Her to have DIED. Even a Dr. in that Hospital said this, there'd be no investigations or questions that way and Me and our 5 Children would have never known the horrors She faced alone that day.
    Then while just getting back on Her feet in the same Hospital about 3 weeks later She was complaining of sever pain in left leg they AGAIN missed a D.V.T. (She rang the Nurses more than 5 times and was even very quickly checked by 3 of them over a 10 hour shift). By the time the Dr. was doing His rounds at 07:00 Her leg was 3 times the size, so bad that the skin was ripping. Again she suffered in silence while trying to get their attention long enough for them to actually examine the problem.

    There is so much help for the doctors but where is the help for victims, I mean Patient after the mistake is done, and their families?
    Please read & SHARE thanks
    No HELP for us

    Bruce Smith

  14. The newly accepted number of deaths by medical errors is 440,000 per year in the U.S. There is many more left disabled.

  15. As a physician who is interested in the Doctor Patient interaction and ways to improve medicine, I think that this talk should be mandatory for all physicians and hospital systems.
    I will share it with as many as possible.

  16. I grieve your loss and your pain. Thank you for your openness about this. This talk should be mandatory for all healthcare administrators, policy makers, nurses and physicians in training. We desperately need a culture change. I am a nurse who made a medical error and immediately recognized that I had done it. Fortunately for the patient it was not life-altering. But for me it was. The scathing review that I went through by my organization was revealing. My boss, fortunately, was the exception and very supportive. I use this as a teaching experience for those I work with and train. And I have spoken at length with our risk department about their handling of the situation and the climate it creates to not be transparent. I am seeing slow change, hopefully for the better.

  17. I believe that what this women experienced, although terrible, should be heard and practiced by everyone in the medical field. All to often medical errors go unnoticed or aren't freely admitted. How can we expect our healthcare system to improve if we hide what happens and continue to let them occur. There should be some sort of system in place where medical errors are processed and a way to make sure they don't occur again are thought of and discussed with all staff members. What the children's hospital in the video did was a prime example. Something unimaginable happened but everyone dove in to figure out the problem. Once the answer was found they made sure that everyone, including people at other hospitals, knew about the mistake that was made that day. By doing so, many future incidences were prevented. If every hospital did something similar to this the number of errors would be greatly decreased, and the family members involved could at least have a little peace. For example, I have worked at a veterinary hospital before and whenever a mistake was made that person was required to write it down and come up with a way to make sure no one every did it again. Then at our monthly meetings those mistakes would be talked about and that person would share their ideas with everyone else about how to prevent it. This brought the mistake to everyone's attention and made us be more aware of it for future scenarios. Our practice improved tremendously and almost immediately. I wish our healthcare system could follow something similar, but all too often people try to hide their mistakes because they are embarrassed or ashamed. Instead of getting those feelings they should be glad that they can share it with other people and ensure that the possibility of it happening again would decrease.

  18. I enjoyed this as you have spoken the truth. As an employee in NHS I advocate this and hope someday across the hospitals the administration supports us all in delivering truth and tranparency along with clinical care. Thank you for sharing.😢👏👏👏

  19. Been there, done that. The medical field lost me after a death and a blame game. My guilt cost me a job. It still affects me today.

  20. This also needs to be viewed by management and developers of Health Technology systems and devices!

    I've worked in IT' HIT and software development; it's very common for developers and [email protected] those companies to have little or no clinical or even healthcare training or experience. This is short-sighted and inexcusable!

    At the least they could just spend a week shadowing the workers who will use the systems.

    It would save countless hours, many lives and suffering, and of course money.

  21. It's rare for a victim to be both accusing and forgiving as well as insightful as this mother. A rare gift which makes change possible by opening doors to the heart. Hopefully the medical team who left would see this some day.

  22. What a beautiful and compassionate way to tell such a horrifying and compelling story. Your TEDx Talk should be share with all medical schools – this should be taught at the grass roots of medicine. What is so terribly sad is that it has been 5 years since you told your story and we are still in the same boat – medical error continues to be the 3rd leading cause of death in the United States and Canada. As Co-Chair of Patients for Patient Safety Canada (A WHO global patient safety program), I took to the TEDx Stanley Park stage in Vancouver BC on March 3rd this year to talk about the same problem. I pray we don't stop talking about until it has been fixed – once and for all! Thank you for sharing your story and for continuing to work and advocate for patient safety.

  23. It’s heartbreaking to be “gaslight” by the very people that you “entrust” with your care or the care of those you love. Being gaslight into believing your “wrong”, on the attempt of a shifty provider protecting their own “rep”…
    Revictimization. By the people you trust and who also have the power to “wreck your credit”…and threaten your healthcare.
    Abuse. All it would take would be for these “providers” to show some HUMANITY

  24. Thank you for your excellent, thought provoking talk. I think the idea of transparency is key to allowing the medical system to move forward. Compassion and empathy as well – we do put a lot of expectations on a system that is often overburdened, with a lack of resources -it’s tough for those working in it. The fact that medical error is the third leading cause of death is important to be aware of. How do we solve for this? Firstly, know that the health care system is complicated, be our body’s own advocates and aim for transparency. I just did a TEDX on the topic of being your body’s own advocate because of medical error – so I truly appreciate your talk! Thank you!

  25. Leilani, please accept the warmest hug from this old nurse. You honor Gabriel by being outspoken and intelligent, and having the spine to call it as it is. What shocked me was your tremendous compassion for the caregivers: the doctor and nurse who left healthcare. That turned my head, I have never heard anyone express with such clear headed wisdom, what it means for a healthcare professional to leave, never to participate in healing ever again. The hole that is left there, it IS huge, and a waste as you said. And a shame…but again just as you said, I understand it, too. I wanted to leave when we had an incident on my unit. Not my fault, but I FELT like it was. I drove erratically for weeks, endangering myself and people around me. I couldn't sleep. I punished myself in so many ways only I can ever know. I finally went to Employee Assistance for counseling only to be told "it's normal" and that I needed to decide if I would stay or leave. I stayed. I try to forgive myself everyday. Bless your heart, dear.

  26. I applaud Leilani Schweitzer for speaking out regarding the mistakes made in her child’s care, and I empathize with her loss. I can’t imagine the pain she must have felt, and for her to share her story shows her strength and passion in advancing medical care. The way that her medical situation was handled should set an example for future practice. Physicians try their best to adhere to legal guidelines, but they also have ethical and moral obligations to fulfill. Sometimes it seems like this is a tricky balance, especially when it pertains to having to own up to mistakes they may have made. In her talk, Leilani discusses how important transparency was to her case. The fact that her medical care team made sure to inform her of their decisions, wrong-doings, and the process of events helped to validate her concerns and gave her a clear picture of what was going on. I would argue that this is not always practiced because the act of admitting to your faults could have serious consequences for your professional career. Unfortunately, practicing transparency is a standard principle of medical ethics because it allows patients to feel confident that their doctors are considering and acting upon their moral and ethical consciousness. It leaves little room for false accusations to be made and allows for open communication between both parties. Physicians are responsible for the beneficence of their patients, even after they have made mistakes. The fact that Leilani was treated with these principles in mind shows a good example of how physicians that use their ethical principles to make a positive impact for a patient that did not initially benefit under their care.”

  27. We should think of Nurses and Doctors as being like Priests, most are great, but a small percentage should be removed and prosecuted for their actions.

  28. My condolences go out to Ms. Schweitzer for the loss of her precious son Gabriel. I was incredibly touched by her experience and the courage that she had in sharing her story. I can empathize with her tragedy caused by a series of medical mistakes at the hands of various healthcare workers. I, too, suffered the loss of a very close loved one due to medical errors. As a mother of four, my initial assumption and belief was that the nurse that was at fault should be fired and have her nursing license taken away. The hospital was negligent as described by the three primary elements in Dr. Bernard Lo’s book, “Resolving Ethical Dilemmas: A Guide for Clinicians.” These elements include: a breach of duty to the patient, the patient being harmed, and the breach of duty causing the harm. After further thought and reflection, I realize that healthcare workers are imperfect human beings and not immune to making mistakes. Even though they strive for nonmaleficence, the ethical principle that expresses their duty to protect the patient from harm, errors will still occur. They are often overscheduled, work very long hours with little sleep, and have a lack of supervision due to understaffed working conditions. Ms. Schweitzer explained that medical errors cause over one hundred thousand preventable deaths each year in the United States and it is the third leading cause of death behind heart disease and cancer. Mistakes and errors will inevitably occur, but change needs to happen. All parties involved need to take responsibility and be transparent when these incidents take place. They need to be solution oriented and make every effort to fix the problem so that it does not happen again. Silence is not an option. They should honor the individuals that have been lost due to these medical errors by learning from the mistakes and fixing them. Opponents will argue that transparency in medicine will cause more malpractice lawsuit payouts, problems with insurance companies, and distractions among hospital staff. I can understand why many hospital administrators react to medical errors with deny and defend mentality. They hide behind legal tactics and avoid dealing directly with the family. It is easier for the hospital to blame the person that was at fault, terminate their employment, and then assume the problem is solved. Actually, research shows that transparency will make us safer and save money. The families of these victims do not want money, but they want to know that their loved one did not die in vain. They want a prompt investigation, honest and transparent explanations, an apology, and to see that changes have been made to ensure that the tragedy will never happen again to anyone else. Ms. Schweitzer expressed that compassion and truth are essential for healing. By sharing her heartbreaking journey with others she is honoring her son and helping to change the way healthcare workers handle medical errors in the future.

  29. Leilani thank you so much for sharing your story; Gabriel's story. It make in difference in my life and how I practice medicine.

  30. I am a middle management nurse for a community based intense outpatient mental health program. I have 12 unlicensed staff working under my license–which seems like very little. Each staff sees 10 clients per day, and administers medications under my license. Today I noticed an error that all 12 staff overlooked. The client outcome was not obviously adverse and I had to issue medication errors to all staff responsible for the error. Sadly, many of the staff, including myself are very discouraged from this error and I was just notified of 5 more errors from tonight's med pass. I believe the staff was unable to focus based on guilt, grief. I have no choice but to put all of our staff on a performance plan. As part of remediation I intend to share this video with my team in the hope that a climate of safety, honesty, and compassion can form within my organization. Thank you for sharing your story. I am deeply sorry for the death of your son, the mourning and grief you endure because of his passing is nothing short of tremendous. I am grateful for the changes you are trying to make as a result of such a devastating experience and most appreciate the compassionate and kind way in which you speak of the bedside nurse who turned off the monitors. Thank you, I am so very glad I watched this video. God bless you and your family.

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