Medical Errors Are Killing Us | Theresa Sabo | TEDxStanleyPark
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- Опубликовано: 4 ноя 2024
- Theresa Sabo - tmsabo@shaw.ca - opens our eyes to the harsh reality that medical errors are the 3rd leading cause of death in Canada. She shares her powerful story about facing a life-threatening heart condition in a healthcare system where medical errors put her life in jeopardy twice! As co-chair of Patients for Patient Safety Canada - www.patientsafetyinstitute.ca - and a WHO Patient Safety Champion, Theresa is committed to advancing safe healthcare while she advocates to raise the standards of reporting practices throughout the healthcare system. This talk was given at a TEDx event using the TED conference format but independently organized by a local community. Learn more at www.ted.com/tedx
Theresa is my sister, we are immensely proud of her for getting up and bringing this issue to light. She has overcome so much to be able to stand up there on that stage and tell her story. Way to go Sis!!!! My own daughter was misdiagnosed at 4 1/2 years old, it took an incredible time and effort plus waiting for her condition to worsen to get Doctors to actually listen to me. This needs to stop - our lives depend on it!!!
If it wasn't for your courage and strength, Elizabeth would be just a memory!! It was you who inspired me to take my healthcare into my own hands and to advocate for patient safety, because it was you who taught me how to stand strong and proud. Love you xoxo
My son died from the mistakes made by not one but three doctors. I have learned the hard way just how dangerous our system is. Complaining to the college does not do any good. They protect the doctors at all costs. You are correct we need a national medical error reporting system. I have learned to question everything and sadly my experience has left me not trusting any of them.
I do not trust the doctors either
Your caring transparency, plus perspective are gratefully received by those of us who have experienced harm. Nothing has changed. It is so unacceptable!!!!!
Congratulations Teresa - your talk was excellent and so needed.
This talk may save your life or the life of someone else you care about! This hidden scourge needs to be brought to the fore. Thank you Theresa for all that you do to make a difference!
Thank you Sharookh!
My mom had a similar problem. She had chronic chest congestion for 15 years and home bound. They blamed it on smoking. One day her heart valve blew. The doctors were aware of her history of rheumatic fever as a child. Thank goodness she got a valve replacement and made it.
I'm so happy to hear she got that valve replacement in time. I've learned now not to let anything just get dismissed by a doctor. I think we all know intuitively when something bigger is happening - we just have to push harder for answers. Best wishes to you and your mom.
Thank you Theresa. You are a saint. I don’t have a doctor anymore. Why? She was very good in the beginning but over time she became a brand name drug pusher and began offering cosmetic procedures in clinic. She strongly recommended I apply for disability while battling Covid. Why? So she she could prescribe the expensive depression and anxiety meds she is so fond of. I recovered, got back to work and watch my health. It is both terrifying and disheartening that a doctor would do this. I’m done with doctors.
Thank you for sharing your story. I agree with you that too much of our health care revolves around short term symptom fixes, rather than a good health care plan and solid diagnosis practices. I hope you eventually find a doctor or healthcare practitioner who you feel confident with. All the best to you!!
Terri, your compelling, personal story really spoke to me. Thank you for being such a strong advocate on the important issue of medical error and patient safety. Great talk!!
Thanks Claire!! So happy I met another advocate for patient safety (and made a life-long friend at the same time)
Sharply true!
Right now I prepare a lecture to my undergraduate medical students titled 'Reporting medical errors and really I found your talk is excellent, informative so thanks a lot for sharing your experience. @Its not shame or blame its to change the game@ really Theresa you are very strong woman, thanks a gain and I'll share your talk to my students.
Thank you for teaching about the importance of reporting medical errors and for sharing my talk. It's important patients know that their safety could rely on them knowing that our system doesn't always work. We need to take our healthcare into our own hands and speak up.
Teresa! Thank you for this enlightening talk. Your personal experience is terrifying. I will not be the same!
Andrea Menard Thank you, Andrea. We need to let our healthcare professionals and governments officials know medical errors are out of control and regulations need to be put into place to ensure changes are made to our reporting practices.
First, thank you for sharing your story, and I am so sorry that you have been receiving such medical errors. As a medical student, I fully commend your call for a regulating body that could receive and analyze mandatory medical error reports. Such an agency could have the dedicated time and resources to aid in implementing solutions for the prevention of such mistakes, and others of similar nature. Healthcare providers and institutions have the responsibility to act for the betterment of their patients, including facing their shortcomings head-on to better the care they deliver, making it as efficacious and free from harm as possible. This idea echoes the ethical principle of nonmaleficence, which ensures that medical providers do no harm. Additionally, physicians are ethically obliged to disclose information that patients and their parents, guardians, and/or caregivers need for informed decision-making regarding their healthcare. According to an article published in the Journal of Clinical Research and Bioethics by Ghazal, et al., the patient’s bill of rights necessitates transparency surrounding medical errors, meaning that medical institutions need a clear, detailed policy for disclosure of information regarding medical errors that may arise. To follow this, the principle of veracity requires that healthcare professionals provide comprehensive, accurate, and objective information in a manner that helps patients and their families understand the information. Being upfront and transparent about medical errors helps establish trust with patients and the community, which is a crucial component of the doctor-patient relationship for the standard of care to be provided to the patient.
Theresa, Such a powerful and motivating presentation, thank you so much!
Thanks, Lyle. I love your rhythm energizer! There's something about a drum beat that's good for the heart (and soul)
It was astonishing to hear Theresa Sabo speak of the statistics of medical errors in Canada. She shared that medical errors are the 3rd leading cause of death in Canada in which 1 in 18 are the victim of these errors. As shared by Teresa, Canada has no requirement for medical errors to be reported to a single organization. In my opinion, this lack of accountability goes against the ethical principle of beneficence. In short, beneficence is the duty of physicians to do good for their patients. Mistakes in medicine are inevitable as physicians are fallible humans, but as stated before my concern with this is the lack of accountability when they do occur. Physicians should inform their patients when medical errors occur and not let them assume that the happenings are a result of their condition or other causes. Convincing a patient of anything other than the truth is what violates this principle of beneficence. This then leads into violation of the other ethical principles in medicine including non-maleficence, autonomy, and justice. In the face of medical errors non-maleficence, or the duty to do no harm, is threatened as a patient can be harmed from the mistake. The lack of disclosure of this makes it worse, and then threatens a patient’s autonomy. Without knowing the truth, patients are deceived and cannot make informed decisions about their care leading to loss of their autonomy. In terms of justice, patients should get what they deserve. Without disclosing what was done, this cannot be accomplished. It is evident that the lack of disclosure and accountability goes against all ethical principles in medicine. This practice of “what they don’t know doesn’t hurt them” needs to stop because it is hurting patients in many ways. To mitigate this, as Theresa Sabo stated, we need to transform to a culture of transparency and patient safety needs to be a priority. As a victim of medical error, I too can speak to the physical, emotional, and financial implications it has on the patient and their family. Something needs to change, and I believe it starts with the voices of patients like Theresa.
To start, I am so sorry for the difficult experiences Ms. Sabo has had to deal with in the healthcare system. I am not Canadian, but medical errors are a universal issue that has to be contended with regardless of where you live. I think there is an idea in the minds of people in America, who strongly believe that single payor healthcare is the answer to all of our healthcare woes, that having a system similar to Canada’s will fit into a utopian ideal of healthcare where everyone has their needs met and there are not problems. This is not to say that it would be wrong to have a similar system in the U.S., but rather that certain issues are universal and no system is perfect. The common thread here is that doctors are human, just like the people they are caring for. They make mistakes, they are going to make mistakes, and it’s an unfortunate reality that those mistakes can have devastating consequences for other humans because of the nature of the job.
A vast majority of doctors, it would be easy to assume very nearly all, strive to uphold the ethical ideal of non-maleficence, which is the concept of doing no harm to their patients. Thus it follows that when physicians make medical errors, it isn’t out of maleficence, but simply from being human. The problem with this is that because of the potentially bad outcomes that can happen to a patient as a result of a medical error, there is a deep level of shame and fear that surrounds these mistakes. There needs to be a system for holding people accountable but not in such a way that results in the physician losing their job, license, and career for simply being human. People all over the world make mistakes at their jobs, and physicians are no exception, but it’s difficult to think of a lot of other professions where any mistake can result in law suits, loss of career or job, or such a prominent level of guilt and shame hanging like a specter over their heads potentially for the rest of their lives.
The other side of the coin is that patients are the ones who bear the brunt of the harm caused by medical errors. They come to a physician for help and sometimes get the exact opposite. They should feel like they can report when errors are made. This will keep physicians who are doing harm consistently from continuing to be able to do so. But there needs to be a way to remove the stigma and shame from all parties involved so that patients and doctors alike don’t fear the consequences of error reporting. The medical institutions should be participating in the process to facilitate the process of honesty and healing from the harm caused. Taking responsibility for an error, being accountable, and doing what is possible to right the wrong are imperative in this process.
You and I could probably sit for hours and discuss this topic! As a group, the members of Patients for Patients Canada have talked at length about what could be done to make this system work for both patients and health care professionals. It starts with full disclosure between the Patient (or their family) and the doctor (or other health care professional) on a "without prejudice" basis. This allows for an open conversation and, hopefully, a mutual understanding which would allow both the patient and the doctor to heal. Because we cannot be blind to the fact that the person who was responsible for the harm, needs to heal too. Second, there needs to be no fault insurance. A patient who has been harmed will experience loss in so many other ways - additional medical expenses, loss of income, etc. Canada invests a lot of money (millions every year) to ensure doctors are able to defend themselves when a patient litigates. This only results in more power to the doctor and no power to the patient. A legal team paid by the provinces will always ensure the patient will not be able to keep up financially and, in most cases, it keeps them from being able to see the litigation to the end. For the most part, patients don't want to sue anybody to get recognition or compensation for what has happened to them and how that has affected them emotionally and financially. They just want closure and they want to know that something will be done to correct the practice that contributed to the harm. We also talk a lot about getting patients into the medical schools to talk about medical error. Who better to educate medical students about the topic of medical error than those who have lived through it.
Thank you for your comments and thoughts. All the best, Terri
Medical errors happen in healthcare at an alarming rate. During this TED Talk, we heard that medical errors are the third leading cause of death in Canada. This is a critical statistic, as errors are preventable and ethically inappropriate. Healthcare is built on excellence and each case deserves to be valued and carefully considered. However, before I dive into the specific ethical points that are necessary to consider, it is also important to consider the other side of the argument. Healthcare is referred to as a “practice.” This means that the doctor swears to provide the absolute best care to each and every single patient with the understanding that they are not perfect. While mistakes will never be completely eliminated, it is vital that each mistake is carefully reviewed in order to prevent that same mistake from happening again. According to the principles of medical ethics, we must consider beneficence, nonmaleficence, and justice. Beneficence translates to doing good. This can be perceived multiple ways, but specifically when discussing medical errors, it is important to note that doing good is doing honest work with clear intentions. Neglecting symptoms, chart review, ordering tests, or not listening fully to the patient are some of the ways that this principle could be violated. Not every physician is going to be able to handle every problem that arrives to their office; instead, it is more important to know when to refer and specifically what department to consult. The principle of nonmaleficence means to do no harm. This principle goes for both sides of the argument. On one end, it is important to uphold this principle because by making a preventable medical error due to carelessness, you are inflicting harm on the patient. On the other side of the argument, not every single symptom or complaint warrants a full investigation. For example, if you were to think something is wrong with you and demand a CT, but the physician does not believe that there is sufficient evidence to order the test, they may be saving you from unnecessary radiation exposure, which can have a plethora of adverse effects. In this case, the physician is using their best judgement to ensure the best practice of medicine in that case to uphold the principle of nonmaleficence. Lastly, medical errors warrant the discussion on the medical ethics principle of justice. Justice is to provide care with equity, equality, and fairness in mind. This warrants further investigation if the error occurred due to an incompetent physician or if there is some underlying bias that is inhibiting the physician from providing the best possible care to each and every patient. Humans are not error-proof-a medical error, while should be rare, may result due to the nature of medicine being a system built on human interaction, knowledge, and care. However, how we handle each error will determine if that error occurs again. Moving forward, each healthcare system should have a medical errors team to consult all preventable errors.
I applaud all you have shared. Our health care systems must start and end with good communications. Part of the communications cycle must include a medical error team who is charged with ensuring both the patient and health care professional heal from the error and learn from the error. Without both parties healing and learning, there can not be change or closure. Thank you for taking the time to comment. All the best to you. Terri
They destroyed me with many many operations it was supposed to be one.they messed up.pain everyday and i can not go to work , nightmare😭😭😭😭 my husband past away they gave him too much fentanyl. ...they protected their dr.criminalsr😭😭😭
So sorry!
Thank you for sharing this important message Theresa.
Thank you Melissa for all your support!
THANK YOU FOR YOUR STORY AND EXPERIENCE THANK YOU FOR LETTING THE PUBLIC PEOPLES KNOW, THANK YOU. I WOULD LOVE TO TELL MY MOTHERS MEDICAL TRAGIC EXPERIENCE as YOU DID, WE ALL GO TO HOSPITALS AND DOCTORS AND WE ALL SHOULD TAKE THESE MEDICAL EXPERIENCES VERY SERIOUSLY AND LIKE YOU SAY IF PATIENTS DONT REPORT THESE THINGS, NO ONE WILL EVER NO, CAUSE I DO BELEAVE THE HOSPITALS AND MEDICAL PROFFESIONALS CAN KEEP THE SECRETS, AND I VERY MUCH SO AGREE WITH YOU WE THE PATIENTS HAS TO CHANGE THE GAME OF MEDICINE FOR ALL OUR LIVES AND THOSES THAT WE LOVE AND THERE LIVES AS WELL CAUSE IF WE DONT THESE THINGS WILL JUST GO ON AND ON AND ON AND IT HAS TOO STOP.
FOR THE BETTERING OF PATIENTS SAFTY AND THEY LONG GEVERTY OF ALL OF ARE LIVES,
SO WE THANK YOU VERY MUCH FOR SHARING YOUR MEDICAL EXSPERIENCE WITH US ALL, THANK YOU.
I love the tag line. "It's not about shame and blame, it's about changing the game." I hope medical professionals will see this and take this into consideration.
Thanks for watching and for your feedback. The tag line is really the essence of how we need to move forward and have more discussions about patient safety and medical errors. We don't want to create a "defensive" conversation - just an open and honest one.
I do not think they will consider it…😔
@@theresasabo4670 Theresa, I am so sorry for the loss of your mother and for the horrible health care experience that you’ve had thus far. Thank you for sharing your story and for shedding light on this topic. Your tag line holds a lot of truth: “It’s not about shame and blame, it’s about changing the game.” In your response to Terri, you state that you don’t want to create a defensive conversation, but an open and honest one. Truth be told, I think the reason why some doctors get defensive is because they are either protecting their ego/name or won’t accept the fact that they can make grave mistakes. And perhaps the reason why medical errors aren’t spoken enough about is due to the fear of shaming and blaming. It is quite possible that healthcare workers and fellow colleagues are afraid to be the one to put the provider (who made the mistake) on the spot. But this fear needs to stop, and this culture needs to change, for the sake of patient lives. When doctors become doctors, they take an oath to follow the ethical principles of beneficence and non-maleficence: to promote good/do what’s best for the patient and to do no harm to the patient, respectively. However, by not reporting medical errors, they are inadvertently violating those ethical principles that they took an oath to - creating harm and not doing what’s best for future patients to come. Like you, Theresa, I believe that there needs to be proper reporting practices in medicine. Though I am part of the healthcare community, my loved ones (and myself included) are not exempt from experiencing medical errors. I would hope that if it were to ever occur, there would be proper reporting measures in place to ensure that the mistake(s) would not happen to another patient again.
I like the part about listening to your Aunties. Im so glad you are ok and I am grateful to Canadian healthcare for taking care of me and not burdening me with bills so I could recover and get back to life. Thank You for sharing your story and message, we are in charge of our bodies ~ on every level.
Thanks, Amy. We do have so much to be grateful for with our healthcare system, but we have to remember to stay proactive with our healthcare and the healthcare of our loved ones so that we don't experience any adverse events. I absolutely loved your TEDx Talk - you are such an inspirational speaker and have an awesome sense of humour.
Thanks!! Feel free to share it like a box of chocolates. :)
I almost died from a medical error at 3 months old. My grandpa almost died years later from almost the exact story this woman told. Medical errors should not be the 3rd leading cause of death. Sickening.
So true wow!! My cousin was ill for 7 years and she fell and went for hip surgery and caught an infection at the OR and died. RIP.😔😔😔
so sorry!
Really important topic .. I first learned of these alarming statistics from the book, Unaccountable by Dr Martin Makary, here in the US. Thank you for this first hand account of the horrible issues.
Excellent ! I'm right there with you. Let me know of I can help. Seriou sly. P. Slaseman 🌠
Lots of people report errors but they use the info we give them against us and modify the medical records accordingly then put on a full-scale attack on us, the injured patients, I know because it happened to me.
You really can't expect seriously injured patients to have to report (writing letters was SO hard after my brain injury) let alone fight: it should (MUST) be a duty for every doctor & hospital to ask for feedback (in many different formats/ways of contacting us) after every episode of care and during all longer ones, repeatedly - only then will they get the real picture and only then can patients be given true % risks of treatments, devices & medicines - but apparently they don't want us having this info because it gives us power & choice and medicine is, and most doctors are, still very paternalistic, arrogant and believe we should be kept in the dark because we can't be trusted to make good decisions so they do it in our 'best interests' but without knowing what matters to each of us - we're all different.
I try to self-advocate with my healthcare (& for housing & social care etc.) but they make this almost impossible on purpose, plus with my brain injury even writing things down doesn't work: so many injuries & now a long & complicated medical history. And you should only need to do or say it ONCE and be believed and get action - and easily contactable accountable person/team who takes OUR side and advocates for us when necessary. But we all know all this, why are we STILL having to repeat it all, has the message STILL not been received loud and clear and if not, why (hmmmm)?
Article written by Pamela Wible MD
Are you a victim of negitive patient profiling
I feel your frustration! We teach our children to be honest and to work through their mistakes and problems - surely it can't be that hard to change the culture of the medical system (famous last words!). I think we need to see more education about patient safety and disclosure in medical schools. I have friends who have been harmed by the medical system and they speak to medical students every year. It never fails, after one of their talks, students are left crying and asking a lot of questions. I'm hoping more medical schools start inviting patients to speak to their students. Take care of yourself - Terri
Cattle abuse, no one in the healthcare system is in prison
my mother is dead due to medical negligence and error, i want them to suffer like they made my mother suffer
So sorry!
Yes I feel the same way you do I lost my lovely mother as well, in 2021, do to medical Errors, Negligence, and wrongful death I've been everywhere for help and for justice no one would help me, or give me justice for what they have done to, and put my Mother through, the Medical System has CAUSE SERIOUS HARM TO MY MOTHER, Resulting in her Death, and Treated me her Daughter Horribley after what they did to my Mother, and the Legal System Has as well, and all of the Medical Boards and board of Health is protecting these peoples every complaint, I filed with the board, they dismissed the Complaints by closing every complaint I filed with the medical board and the board of health against every doctor and Nurse they are very protected by a Dangerous System Called Health Care, that cares nothing about Patients lives, there Care, or There Safety, they are Protecting the bad Doctors, I don't think all doctors and Nurses are bad, Not ALL, but the very Bad ones make it hard for the real good ones, where you can't distinguish which is good and which is not. may the lord jesus chris bless us all to get justice for the lost of our ones. AMEN.
Watching this in 2022 after many people were killed by ventilators and a man made pandemic that led to some patients to be mis diagnosed
My Grandson died at 1 year. He had a high pitched cry and one of his eyes went cross eyed. He was taken to the doctor and symptoms dismissed. He did a few days later.
I'm so sorry to hear about your grandson. It's such a tragedy to think had the doctor taken just one more step to check into his symptoms he could still be with you. It's hard for a lot of us to understand that we can't leave our lives in the hands of one opinion - even if it is the opinion of a doctor.