Ep 7 - "A Life in Error" - Remembering Professor James Reason

Show notes

• Errors occur when a planned sequence of events fails to achieve its goal without an element of chance.
• Slips and lapses are absentmindedness.
• Trips and fumbles are maladroitness.
• Mistakes involve higher order cognition
• Main classification of errors:
  • Skill-based slips
  • Rule-based mistakes
  • Knowledge-based mistakes
• Examples of skill-based slips: putting cat food in the teapot, getting into the bath with your socks on, trying to open a door with the wrong key.
• Examples of rule-based mistakes: proceeding when it’s not your turn at the intersection (most driving errors are rule-based.
• Examples of knowledge-based mistakes: devising an alternate route when there is a road-block, devising a differential-diagnosis and arriving at a working diagnosis.
• In order to prevent, trap, and mitigate errors, we need a common language to discuss errors and how to manage them.
• Violations are intentional deviations from norms and rules.
  • Corner-cutting or routine violations committed to avoid unnecessary effort or to circumvent inappropriate procedures (the written vs unwritten rules);
  • Thrill-seeking or optimizing violations (e.g. speeding);
  • Necessary violations that occur because the people making the rules are not the ones performing the actual work; and
  • Exceptional violations: one-off events that occur under exceptional circumstances.
• The Swiss Cheese Model of defences in depth
  • Defences protect against hazards reaching losses, like barriers.
  • These barriers have holes in them, like swiss cheese
  • The holes are latent conditions and active failures
  • Latent conditions exist for years and are due to system factors (understaffing, policies etc)
  • Active failures are errors created by people at the front-end (doctors, nurses, pilots, technicians etc) that are closely connected in time to bad outcomes.
• The current medical model is not error tolerant. It expects practitioners to be perfect. If a pharmacist, nurse, physician etc makes a mistake, the safety margins are so razor-thin that it can easily result in a bad outcome for a patient.
• Conversely, the response in most medical safety protocols is to warn practitioners of the dangerous conditions and then blame them when the bad outcome occurs, because this time they knew about the dangers. We should instead insist on changing the working environment, which produces the errors.
• Medicine being one of the oldest professions in the world and certainly one of the most complex, contributes to the difficulty in changing its culture.
• In changing the culture of medicine to improve the overall system, we also need to consider how the training of healthcare professionals entrenches the stigma of reporting errors.
• There is no true tension between training excellent physicians and reporting systemic deficiencies, because “stress testing” of physicians can happen in simulations and true-emergencies, while we also work to improve day to day conditions for everyone.
• We are moving towards a model of care where we speak of Centres of Excellence, rather than “who is the orthopaedic surgeon?” Medicine is team-based and even, or perhaps especially, community hospitals whose teams are well-known to each other can deliver excellent and safe care.
• R v Omstead, [1999] OJ No. 570
  • 1999 in Leamington, Ontario Nurse Omstead was charged with manslaughter (criminal negligence causing death) after she gave potassium chloride thinking it was furosemide because they were lookalike drugs stored close together.
  • The judge acquitted Omstead because the Crown failed to prove beyond a reasonable doubt that her actions were a marked departure from a reasonable nurse in her situation. The judge noted that latent conditions such as the drugs looking alike and being placed together were significant factors in the error.
  • The judge also noted that the error had been reported by Omstead herself and a conviction could have a chilling effect on future reporting of errors.
  • Criminal trials are held to determine criminal blameworthiness and judges in such cases cannot make recommendations to hospitals or policymakers.
• Investigating errors as being produced by the working conditions and being related to systemic deficiencies does not mean that individuals cannot be held accountable for gross negligence (e.g. intoxication). It does mean that if, for example, training deficiencies are found, the training system can be corrected and everyone who was similarly situated can benefit.

Safety intervention worth mentioning: leadership walkthroughs

• Dr. John Dornan, New Brunswick’s Health Minister, spends 24 hours in Moncton Hospital’s ED
• Dr. Warren Thirsk challenges Alberta Premiere Danielle Smith to come on shift

Other resources

1. Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min)
2. A Life In Error: From Little Slips to Big Disasters by James Reason

Random recommendations

1. Adam: Politics Without Politicians by Helen Landemore
2. Amir: The Black Swan by Nassim Taleb

Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

Transcript

SPEAKER_01 0:04

Oh, you as medical learners now know about these things, therefore be more vigilant and be on the lookout. Where does that place the emphasis? It places it on the frontline staff. It's the reinforcement of the same medical model you need to be knowledgeable and vigilant and on your skills. We're not actually going to change the work environment. We're going to acknowledge that these risks exist, but we're not going to change it. It's almost a throwing up of the hands and saying, well, we can't change the system. So somebody has to at some point do something about it, and it can't be a single person. It has to be a patient safety movement. This could be at a single hospital where they decide to change call shifts or local working conditions. It could be within a province, and that's how socialized medicine in Canada happened, where we had one province that decided that they were going to do this, and then we had the Canada Health Act. Welcome back to the Medical Safety Podcast. I'm Adam Shahada.

Introducing Professor James Reason

SPEAKER_00 0:53

And I'm Amir Hammond.

SPEAKER_01 0:54

In today's episode, we will discuss Professor James Reeson's work and in particular his memoir, A Life in Error. Professor James Reessen is most famous for his conception of the Swiss cheese model of defenses in depth for hazardous industries. And this is the idea that there are multiple layers of defense, kind of like layers of Swiss cheese, where there are holes. Those holes are the weaknesses in the defenses and they are constantly in flux. But if all the holes line up, an accident can occur. James Reesen died at the age of 86 on February 4th, 2025.

SPEAKER_00 1:28

So it's very interesting. I think a lot of our listeners have heard about the Swiss cheese model to some extent, and so I hope that in today's conversation we can give a little bit more context and new ones, particularly how it relates to why we think it's relevant to uh this podcast and why we think it's interesting. So, Adam, as you're the one who clued me into this work, um can you give me some more information about his early work and when you first heard about this guy? What brought you to it?

SPEAKER_01 1:54

Yeah, absolutely. I uh studied Professor Reeson's work back in the early 2000s at Seneca College in Toronto, and then I went to what at the time was called the University of Western Sydney in Australia. And at that time, the sort of Bible of hazardous industry accident investigation, uh including proactive safety measures, was his work and his book called Managing the Risks of Organizational Accidents. And it takes us through this idea of what is an error, which we'll talk a little bit more about later. Uh, what is sort of an accident, how what a little bit of the history of accident investigation, because of course, as long as humans have been around, we've been making errors. Um, and then why we talk about them in a large organizational accident, such as a petrochemical fire or um an aviation airliner accident or a medical mishap or any of those things, as opposed to individual behavioral accidents and so on, and why they're different and most importantly how we might prevent the next one, because that's what we're really after is how can we improve what we now have come to call system safety. And so did you Yeah, go ahead.

SPEAKER_00 3:02

I was gonna ask you, did you come to this work in your studies to become a pilot? Was this something kind of incidental to that, or you know?

SPEAKER_01 3:09

No, it was exactly that. Um, so the Swiss cheese model was still famous uh even in the sort of mid to late 90s, uh, and it was taught in a very cursory way um when I was in college. And of course, then uh in university you do a little bit more knowledge work and you look at sort of more managerial aspects. And so all the technical flying aspects I did out of Seneca College, and so I got what's called uh multi-engine instrument rating, which uh sorry, commercial multi-IFR, which is this idea that you have a commercial pilot's license, which means you're allowed to be paid to fly an airplane, um, and you have a multi-engine rating, meaning you can fly an aircraft with more than one engine. And then you also have the ability to fly that aircraft uh for hire in bad weather, and that's the instrument rating part of things. And so when I went to the University of Western Sydney, um a lot of it was the managerial business side of things. And so it's for people who are going into aviation management. Now there are whole degrees in aviation business management, essentially. And these are people who are director of flight operations, these are people who uh are running airports, running airlines, etc. And so a lot of it came down to, well, you're gonna be working in aviation. Aviation is a high-risk industry, but it's not the only high-risk industry. We knew things, for example, like the nuclear safety industry, like the petrochemical industry, offshore oil rigs. We did talk about medical error at that time. And so the idea where we have experience now, especially decades of experience, with these large organizations and these big organizational accidents, where there are, as Professor Reason would say, these defenses in depth. And so that's how I came to this. And

Motivation (the whip) as an error prevention factor

SPEAKER_01 4:48

then the really interesting part was as I say, he takes us through the idea of what are what are errors, what were the early attempts? And you know, one of the early attempts was just the whip. You know, you had, for example, if you look, my background is Egyptian, both my parents are Egyptian, and so the pyramids were built by slaves. And so, I mean, if they were making errors, they would just essentially be whipped. And and Professor Reeson talks about this, and this is how we used to punish people for errors, and well, that really didn't serve us very well later on. Not only was it inhumane and so on, but also just didn't work. And so we had to over time come up with different theories and then also, of course, put them into practice and see what actually works.

SPEAKER_00 5:24

Thank you for that, Adam. I think

The spark that ignited James Reason’s career

SPEAKER_00 5:26

what I found interesting in reading the book is just how it all started. Can you recount that anecdote? How uh Professor Eason got into the field of human error because I think he was a psychologist by training initially, but his work was not to do with error at all. I think it had to do with motion sickness and things like that first, right?

SPEAKER_01 5:43

That's right. And in his book, A Life in Error, he talks about how he kind of knew there was a bit of a limited scope for his work because you just can only make so many undergraduate students physically ill before they stop coming to you. And uh, so he knew he was gonna have to sort of switch careers or switch fields, I should say. Um he wanted to stay within psychology. Uh, he didn't want to be a clinical psychologist. And he decided one day to go into the field of error, but because of a mishap that he had in a very sort of English way, if I can put it that way, which is that he was trying to make a pot of tea, and his cat was there just meowing away at him, as cats are wont to do when they are wanting their food, which was the case here. And so it all started when he was making this pot of tea, his cat was meowing for some food, and he accidentally put the cat food into the teapot. And, you know, he would later call this this absent-minded slip, and it was this spark that kept him researching for the rest of his career.

SPEAKER_00 6:40

I think what stands out to me about this story is that the way he reflects on it, as we're gonna mention the book a billion times, everyone go read it. It's a short read, it's a hundred pages, like you can get through it very easily. Um, but all this to say that you know, he makes a comment that this is a very simple event, and this probably happens hundreds, if not thousands, of times over the course of a day. But serious analysis of why these events happened, why even when he's scooping the cat food, which feels different, it's on a spoon, the actions are different, why his mind isn't consciously aware of these mistakes, and he does a much better job than I ever will explaining it because of course he's made a whole career of it, and secondly, he uses old British prose when he writes, so it sounds much fancier than anything I could say. Anyways, Adam, could you talk to us about how Professor Reason defined error?

SPEAKER_01 7:25

So it was a really good intro in that he had this a little mishap happen to him that we've all had, except he somehow fashioned an entire career and became immortalized in the idea of accident investigation and of safety measures. He actually came to this after a fair bit of work.

Defining error

SPEAKER_01 7:41

So we get the end product, but he actually struggled with this for quite a while. And he goes into a lot more detail even in his memoir than we're going to go into here, but he defined error as quote, the term error will be applied to all those occasions in which a planned sequence of mental or physical activities fails to achieve its desired goal without the intervention of some chance agency. And so, to put that into sort of more common parlance, the idea that it is an error when the plan that you had did not come to fruition uh and it wasn't due to chance or the lack thereof and so on. And gives a couple of examples. The idea that if you run a red light because a wasp stung you, well, that wasn't planned, and therefore that wasn't due to your error. Or if you slice a golf ball and it hits a tree and it happens to still go in the hole, well, that was chance and not planned on your part. Uh and so he basically says, okay, let's talk about errors in these ways. And then he gets into a little bit of a discussion about slips and lapses, which are more from absent-mindedness, trips and fumbles, which are more clumsy or maladroid things, and then mistakes which involve these complex higher-level processes.

Skill-based slips, rule-based mistakes, and knowledge-based mistakes

SPEAKER_01 8:50

But he does eventually break it down into more refined three-specific error types. And this is, I think, the meat of when we talk about error and James Reese and this is what we're getting into. And he breaks those down into skill-based slips, rule-based mistakes, and knowledge-based mistakes.

SPEAKER_00 9:08

Through my read of this, the skill-based slips happen when there's not very much conscious control, right? These are things that happen kind of like the cat food in the teapot situation. The rule-based and knowledge-based slips are a little bit more complicated, and uh they only really occur or triggered when the actor becomes aware of a problem when they have to stop and think about it. So these are kind of the things when um, you know, you fail to stop at a stop sign, or the knowledge-based ones, which are probably the rarest of them, when you need to think hard because there's no set rules, these are much rarer situations. Do you think we like to think a lot of these things happen in medicine because that's the world that we live in? We like to assume that a lot of our stuff is very knowledge-based and decision-heavy, but I think he posits correctly that most human experiences reside at the rule-based level. So not so much skill-based, not so much knowledge-based, but a lot of the rule-based stuff. And Adam, as someone more familiar with his work than I am, do you think that a lot of medical errors occur in the knowledge-based space where we need to think really hard because there are no set rules, or do you think there are more rule-based errors, like when we have certain policies that we need to follow and then deviate from the either intentionally or unintentionally?

SPEAKER_01 10:20

It's an excellent question. And in the way that Professor Reason defines it, the knowledge-based errors are far more rare because we're not often thinking about what we're doing. So if we think back to his slip that he had, the skill-based slip of him mixing up the cat food and putting in the teapot, there was you're on essentially automatic pilot, which is one of the reasons that that happens. And I've got a great a great list of those that that are again, I'm I'm stealing this directly from his book on page 30. He talks about stepping into the bath with your socks on, struggling to open a friend's front door with your own latch key, squeezing shaving cream onto your toothbrush, trying to drive away without switching the on the ignition, and he goes on and on about these things. And those are are more uh of those sort of skill-based slips and so on. The rule-based mistakes are far more common in medicine, because if we had to constantly think about exactly what we're doing, basically figuring things out from first principles, we just don't have the brain capacity to be doing that. And so the example for knowledge-based mistakes or knowledge-based issues that is often used in these rare situations is something that we talked about very briefly on this podcast before. This was United Airlines Flight 232, which was Captain Al Haynes at the helm. And this is where they had a loss of primary flight controls where they literally could not control the airplane except by use of the rudder pedals. And they still miraculously made essentially a crash landing, and some people did survive. But otherwise, that aircraft was doomed, and they had to literally figure out a new way to fly an airplane that had never been done before. That's in the knowledge-based realm. And it's not that we don't have those things in medicine. We do, but thankfully they're exceptionally rare. They're usually for not just emergencies, but rare emergencies. So, Amir, if I asked you how do we manage larger spasm in the OR, you're looking at rule-based because you have identified it and you have almost a checklist or algorithm that you're going through and you're applying those rules. You might still make a mistake with that, but that's the column that you're in until you get to the point where you've exhausted this algorithm, you still have a problem, and you've realized that hey, we're not actually talking about laryngospasm anymore. We're talking about something else, and we don't actually know what that something else is. Is this a pneumothorax? Is this something else? Now we're in that knowledge base because we actually have to apply a lot of the learning that we did in medical school and residency to come to a diagnosis, to then appropriately treat it and so on. But even that initial portion of figuring out what the diagnosis is and what the problem is, that might still be rule-based when we think about how we then come to an approach. And often in medical school, we're taught that you don't need to know everything, you need to know what an approach is. And that's still the application of rules. So it's not entirely clear, but I can say that from what Professor James Reeson would have told us about his work, you were rarely in the knowledge base, right?

How does knowing the theory about errors assist us in medicine?

SPEAKER_00 13:12

So why is this actually useful to all our discussions about talking about medicine? Like do these definitions or does this framework help us in addressing some of these errors?

SPEAKER_01 13:19

Yeah, it's it's a perennial question. Whenever we talk about any theory, what is the application? And so we can say that whether you talk about the nervous system and how much do I have to know about that if I'm pushing drugs or what am I doing and so on. The reality is that these are theories. And so we need a common language with which to speak about in order to come up with a discourse in order to be able to properly discuss whatever it happens to be. When we talk about how are we going to manage system performance and system safety, this is at the very beginning part. Do we in fact have an error? And then we can talk about the types of error, and then we can talk about ways in which those errors can be prevented, ways in which those errors can be trapped, as we've discussed in the past with Captain Mike Schuster, and then ways in which the harm from that can be mitigated. And if we use an aviation term, how we can get out of that undesired aircraft state, or how we can get out of that dangerous situation in the OR. But you have to go all the way back to medical school, and everyone has to learn anatomy before they become a physician, and everyone, in my mind, has to learn about what the error types are before they can properly manage a whole system of errors.

SPEAKER_00 14:32

Fair.

Violations vs Errors

SPEAKER_00 14:33

I follow you. I buy it. So, Adam, I get your discussion about the theory of errors, but what if these errors are intentional? What if they aren't accidental or flowing from incomplete information? How does Professor Eason help us frame those?

SPEAKER_01 14:48

He would call those violations. And so he again categorized the violations, which are deliberate, although they don't generally intend the bad outcome that may occur, right? The violation is an intentional violation of whatever happens to be the norm or the attitude and so on. And those violations flow from motivational factors such as beliefs, attitudes, norms, and from the organization at large. If we say that errors are slips, lapses, and mistakes and flow from unintentional actions and incomplete information, violations of those deliberate uh actions, though they don't necessarily intend a bad outcome. And he had several types. So Professor Reason would say that there are corner cutting or routine violations, and those are committed to avoid the unnecessary effort or to circumvent inappropriate procedures, right? The written versus the unwritten rules, and anyone who's ever had a job anywhere, whether it's at a fast food place or in the hospital, can understand the way these things can happen. There's a second category that he would call thrill seeking or optimizing violations. These are things to get more joy, speeding, for example. These typically happen more male than female, more young than old. A third category called necessary violations. These arise either because the people that are making the rules are not the ones that are performing the actual work, or because new rules are imposed after a bad outcome and that make future work impossible, the kind of closing the barn door after the horse has left effect. And then the risk in that third category of necessary violations is what we call the normalization of deviance that people may have heard of in the aftermath of the NASA Challenger 1986 explosion about the O-rings and so on. That there was a culture that, well, in order to get the work done, we had to do this violation and that violation, and that normalized the deviance. So just to recap here, we talked about corner cutting or routine violations, we talked about thrill-seeking violations as the second category, we talked about necessary violations as the third. The fourth and final category would be exceptional violations, which are one-off events that occur under exceptional circumstances.

SPEAKER_00 16:48

Adam, it seems to me that hearing these definitions, like I encounter a lot of these in my work in medicine and healthcare.

SPEAKER_01 16:55

It seems that they're oftentimes That's why we'll never run out of topics, Amir.

SPEAKER_00 17:00

Well, I mean, it's it's good for the listeners, maybe not so good for patients, um, or us as practitioners. But here we are. Uh like I sit here and I and I think about these, and particularly the corner cutting or routine violations, the necessary violations, those are the ones that I feel occur most frequently. And and it's hard reflecting on these because it seems like those are outside of the control of the individual. It's not to say that the individual isn't making intentional decisions, it just feels like the deck is stacked against us doing best practices or uh things that are in the best interest of patient safety, either because there is a lot of unnecessary effort uh related to, for example, getting a patient uh admitted in let me take that back.

SPEAKER_01 17:45

I I wouldn't take anything back. I think you I think we could stop the podcast right here, America. You got it exactly right. I think I think in what in our work it is corner cutting and it is necessary violations. And if we go back to the previous episode where we talked about Martin Bromley, part of the big issue, particularly in medicine, particularly in inpatient medicine, is this idea that the system, as you say, is sort of stacked against the people at the front end, whether that's nurses or doctors or allied health professionals and so on. And so we have a lot of these necessary violations because we have to look at who's making the rules. It's often politicians, policymakers, administrators, and so on who aren't there at two o'clock in the morning. And I mean, we can talk about all kinds of issues with this. Um, there was one recently at uh one of the hospitals that I work at where we needed a scan in the middle of the night. It was clearly after hours. This patient was going to die because they were bleeding profusely. We had been in the OR for five hours. And the surgeon says we need the scan. I said, Don't worry, I will call radiology because he's got his hands full. And I call down, and the tech says that they're not allowed to do that. So I'm on the call with an administrator, and the administrator, in this case, wasn't in fact the head of housekeeping, but sometimes the person is literally the head of housekeeping and does not have any clinical background whatsoever. But that person is saying, Well, we can't do that type of scan because it's not a brain bleed. Uh, you want uh a scan of the belly to look for bleeding, we don't do that after hours. And I said, it shouldn't matter what the scan is, it should matter whether or not the patient's gonna die. And in the end, we got the scan done. And then, of course, when I reported through our safety reporting system, within a few days, it was changed. The whole hospital policy was changed to say, it actually doesn't matter the scan type, it matters whether a patient's going to die. But somebody had to write a policy in that, and that's an example of a necessary violation. So I think as Martin Bromley would say, we want to change the system to make it easier to get things right and harder to get things wrong. And if we look at other industries, they have a leg up than we do in medicine in that regard.

SPEAKER_00 19:43

I really like your example, Adam, because what I think it demonstrates, and to give credit to the people initially making these policies, like they have other things that they have to be concerned about. Resource utilization, it's making sure the hospital runs efficiently for all the other patients that are going to be there the next day. And so I think what we get into when we have these discussions of necessary violations, corner cutting or routine violations, I think it's when you have friction between, for whatever reason, between the people making the rules and coming up with these policies versus the people implementing them. And like you said before, there's some industries where that gap is much, much smaller and narrower, or where there's a lot of work that's been done to mitigate that gap and to actually have a better discourse. I think as we'll see later on, why in medicine that's particularly difficult.

SPEAKER_01 20:26

And to your point, Amir, we're gonna get into this later on, but there have been a lot of efforts to narrow that gap. And one of the simple ways that we're gonna talk about later on in this episode is the idea of walkthroughs from either senior leadership or administrators literally walking through the sites or coming after hours because you see the hospital nine to five, it's completely different than on a Saturday at 2 a.m. First of all, there are far fewer hands, there are far fewer resources, people are are a lot sicker. Things just work differently in the middle of the night, and that seems obvious, but it's very different when you actually experience it. And it doesn't have to be a safety critical issue. I think you can go to almost any job anywhere, and you'll see there is a big difference between the people who are at the top end of the organization and the people who are actually performing the work. We to used to talk about safety one and safety two in the sense that work as imagined, which was safety one, how do we prevent these accidents that have happened versus safety two, which is how do we keep doing the good things that we've been doing? In other words, medicine gets it right sometimes, very often, I would say, and how do we keep doing those good things? The first one is work as imagined, and the second one is work as it's actually performed. And so these are not new thoughts or new schisms or anything like that, but they are problems that are perennial that are continuing to happen, and there are things that we can do, and some of them are very low tech, like let's get the people who are making these decisions to the workplace that is actually happening.

SPEAKER_00 21:54

Well said.

The Swiss Cheese Model of defences in depth

SPEAKER_00 22:00

Some of the key themes regarding organization accidents and a few key concepts that Professor Reese has worked on over the course of his life and that we can find in his memoir.

SPEAKER_01 22:10

Absolutely. So just like Dr. Jesse Guscott said, you've

Adam’s example of a necessary violation: arranging an after-hours CT scan for a bleeding patient

SPEAKER_01 22:13

got a few days for this, right? I'm going to boil down some of what Professor Reesen was saying essentially. And again, we'll look at that SwissGee's model, the defenses in depth. Those are the defenses that prevent those hazards from turning into losses. And the holes are how those hazards would connect to the losses and those bad outcomes. And the holes are our weaknesses. And sometimes all the holes line up and an accident occurs. And there are two types of holes. There's what we now call the latent conditions, which can exist for years, and they're often due to system factors. I think we are now closely examining, for example, in the LaGuardia accident that happened a few months ago before the Air Canada CRJ that hit the fire truck. They're looking at, well, should we have more staffing of air traffic controllers? Think look-alike drugs. Think fatigue-inducing schedules and inadequate training. These are all things that anyone who's been even tangentially associated with a hospital knows all about. And yet we live and work in this system that, as Amir has often said, is operating in the red. And so those are the things that push us really close, that razor's edge. Essentially, we're wearing down those Swiss cheese layers. So instead of five or six layers, maybe it's closer to one layer. And all we need is one thing. Sometimes you don't need anything, as in the case of the Challenger explosion, where you just have a cold day and the latent conditions and the O-ring fails, and that's it. But more often, more often there is what we call an active failure, which is usually somebody at the sharp end, or is always somebody at the sharp end, and that makes an error or potentially a violation, and they have a drug administration error because perhaps there's a look-alike drug. They intubate the esophagus and they don't recognize it, or they misread a monitor, or there's a communication error. Those two types of holes, the latent conditions and active failures, are really important to distinguish so that we can address them. And often we need proactive measures to identify those latent conditions because they're kind of all around us and we live in that environment. And then the more difficult part is it's easy to identify the active failure. Oh, the nurse or doctor gave the wrong drug. It's very easy to punish that person for doing that, but it doesn't actually necessarily make the system safer.

SPEAKER_00 24:17

Is it fair to say, Adam, then looking at these things in the context of latent conditions and active failures, it's that the to use parlance that we're we're familiar with, an active failure may be a symptom of the underlying problem, which is the latent conditions.

Amir’s example of a near-miss administering a medication in an OR

SPEAKER_00 24:30

I think we can discuss that when we talk about drug administration errors, for example, I can recall a case where I was in an OR and two drugs that had very, very, very different effects, almost uh almost opposite to some extent. We had switched the supplier of the medication. And so they actually came in vials that looked almost identical. They had the same kind of volume, or they looked to have the same kind of volume, they had the same colored label, and they had the same cap on them. And so, you know, when I went to go administer the drug, the only thing that stopped me from giving the wrong medication was when I pulled it up, I noticed that the volume in the syringe was different than I was used to, right? So had I given that, that could have been considered an active failure.

unknown 25:09

Right?

SPEAKER_01 25:10

A drug and they had to be placed close together, otherwise you wouldn't have made that error, right?

SPEAKER_00 25:14

Adam, I'll give you one step further. The pharmacist stalking them, or whoever was stalking them, did not recognize that they were different. And so they had actually put them in the same container in our like and I've had that.

SPEAKER_01 25:26

I've had that too, yeah.

SPEAKER_00 25:28

And so all of this to say while I bring this up in the context of laying conditions and active failures, yes, we have a lot of things in place to mitigate this. In theory, we have someone downstairs and upstairs in the pharmacy going through and sorting the medication. We have a separate person tasked with going into our drawer and labeling them. But at the end of the day, as you mentioned, all it requires is the right amount of holes to line up to have that like um be erroneous. I would say this is the success of the Swiss cheese model or demonstrates that we have multiple layers of failure. We have someone going down and sorting the medications because someone's stocking them, and we have someone administering them at this point in time, me, and I was able to catch it, preventing the hole from going all the way through. But you and I can imagine a scenario that if this happened at like three in the morning in the middle of a four-hour case where we didn't have all our mental faculties in place, that would be a through line demonstrating that we have latent conditions leading or associated with active failures that can cause a true error. Is that fair to say? Is that a fair example?

SPEAKER_01 26:24

And then the other thing to realize is how close to a bad outcome did we come? Uh, and and that's that one thin layer. And that's why, I mean, we really don't have good data on how many near misses there are, which is what I would categorize that as, right? That was a near miss, right? Um, there was no harm to the patient because you ultimately were the last and final defense. And I would say we're relying far too much. We expect, as Dr. Jesse Guscott has said, uh, we rely far too much on the the physicians, the nurses to to trap these errors. But let's take it back, right? I don't know what the pharmacy was like, but I know that there is often concern that, well, do we have enough pharmacists and so on? And people don't see pharmacists, but they they not only prevent a lot of errors, but they trap a lot of errors too. We've all seen the TikToks of the pharmacist to the you know R1, um, but sometimes it happens with me too. They're like, Doctor, did you really mean to prescribe this? Uh you know, oh, do you have a suggestion? Oh, yes, uh, would you suggest this, right? So the pharmacists do a lot in the background that patients never see. But also, what about staffing for pharmacists, right? Um, I recently, for epidurals in Ontario, we have a shortage of ropivacaine, and I think there's a worldwide shortage of rupivacaine, and so now we're using uh bupivacaine at a different concentration. And so part of that, not in this case, but might be related to, well, how well staffed is your pharmacy in your hospital? Well, how much does it cost to have a pharmacist? It's probably got to be in the order of let's just ballpark it at $80,020,000 a year for a clinical pharmacist. I hope it's more, but let's just say that's what it was. Well, where does that money come from? Well, what if we reduce the OR costs here and there? And this is budget problems. But if we look at latent conditions, I don't know, but perhaps there was a shortage of staff in the pharmacy. Somebody for sure made an active error, right? An active failure in that they stocked that medication, that incorrect medication, with the same medication that it was supposed to be in your tray and it was something else, right? And then you made an active failure when you didn't when you didn't read the label of that. Now it's understandable considering the fact that the labels are are very, very similar, but you have latent conditions and then at least one active failure. And then only because you then went and said, hey, this is a condition that is not expected in that you drew up more volume, that was why you double checked it and you actually trapped your error, right? And there was no harm to the patient. And so those provocative conditions are likely to be the product, as Professor Reason will tell us, of decisions that are made by top-level management. And decisions may be proven to be mistakes, but it's not always the case. Almost all of those high-level decisions are likely to carry a penalty for somebody at some time. And that's the nature of managing large resources. And so sometimes we say, well, there's a distribution that's made on an equitable basis, but that doesn't necessarily translate to everyone having what they need. There are often good reasons why one department will have sort of a larger slice of the cake, but it's not always appreciated that those decisions that are made at that level can translate into the workplace conditions, i.e., let's say there was a good reason that they just don't have an extra pharmacist on or the whatever it was. And of course, that manager is not thinking, well, maybe, you know, Dr. Hammond will one day make a medication error because the wrong medication is stocked in his drawer.

SPEAKER_00 29:41

I think that last point is something I really, really empathize with Adam. Like I think we want to believe that people are performing at their best at the majority of time they're working. And and from my experiences, that's not true. I would love to tell you that every day come into the OR, I'm better than the last. But the reality is there are factors outside of our own control, whether that be the schedule from the day before or other competing demands at our work that impact our ability to be cognitively present. And yes, it's on the individual to optimize those conditions to the best of their abilities, but at the same time, there's only so much one person can do. If I had been called several times before I even get into the OR for an elective case for some other tangentially related anesthetic issues, my mind is not necessarily focused in the same way that it would be when I step into the R for the first OR for the first day without those distractions. And that's not anyone in particular's fault. I use this example to demonstrate that the system is designed for people functioning at optimal efficiency.

The medical system is not error-tolerant, it expects practitioners to be perfect

SPEAKER_00 30:34

I think that's exactly it.

SPEAKER_01 30:35

As Jesse Guscott said, we should really focus on how much the medical system relies on perfection by the people at the front end. We expect nurses to be perfect, we expect doctors to be perfect, we expect pharmacists to be perfect. That is not the reality for any human endeavor ever. The margin of safety cannot be that way, right? As I said before, we don't blame that air traffic controller, even if it turns out that he made a mistake in clearing that fire truck across, because we don't place all of those lives in one person's hands. And why should we do this in medicine or anything else? And so the reality is we need to be looking at system safety as a whole. And so to get back to something that you were getting to before, if we take a step back, Professor Reeson would tell us we know from the history of accidents that errors are a part of the human condition. And we can't change the human condition, but we can change our working conditions. And so, to a degree, you got lucky in that you noticed this because you weren't as task saturated, you weren't fatigued, the conditions were there, and you're a very diligent practitioner. But as you said, it could have just as easily been the middle of the night, it could have been an absolute emergency, you could have been either cutting corners or simply just not been as astute as you were to say, hey, this vial is normally one CC and now it's two CCs, and that's not normal for this. And then you look at this and go, Oh, the pharmacist made an error here, I better not do this. And so we live at that razor's edge. And the question that we all need to face is, how can we build in more safety? How can we rely a little bit less on people trapping those errors at the front end? And how can we make it easier, as Martin Bromley will say, to get things right and harder to get things wrong?

SPEAKER_00 32:23

I just want to mention again, if you guys have not seen the video called Martin Bromley, A Patient's Perspective put up by the patient safety movement, we will link it again. I think this is a crystallization of a lot of the things we talk about because uh in his talk about patient safety and medical error in particular, he mentions a phenomenon that I think we've all experienced if we've worked with healthcare. You have someone come up and say, hey guys, we know this is an error-prone situation. We've told you about it. Now the responsibility is on you. And you better not make a mistake, because we've told you, so we've done our job, so now it's your job to carry the weight of that. And I think through this discussion, we realized, like, yes, that's certainly a part of the piece of the pie, but the onus shouldn't be on the individual, right? We will all make errors. There's no way I can be convinced that humankind will eventually evolve our way out of making errors and becoming perfect human beings.

Checkout Patreon.com/medicalsafetypodcast where you can find the extended version of this episode

SPEAKER_01 33:08

If you've enjoyed this conversation, we've actually got another 23 minutes of our episode that's available exclusively on Patreon. For just five Canadian dollars a month, you'll get access to extended versions while keeping the medical safety podcast going. We don't receive any outside funding, so your support goes directly toward produce in future episodes. In this exclusive conversation, we discuss how changing the EMR is a small example of changing working conditions. We also discussed how difficult the culture of medicine is to change, how things have changed since A Life in Error was released 15 years ago. Adam compares aviation safety culture and medicines, the origins of how error is stigmatized in medicine, and patients who ask for the best surgeon, but what they really want is timely and quality care. 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 we're back to the rest of our content in the free version.

Local investigation of medical error instead of centralized, anonymized, and published

SPEAKER_00 34:05

Another key point that he brings up is local event investigation. We've talked about this in our previous few episodes about how easy is it to develop systems in your own institution that will look at near misses, that will look at errors. It may be very easy, but then how do we disseminate that information across? I think in one of our uh first episodes, Adam mentioned that it's very hard to find a central repository of medical errors that have been disclosed, discussed, and made available to the public, whereby we know in aviation that exists, that exists in multiple countries, that exists internationally. And so much easier to manage that than in medicine. That means that's the same error can be repeated in multiple institutions. We just don't have that kind of uh discourse across. I'm not sure as to why. I presume there's some archaic reason as to why that happens, but I think that's not to anyone's best interest.

SPEAKER_01 34:49

I think the reason is is exactly what we've been talking about, which is the culture of medicine. It's this, it's it's stigmatized at an organizational level instead of an individual level. We talked about hospital row, and where the real failure here is not just that errors go unreported, it's that solutions go unreported as well. And there is always the potential that an elegant solution is made at one hospital and you go across the street and that hospital doesn't even know about it, which is the real failure here. And so hopefully we're gonna see as Norway and the UK have these medical investigation bodies that now publicize these, there is the potential that we can be learning from them. And so that's a huge change over the past 15 years since this book was published.

SPEAKER_00 35:31

Absolutely. I think that's that's a good

R v Omstead, [1999] OJ No. 570 - Nurse acquitted of manslaughter after giving lookalike drug

SPEAKER_00 35:33

point.

SPEAKER_01 35:33

Just turning our attention to a case that I learned about when I was in law school. It's actually a case from 1999 in Ontario. It's called the Crown Against Olmsted. Olmstead is O-M-S-T-E-A-D. And Omstead was a nurse in Leamington, Ontario. And it's quite rare for a medical error to attract criminal charges. But what had happened in this case was that nurse Olsted had given a look-alike drug. She gave potassium chloride instead of furosamide or LASIKs, and the potassium chloride killed the patient. The following day, she realized that the error had been made and she reported it to her supervisor, and she was later charged with manslaughter. Manslaughter is not a formal charge in Canada, but the charge is actually criminal negligence causing death, but commonly we would call this manslaughter. At the trial, the judge found that had the nurse not reported her error, it would likely not have been discovered. And the judge accepted the evidence of the expert witness regarding how information is processed and found that the mere presence of an error that results in a fatality does not by itself mean that there is a marked departure from the standard expected of reasonably situated nurse. That's the legal standard on which we talk about criminal negligence causing death. It can't just be negligence. It has to be at the time they talked about a marked departure from the standard of a similarly situated nurse. And I mean, we were talking about an investigation at the time that looked at these similar look-alike drugs on the same shelf in the same location, almost exactly what Amir had mentioned before. And so the judge then using language similar to that of Professor Reeson, again, remember, this is 1999 in Ontario, the judge found that the death was the result of a systemic failing. And it included not only active failure, the error made by the nurse, but also latent conditions, the manner in which the drugs were stored, and that they looked alike. Finally, the judge noted that a conviction in that case might deter others from self-reporting, which would increase the risk of this happening to others. So nurse Omstead was acquitted. Unlike public inquiries, criminal trials are not tools to determine facts. They are to determine criminal blameworthiness. Did this nurse commit manslaughter, essentially? Their rules are predicated on fairness to the accused and whether the crown has proved beyond a reasonable doubt that they committed that specific offense. The rules of evidence and procedure determine what evidence is admissible and for what purpose it can be used. So criminal charges are rare and trials even more so, and this went to trial as we saw, and the focus is on the accused and not the medical system. And the judge cannot make recommendations to other actors or institutions. That judge in that criminal case cannot recommend to the hospital, for example, that it change its policies. And so I just thought it was really important because we talk about precedent and so on. And if there was ever a time when we look at the application of Professor Reason's research, and again, this is 27 years ago, to a medical environment, to a specific trial, um, you know, this is it. And so that's the crown against OMSET in 1999. We'll be right back. And we're back.

Summary

SPEAKER_01 38:23

Just as a brief summary, we talked about the fact that errors are inevitable because we're human and humans are fallible. And experts, including expert clinicians, do not make fewer errors than others. But what they do, as Professor Reese will tell us, is that they detect and correct them faster and more frequently. And so errors are the product of our working conditions, and we can't change the human nature, we can't change the human condition, but we can change our working conditions. And so a really big emphasis on how can we change our working conditions has to be how we go forward. And we're going to look at how investigative tools and a reporting culture are the way that we can identify these working conditions, but then it takes a bit of courage of our leaders in the organization in the country in order to actually change working conditions. Organizational accidents are the result of the Swiss cheese model, or at least can be looked at in the lens of the Swiss cheese model, which shows that weakness, that there are weaknesses in these defenses in depth. And those weaknesses come in two forms: the latent conditions, which are present for a long time, such as look-alike drugs, and they are the result of organizational decision making. The other type is active failures, which are the result of people at the sharp end making a mistake or a violation. And those active failures are usually connected temporally to the bad outcome. Usually they happen just before. Due to the nature of medical training, as well as how long medicine has been around, errors are stigmatized in medicine and they're seen as a source of shame. While James Reeson doesn't say this, I say that there is a lack of data in medicine and a lack of investigative tools such as audio and video recordings that exist in aviation, those black boxes. We talked a bit about this with Captain Martin Bromley. And because of the private nature that medicine comes in, and because medical deaths are not mass casualty events like large airliners, there just isn't the same impetus to put those tools in place. But that doesn't mean that we couldn't do that. And hopefully we're working towards there. We talked about how in the UK and Norway they have medical investigation and publication of these things, so we have a repository, but hopefully we get a little bit more in terms of these investigative tools.

SPEAKER_00 40:28

Amir? I think what I would like to underline is that although most errors occur at the sharp end in Adam's terms or in Dr. Reese's terms, active failures, I would say there is an individual at one point of error in most of the time. The reality is it's not just on them. This is the whole Swiss cheese model. But when we look back at the system, we don't just stop at thinking, why did this individual error occur? Who's to blame? We look at all the preceding factors and try to address them. I think I said this in the last episode, but I just want to bring it in here. When we look at errors investigated in the airline industry, if you watch the May Day episodes associated with our episode number two, you will see that their investigations, although they spend quite some time looking at the individual pilot or pilots or technicians involved in any given accident, they never just stop there.

SPEAKER_01 41:28

And just to highlight exactly what you said there, there is a school of thought that seems to say, well, if we accept that this is a system failure, there either isn't anything that we can do about it, or we're absolving the people at the front end of not having to be better, quote unquote. That is not the case at all. Sometimes, not often, but sometimes there will be a deficiency in training or a gap in knowledge at an individual level. And we don't punish that, we need to retrain that. And also, if that happened with that one physician, nurse, whoever, perhaps that can also be addressed so that other people will also not suffer the same weakness. But there seems to be this idea in, especially people who are older clinicians that haven't grown up with this kind of conversation happening that, well, if we say it's a system failure, aren't we going to promote bad training? Aren't we gonna promote laxity? Aren't we gonna promote, you know, people who are not vigilant, etc., etc.? That is not what anyone is saying. And to the point where if there were, let's say, gross negligence, in other words, intoxication, things like that, well, we're not saying that can't be identified, brought out, punished, etc. However, those will be the rare cases. Far, far more often we're gonna make the system safer because we've identified not just the active failure, but those latent conditions and how we can change those.

SPEAKER_00 42:46

Well said.

Safety intervention worth mentioning: leadership walkthroughs

SPEAKER_01 42:47

So on the idea of who can do what tomorrow, this is the idea that there are a few things that specific people, whether you're a practitioner, department head, hospital CEO, government official, can do tomorrow. James Reeson has some specific advice and words of caution for healthcare providers. And one of them that we would say is to read his memoir. It's only 100 pages, as Amir said, and they can start with the chapter on medical error. And we highlight just a few things. This idea that there's a disconnect between administrators and clinicians, uh, and that sometimes the solutions that are presented uh actually affect future work and result in these perhaps necessary violations that we talked about and so on. And Amir went out of his way to say that often administrators are trying the best that they can in a constrained system and have to make make difficult decisions with either unintended or even unforeseeable consequences. And we're going to talk a little bit about the safety intervention work worth mentioning in a minute. But it's this idea that A, there is a bit of a disconnect, and B, sometimes organizations may rely on the fact that they haven't had a bad outcome in a while or at all. And so that lulls people into this false sense of security because, and I'm quoting Professor Reeson now, it fails to take into account the many unrecorded adaptations, adjustments, and tweaks performed by frontline operators to keep what is almost always an Imperfect system operating safely. Professor Reeson primarily identifies nurses because they are so resourceful and identify as, well, a good nurse is a problem solver and we'll fix these things. Very often, they're preventing and trapping so many errors that then don't get reported upward, and then the system doesn't change because that's just become the nature of their profession. And so while the nurses are doing an amazing job keeping everyone safe, we're relying too much on those frontline personnel and we need to seek out those working conditions that can be changed rather than waiting for something to happen. Okay, moving on to the safety intervention worth mentioning, to kind of connect it to this idea that administrators may be disconnected from the front line. To mitigate that, we have leadership walkthroughs, and this is where members of senior leadership will walk through clinical areas, whether you're talking about the recovery room or the OR or the ICU or the Ward or any of these places, to actually see how the work is done. Not how it's imagined, but how it's actually done and how their decisions affect day-to-day working conditions. And I note that members of various provincial governments have been invited to tour emergency departments in Canada because there is an ongoing crisis of emergency medical care in this country and in other countries, of course. But we all know that wait times have gotten out of hand absolutely, that people have died and will continue to die in waiting rooms for a variety of reasons. And I'll just shout out a couple here, for example. One was in November of 2025, the New Brunswick Health Minister, Dr. John Dornen, spent 24 hours in the Moncton Hospital Emergency Department after being invited by a patient who had experienced a greater than 24 hour wait. And of course, Dr. Dornen is a physician and a former health network CEO, so arguably he didn't necessarily need to do that, but at least he is trying to sort of walk the walk in that sense. The real walking the walk will be what, if any, policy change have we seen after that? And on the other hand, we saw that in July of 2025, Dr. Warren Thirsk, the head of the emergency medicine for Alberta's Doctors Association, challenged Premier Daniel Smith of Alberta to visit his department to see the overcrowding. This was not acted upon. And then further in January of 2026, Alberta physicians called for a state of emergency regarding hospital overcrowding, and they were reporting over 110% capacity. Those facts were in fact denied by the Alberta government, and there is an ongoing disconnect between the physicians who are working in the healthcare system and the government of Alberta. But this idea of leadership walkthroughs can really help. And that's the safety intervention worth mentioning that we're talking about on this podcast.

SPEAKER_00 46:40

I think that's a really great intervention. I have nothing to add to that. I think it's very important for people in senior leadership to actually know what's going on, boots on the ground, if you will. I think if you're in a position that has more senior leadership, it's worth your while dedicating a day, two, three. Treat it as a day of work. But your job instead of doing whatever it is you are is just to see there and observe what's happening. The other safety intervention I say is worth mentioning is actually chatting with people in other healthcare institutions that are either similar size, reflective of your own, or who have people you trust and actually developing a network of disclosure. Just make sure that when you have an error or if you think there's policies that are not working ideally in your institution, it's worth reaching out to people in other institutions and see how they work. I would say that I know some people who do this fairly frequently and fairly well. I think at one of my training sites there was a very industrious chief of anesthesia who did a very good job in asking his colleagues what they were doing with regards to certain problems. Uh obviously there are local practice groups, uh, whether they're connected on WhatsApp, Slack, whatever you want to, whatever messaging app, email chains, whatever that are doing.

SPEAKER_01 47:42

Talk about brand solutions, basically. Is that what you're saying?

SPEAKER_00 47:45

I don't know if that's what it is. But I guess what I'm trying to say is that if you are encountering a challenge that is difficult to fix, if you've encountered an error that you think is systemic in your institution, it is worth reaching out to other institutions to see how they have addressed this error or if they had similar things like this in the past. I like to say there's nothing new under the sun, someone has done it. It is very hard to go to other places and say, I messed up, can you help me? It's much easier to say we're trying to address this problem. Have you faced similar problems like this before and see if that that moves things forward? I think, especially when it comes to developing policies that may be novel for your institution, it is certainly easier to at least take them or adapt them from existing institutions that have some clout in your region.

SPEAKER_01 48:26

Uh we'll move on to random recommendations. Uh Amir, what do you have for this?

SPEAKER_00 48:32

So this episode got me thinking about another book that I found to be very, very impactful in my learning and training and life. The book is called The Black Swan. It's by Nestim Taleb, who is a mathematician, philosopher, polyacademic individual. The premise of the book I think is very, very cool. Uh, it is a different way of analyzing rare but significant events and framing them in the context of what they actually are, not using hindsight bias to misattribute them, not using inductive or deductive reasoning inappropriately. It's dense, it's very hard to read. But I think in the world that we live in, insofar as practicing medicine, it is helpful to have this kind of framework in looking at rare and significant events because it really helps.

SPEAKER_01 49:16

Awesome. Awesome. Uh, I've got a book that I'm reading called The Politics Without Politicians by Helen Landmore, uh, L-A-N-D-E-M-O-R-E. And this is the idea that, you know, professional politicians as a profession haven't necessarily served us very well just due to due to the nature of democracy, of how it's running, and perhaps a random lot, essentially, it's called sortation, which is the idea that if you picked a thousand people out of the phone book, I'm sorry, that's an old reference. I don't know if people know a phone book, used to be no kidding. If you just picked at random uh a thousand people, a thousand citizens, that they might actually be able to govern just as well and arguably a lot better than politicians, because politicians are tied to being re-elected, uh, special interests, money, etc., etc. And at first I thought, well, this'll be a really radical read that I'll probably disagree with. Uh, and uh it is a very interesting idea uh in terms of if you have a random group, you'll have, you know, perhaps some tradespeople in there, some physicians, you know, some lawyers, and just average everyday people. And uh if we limit their terms, then they can probably get a whole lot done. Uh, and then they've played their role in society and they'll take it seriously, just like I know people take jury's duty actually quite seriously, even though no one usually wants to be on a jury. Uh, and it's this idea that if we take a random group of society and we give them the power to come to uh a consensus and how we can actually have them make rules and laws and so on, then perhaps they'll do a better job than the actual professional politicians. Okay, and that's it for this episode of the Medical Safety Podcast. I'm Adam Shahada.

SPEAKER_00 50:50

And I'm Amir Hammid. And as one TV doctor said to another, what? You have to say it.

SPEAKER_01 50:59

It's a beautiful day to say bye. Okay, please consider following us on social media. We are looking for an intern to help do research and make show notes for the show, as well as a producer to help with technical aspects such as mixing and editing. Uh, as the podcast receives no outside funding, this would start as volunteer positions, but maybe if enough people are interested, it would become a funded position. This could be a great opportunity for medical students, residents, those people interested in patient safety, critical care, anesthesia, or aviation. You can find us or email us at medical safetypodcast at gmail.com. Again, that's medical safetypodcast at gmail.com. And 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 supporter of the show, please consider going to medical safety podcast.com where you can make a donation. Even if it's just a dollar or two, it makes a big difference and we really appreciate it. If you are interested in becoming a patron of the show, please consider going to patreon.com slash Medical Safety Podcast, where you can become a patron of the show, and for five Canadian dollars a month, you can get exclusive access to the extended version of this episode. We would like to send along a big, big thank you to those of you who have already supported the show. 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 working to make every day savier than the last. Thanks very much. And now for our outtakes.

SPEAKER_00 52:27

What I want to say is they we certainly lamented the fact that our systems could be better, but the realities in terms of error mitigation, I think uh addressing the error boiled down to a few key ideas, like watching out, you know. Sorry. I thought this note was a lot clearer when I first wrote it down, and so reading it again, I realized it's very messy.

SPEAKER_01 52:46

Um, say say your thing, and then we'll massage it a little bit, and I think we're gonna come out with the idea that we want in the end.