Now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety, and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Reeds University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We are so thankful that you're here with us today, Laura, and we invite you to go ahead and get us started. Okay. Thank you very much, Lindsay, and welcome, everyone. This program is always so much fun because it's a little bit different than what my normal programs are. These cases that I'm going to talk about today, they're all been sanitized, and so there is no identifying information such as patient names, facilities, et cetera. If it does look like something within your facility, that is not the intent. I've always tried to find these cases that are especially outside of Georgia. In fact, one of them's from my state of Colorado, I'm sorry to say. As for my programs and the information I'm going to provide, it's informational only. It is not meant to be legal advice or establish any attorney-client relationship. Please consult with your own in-house counsel, your representative, your attorney for any advice, especially if it relates to a particular substance within your facility. I'm going to do just a quick introduction, give you some numbers and the overall focus. 15 million incidents of medical harm in a hospital each and every year. Now they really toned this, really spelled it out for us. 1.1 million Medicare patients suffered an incident over a three-year period. 44% of those were preventable. This is an OIG study, I have the link there on that slide. So we all remember, probably almost all of us do remember that infamous IOM report, the air is human. Now that report did spell out that up to almost 98,000 patients die because of medical error. And that's more than breast cancer, a motor vehicle accident, or at that time the AIDS pandemic. And the total cost nationwide was almost $30 billion. So where are we now? What's changed? Has it improved? Still now, though, the leading cause of death, errors account for $4 billion in costs per year and medical errors, approximately $20 billion per year. So there's a couple different studies that have shown it, but again, have we really, really improved? They give us a definition, medical error, again, leading cause of death. And the problem is trying to find one consistent cause. And even if you do find it, well, then what's the best solution to minimize that change so it doesn't happen again? But by identifying some of those causes from these events, maybe we can learn from them and work to prevent them and therefore overall improve our patient's safety. For anything, and this has really come out in the last 10 years in particular, culture is so important. And that's also important in coming up with some of those really viable, those that are going to work, those that are going to stick solutions. We've come away from what was very prevalent in my early days of nursing, a blame shame and train. It's your fault. You were wrong. We got to go back and train you again when that's not really, really, we need to look at overall what's our culture. Look at that system to improve it because these are things usually beyond our control. So that's why we need to have them as challenges that we can overcome. There are two major types of errors. One is, of course, the omission. We didn't do what we were supposed to do. For example, secure that gurney before the patient was transferred and patient ends up on the floor. Or commission, where it's actually the wrong action was taken. We give the wrong medication to the patient. We know they have an allergy or we mislabel something like a specimen. And therefore it's the wrong diagnosis given to the patient. Usually this is more than one factor that comes into play. In fact, there's probably multiple factors that come into play. We cannot take out the human factor. It's going to be there because we have to stop blaming or punishing for errors that are due to the systems because that doesn't address the causes. In patient safety, they really focus on improving systems. So we reduce the chance that's going to happen. And if it does, still we can prevent it. We're going to mitigate those effects. Now, joint commission, we're all familiar with that. And they have those patient safety goals. And they talk about what can we do to maybe mitigate these events from happening. Patient identification, improving our communication skills, simple infection prevention, wash your hands between patients. Setting those alarms not only on, but that will respond to them. On our medications, doing those double checks, labeling them appropriately, and really being careful with those high alert medications, those ones that can really cause harm, whether it's chemotherapy or anticoagulants. Adverse events, those are those injuries most frequently due to an error in our treatment. We have to recognize not all results. All of this is not the result of an error. These things sometimes happen. Preventable adverse events, those are attributed to those errors. And they can result in injury. Maybe the patient has to stick around longer or sadly, maybe a physical disability. Now this can include complications from prolonged hospitalization. So a patient unfortunately goes septic while they're in your care. They have prolonged hospitalization. They're immobile. An adverse event might be a decubitus that results from that. And then we have errors. There's two types. Active error. That's the one that takes place between the person and an aspect of the larger system at the point of contact. Then we have our latent errors. This is when we have something going on in our process design. Maybe it's something with the installation or maintenance of equipment. That can go on unnoticed for a long period of time, and we're lucky. There's no problem that comes up. But these occur when everything comes together, whether it's an active human error that can trigger that latent, hidden event. In other words, it's simply an accident waiting to happen. Joint commission has several definitions for us. And of course, one of them is a sentinel event. This is a safety event that's not primarily related to that patient's normal course or their illness or their underlying condition. If it reaches the patient, it can result in death or severe harm, doesn't matter how long that harm lasts, and it can be permanent, and it doesn't matter the severity. This is a subcategory of adverse events, and just a couple years ago, they did update this. It is not limited to those events that occur during care and treatment. It can be verbal violence, abductions, power failures. Again, that can lead to an event that led to permanent harm or even death of a patient. IOM, they have their own definition of a medical error, and that's, of course, where we don't complete our intended plan of action or we put the wrong plan of action into place. It's an unintended act that fails to achieve what we wanted to happen. They can also be deviations from our process that may or may not cause harm. So they've kind of expanded it there. And then it's an act that contributes or may contribute to an unintended consequence. Most of us are familiar with negligence. We don't meet that reasonably expected standard of care. We have our negligent adverse event. This is preventable, and it meets that legal criteria of negligence. In other words, the injury was caused by substandard management or care. Then we have our near miss, any event that could have had an unintended adverse consequence. You've probably heard of the NEVR events, National Quality Forum. They identified them now, serious reportable events, care management, maybe it's a defect in that product, could be an environmental event, surgical event, a radiological event. So they've cumped those together. And then, of course, our root cause. This is all part of this serious event. And we know that that is a deficiency or some decision that, if we corrected it or eliminated it, would take away those undesirable consequences. There are many common root causes. Communication that always comes up is usually number one. Then maybe we don't have a way to identify patients, we're not doing a full assessment. Maybe it's a technical failure with our equipment, inadequate staffing or poor supervision. And then maybe it's just not enough policies to tell these workers, hey, this is what we need to do. AHRQ has set out some of those error-prone situations. That's the healthcare research for quality improvement. And they have several, such as adverse drug events. We have pressure ulcers, surgical site infections. We still have obstetrical adverse events. Falls, we went over that just a couple weeks ago about falls and immobility. We have peripheral lines, ventilator-associated pneumonia. So these are really high ones. CDC got involved in the act, too. Now, they talked about healthcare equity. And you're probably wondering, why are we talking equity? Well, because with healthcare inequity, they seem to find some of these folks have a higher potential for errors or bad outcomes, adverse events. Health inequities, they can result in differences in length of life, rates of disease, death, severity of diseases. And I've always also put this in here as far as the link. So as population, we know we have our minorities, those who have low socioeconomic status. Maybe there's general sexual and gender, excuse me, issues. And then others, those who are subjected to just simply discrimination. These have really poor health outcome. And these results in being underserved in the full spectrum of healthcare. So, you know, we don't want these to happen, but sometimes this disparity does result in it. CDC does have some strategies for us to help reduce those. And in the interest of time, I just want to make sure we're able to go through our cases pretty quickly. So what do you have to reduce these disparities and help prevent perhaps those avoidable readmissions? Home visits. Maybe we can reduce our asthma-related hospitalizations. Counseling. Reducing those risk of HIV risky behaviors. Programs. Maybe better neighborhood. Reducing the violence, again, so we can reduce those admissions. Expanded vaccination recommendations. They eliminate some disparities, actually, in our hepatitis A disease. So I'm going to start now going through some of these cases. Again, these are all actual cases. I have sanitized them. I do have one, I think I have one or two medical record examples totally sanitized in that respect. So our first case involved a failure to report. And this is what happened. We have a 14-year-old. He was admitted to the hospital. And this patient came with suicidal ideation. And during the examination, this patient reported that an adult relative had been physically and sexually abusing him for the past six months. Now, this information was reported to the nurse during their initial examination. But also to the physician. So we decide this patient was admitted for further evaluation and treatment of their suicidal ideation. In this particular state, they required all healthcare providers, all teachers, law enforcement to report any allegation or suspicion of physical or sexual assault or battery. That was a mandatory reporting. The hospital processes required staff to report any suspicion or indication to an internal review team rather than law enforcement or social services. So there's a little bit of separation here on what the state law required and what the hospital policy or process is required. So our patient's admitted for three days inpatient care, sent home with his parents. Unfortunately, the alleged abuser came around to the house frequently. And he finally told the patient, hey, you tell anybody, I'm going to kill you and your parents. Well, this didn't help with the patient. In fact, this patient continued to refuse to go to school and was very, very anxious. The parents sent him to a private psychologist. And the patient again disclosed the abuse to the psychologist. But the psychologist didn't report it to the authorities under the guise, well, that'd be too traumatizing to repeat these events. And honestly, just didn't believe the allegations for whatever reason. So three months go by. This patient comes back two more visits to the same hospital for an incomplete suicide attempt. During the visit, the mom asked, has police been notified? She asked him. The social worker documents a report had been made with the previous visit, so another report wasn't done. Patient was sent back home and within one week, sure enough, back in for another attempt. With this time, the mom said, I'm done with this. And she contacts the police. At that time, she finds out no other report had been made by anyone. Not the nurse at the hospital, not the physician at the hospital, not the psychologist. No one made that mandatory report. Well, fortunately, they get this patient over to another facility. The patient gets good treatment for their severe depression, their ideation. And right now, as of this time, they still continue to have severe emotional trauma. Through the parents, appropriately, they filed a lawsuit for failing to provide, number one, adequate care and meeting the mandatory reporting requirements. Well, the hospital in response said, we're just following our internal processes. This is what came out of discovery. And that is through, like, production of documents and depositions. Through this discovery, they found out they only reported this abuse a year and a half later. And that was only after the record was requested. And then it was found out, oh, yeah, we can't find anything that this report existed because no one filed the report. And this discovery showed that someone at the hospital wrote a report, backdated it two years to make it appear the social worker had indeed filed that report promptly. And they only learned that because they got the record, and they said, that doesn't sound right because the police report, the police documents contravene that. So they did a metadata analysis on it, and that's when they found out it had been inappropriately backdated. All right, so here's our deposition. Here's from the ER staff. Hey, we're only following our internal procedures. Some of them questioned the veracity of the patient. They just simply didn't believe these allegations. Psychologist, well, you know, I've had experience with other abuse, and, you know, retelling the abuse could cause further, quote, damage, end quote, to the patient. Now, that may be very true. Absolutely, I'm not a psychologist. I don't practice psychiatric nursing. That could be very true. The social worker, well, I didn't go back and confirm. I didn't go back and make sure, you know, there was one in the record or that other staff had actually made it. I just believed it, you know, so that's, I didn't confirm it. So here's the questions in this case. Do you believe, you know, you've worked with this, so do you believe that internal reporting process is defensible? Did the psychologist have a valid reason for not reporting? Should the parents have just said, forget it, we're reporting the abuse, and go forward? What about additional checks and balances? When mandatory reporting is necessary, should we have something to confirm, yes, indeed, we made that report? What processes, then, would you recommend this hospital maybe go back and revisit? So, Lindsay, I think that's the end of my questions. So I'm going to open it up and see what do the attendees feel we need to do here. Are there any questions on this case that you'd like to have clarification? For our attendees, if you do have any questions specifically for this case, you can utilize the Q&A option, or you can just type that into the chat. We'll read that out to Laura, or just type in your responses here, maybe to some of these questions here. Laura, do you want to maybe start with that first one, or just see in general if they have just some comments? Yeah, just see if they have any comments on any of these. Do you think their internal reporting process is defensible in light of what the state law says? And by the way, I'll tell you what happened at the end of this case once we finish with it. The comment here, hospital internal process is not defensible. Their process did not meet the level of state requirements. Lots of not defensible. What about the psychologist? Not a valid reason? Again, any allegation of abuse. that, to me, is pretty clear. One person says the psychologist is a mandated reporter. Right, right. Providers did not comply with mandatory reporting laws. Should the parents have reported the abuse regardless? See, this is where I had a little concern with this case. You know, mom's bringing this kid back in. My question was, did the patient tell mom and dad or not? I don't, I, and you know, that really wasn't ever brought out in this case. Did mom and dad know, and when did mom and dad know that this had occurred? I see lots of yes, they should have reported, but then comment here, but they're not healthcare professionals. You know, of course, they should have reported if they did know, if it was known to the parents, then yes. Yeah. A lot of those same comments. What about checks and balances? When you got mandatory reporting, who's gonna go back and make sure this was done? I mean, is there another process internally where, hey, this child has reported this terrible abuse. Do we notify anybody else internally within our hospital? Is that something you wanna start going down that road where, yeah, I'm gonna tell the risk manager, make sure it was reported, et cetera. Do we need to go there? Do we, you know, how far do we take this internally? And these are just some of the questions I threw out when I was reviewing this case. So I said checks and balances would have been extremely beneficial to ensure that the reporting has taken place, process to ensure reporting. There should be checks and balances built into the process. Yep, absolutely. Yep. And when you feel you have enough of the comments, I'll go ahead and move on, Lindsay. Yeah, I think we're in good shape. Okay. All right, I'm gonna back up and talk about two biases because remember, they didn't believe this kid. The staff, the psychologist even had some issues. Two types. Number one, that's our intuity process. That's where we're fast thinking, automatic. We respond to the stimulus. That's your ER providers. Then we have the deliberate one where we can kind of sit back and think about it. Perhaps that's a psychologist. Did they have that opportunity to think, sit back, look at the notes, look at this person that they're evaluating. This is one of our slow thinking where we can do that. Of course, we're all familiar with that term anchoring. We jump to conclusions and no matter what happens, what new information comes in, we're not changing our mind. Then we have ascertainment. Maybe these are prior experiences and expectations. So here we have this person coming back in saying the same thing, saying the same thing. And then availability. What do we have based upon our examples in the past that we can make a decision? And then confirmation where we seek out information that just looks at what information we have and then we're done. We don't go anything else. We don't consider any other information that might contradict that. We just, that's it, we're done. So with this case, we had anchoring. We relied on previous information and disregarded what this patient was telling us. Ascertainment, been in before, nothing new, same old, same old. And then availability. We've seen it with this patient and the same complaints. And so we're done, nothing more, nothing new. Why should we change our mind? So here's the outcome of this case. The hospital did settle for an undisclosed amount. So I have no idea what that was, high, low, mid, I don't know. Internal processes though, they did go back and visit them. They had to go back and recognize we're not in compliance with state law. So we need to go back and they did update it. Anytime an allegation comes in, automatic referral. The psychologist, the hospital staff, and the social worker pled guilty. Now you think, why would they plead guilty? It wasn't necessarily so much of a criminal case, but they pled guilty to violating that state mandate. This requires reporting, even if the person doesn't want the abuse reported in this state, that's how this worked. Everyone from their licensing boards got a letter of admonition and had to go through mandatory training. And that was everybody, every physician who touched this patient or the record, every nurse or other clinical person and the psychologist. And in fact, their licenses were held in suspension until they got that training completed. Finally, the abuser did confess. Then they ended up with a 20 year sentence and they are still serving that time. So this is just, unfortunately, and I hate to admit it, this case came from my state and it took this poor patient that long. The patient is now an adult. That's how long, four years for this person to get justice. Look at your processes, always follow your state law. Make sure you're in compliance with it. Don't assume something's been done. And especially if something in the back of your head tells you this isn't right, something's missing, follow up with it. Keep an eye on your biases. Sometimes we may not see them in ourselves. And so that's why those checks and balances help. And no, ever, don't ever alter the record because they will find it. They will find it. If you find something that's missing or something that is incorrect and you have to change it or it needs to be changed or explained or updated for safe continuing care, check with your legal counsel, your risk management, how do I do this? Because it's just flat out wrong. I need to make that correction. Okay, next case. This one involves where we have a lady wrongful death because she had ruptured intracranial aneurysm. The allegations in this case were that the radiologist did not personally speak to the internal medicine physician after radiological tests showed possible aneurysm seen on a CT. And then a negligent failure to timely diagnose, refer or treat this patient. We have a 35 year old. She is a mother of two. The physicians, the defendants were a radiologist and an internist in this case. Well, here's the background on this treatment. In O2, she's 35. She calls her internal med because she has a bad headache going on for five days. She's been taking Allegra. She's been taking Excedrin because is it a migraine? Is it related to allergies? She noticed herself that her right eye, her pupil was larger than her left eye and she couldn't quite focus. Her vision was impaired. She was referred to an optometrist, not an ophthalmologist, an optometrist to have this checked out. She's seen there complete several tests and they do note in their documentation, this patient had right eye pain and headaches, a dull ache and sinus problems. Vision was blurred. Right pupil was larger than the left and visual acuity though was 20-20. So she does go back to the optometrist again because she's not quite getting her vision fixed out. Now the right pupil is a little bigger. She's now sent to an ophthalmologist and the referral form notes right-sided headaches with a pupil larger than left and blurred vision. So it's all documented, it's all in there. 10 days later, she's examined by the ophthalmologist, notes the right eye is dilated. She has trouble focusing, no head injury. So there was nothing as far as trauma and she's had headaches for the past three weeks along with sinus trouble. So the ophthalmologist says, let's go back to your internal med to rule out any possible migraines or sinus problems because again, from a visual standpoint, he really couldn't pinpoint it. So the patient goes back one month for follow-up. Next time, she also calls her internal med for a referral to an ENT or maybe a neurologist to see if they can find out what's going on. Seven or 10 days later, they do request, the internal med request a CT of head and maxillofacial without contrast. And the reason was, quote, headache, sinusitis. So CT studies are done. They're read by the radiologist that same day. They note a minimal paranasal sinus disease, minimal. There's a prominence on the uppermost basilar artery, about seven millimeters in size. Now this finding does raise a question, is there an aneurysm at that basilar tip? An angiogram, CT angiogram, that would be better to help really assess that area. So the impression, the overall impression was a basilar tip abnormality, and an angiogram again was further recommended. So the radiologist transcribes, dictates a report that's available for immediate review. That's at 1230. 1236, the radiologist calls the hospital operator trying to reach its internist. So the operator sends out a page to him. That's at 1230. 5 p.m., radiologist signs off on the report, and it would be printed out the next morning, then mailed snail mail to the internist for review. And that happens to be the actual report that you're looking at. So they say there's a prominence. It raises a question of an aneurysm. So right now, you kind of raise your question, are we talking a critical value here? So on the third, patient telephone records says she herself is calling the office. She spoke about a minute, about one in the afternoon. There's no note in the chart about that call. Next day, telephone message on the record notes the patient called again. I need to have an appointment. I want to find out what's going on with this CT. The patient's phone records say she called a little bit over a minute. Another call about 45 minutes later. This one lasts a little bit longer, about two and a half minutes. For that same day, her phone records showed she called two more times after that at 2, 205 and about 245. There's no note in the record on any of those subsequent calls to this office. It's quiet. So the next day, this is now the fifth. Patient collapses, she's admitted and she now has a CT. She has an intracranial bleed, brain stem hemorrhage with intraverticular extension. She is transferred by helicopter to a higher level facility. She's going to a level one trauma. She undergoes brain surgery five days later, but sadly dies eight days after surgery. Death certificate says it was due to a cerebral infarct secondary to that ruptured aneurysm. Now they don't do an autopsy because they figure with the brain surgery, they have enough information to find out what happened and what was the cause of death. So here's some additional information for you to consider. We have a board certified radiologist in diagnostic radiology. We have a very young patient, two very young children, four and six. So we have a sympathy factor that was brought into this case. A lot of finger pointing between the two defendants, between the radiologist and the internal med. And then of course, the internist, not exactly the best defendant. Little Pompous came off as uncaring, very intelligent, very good doctor, but the bedside manner factor was quite missing in this individual. So here's a concern with this case. Got multiple attempts and there's nothing, no response by the provider. Now you think, wait a minute, she called at 10 in the morning and at two in the afternoon, you expect us to respond? Okay, so there's one. That report, does that rise to the level of a critical value? Number three, no documentation that our radiologist actually tried to reach that internal med. Did he do that and discuss the findings? No direct communication. Oh, that's the same thing, excuse me. All right, here's our expert comments. Judgment call, whether or not the radiologist actually reached out and talked to that internist. If he really thought it was an aneurysm, maybe he should have picked up the phone and called. Would have made direct contact with the ordering physician? The ACR guidelines, these again, the experts. ACR guidelines say, hey, look, you need to contact this physician when you have something you didn't expect or you had a potentially significant finding that you found. Again, the CT was for sinusitis and headaches. Document the record that you made the contact, nothing was done here. Well, I called the hospital, they put out a page, I signed off and went on my merry way. Here's the concern, communication between the physicians. Did that occur? Should the internist have called back to the radiologist and said, what'd you find? Is that reasonable? Is that the standard of care? What were the critical value reporting systems? Was that clear enough? And then the handoff between the sites, clinic to the radiologist. Here's a report of their complaints. Here's what this patient was complaining to me as an internist, I think it's important for you radiologists to know this because her pupil's different, it's getting bigger and her vision is being impacted. So any concerns? And then I wanna open it up. What do you think of this case? Okay, any comments you have, just like in the last one? Let me type in those into the chat and then if you have any questions for Laurie, you can type that into the Q&A or of course in the chat as well. I see one comment here, NPSG, that's National Patient Safety Guidelines. National Patient Safety Goals, yeah. Goals 100.02. Yep. Multiple failures, there should have been communication between radiologists and internist. Better communication. Yeah, that seems to be the common theme here. Failure to report or respond appropriately to critical results. And I like that a lot of you have identified this as a critical value. And that's where your medical staff and working with the internal med, whatever, and radiology lab, whoever it happens to be, what do you see as a critical value? This was not expected. That aneurysm was not expected in this one, okay? Is that an incidental finding? Or is that something, oh, hey, by the way, you may need to check this out. To me, an incidental finding is I'm doing a chest X-ray and it's long enough, maybe I'm short stature enough, that maybe you see something down in my lower right side. That's an incidental finding. That's not where you were supposed to be, but hey, we see this down here. You better go check that out. But still, does that rise to the letter of a critical value? You know, the question here that says, was there any policy in place about the size of the spot determining requirement for radiologists to reach out to the ordering physician? Right, right. At that time, no. And so there, do you go back to your ACR values and say, well, would a reasonably prudent radiology under the same or similar circumstances have reached out to that internal medicine or even the PCP and said, I found something. You might wanna know about this. I don't see any other comments here. Okay. Well, yes, this was a very sad case. They did decide to settle. The internist, the internist professional carrier was really having some concerns with this case. In fact, they were having a heck of a time trying to find another internist to defend the actions. You know, here's this patient calling. She's having these repeated issues and it's just not being addressed. Was she a challenging or concerning patient? Maybe, maybe she was. But again, she's got a lot of red flags. My pupil's getting bigger. My vision is getting blurred. I can't focus and my head is killing me for how many days. So those were a lot of red flags. On the radiologist, they had some concerns with it also that, you know, you didn't communicate, but going back to the policy, the one person who mentioned the policy, policy was really vague on what they were required to report in a perfect world. Yeah, pick up the phone and call him. Say, no, you pull him out of a room. He needs to know this. That's the perfect world. And we didn't have that here, unfortunately. So the radiologist did not, didn't have to really, they didn't pay anything. It was all the internal med. That that's who did end up paying on this case. Again, undisclosed amount, but I understand it was in the higher range. All right, now we have a failure to diagnose. And I believe, no, that's not the one. So we're gonna talk about a missed pulmonary embolism. We've got a healthy 36 year old male. Comes to the hospital, has no complaints of dyspnea and vertigo upon standing. Past medical history, nothing. He's active, no comorbidities. So once it gets in there, here's his physical exam. Vitals, his pressure's good. Pulse is a little high. Stats are a little low. For me, those are low for room air on somebody who's this healthy and this young. He's not a smoker, by the way. Chest X-ray, routine labs are ordered. They notice a slight decrease in his bilateral lung sounds, left greater than right, lower lobe. He has several areas of bruising on his extremities and his chest. And he was in a local charity football game over the weekend. And of course, got tackled a few times. So here's now 530. He gets up and asks to go to the bathroom. So upon standing, that's when his vertigo hits him. He has trouble breathing. He is pale and diaphoretic. They put him back on the cart. They do positional pressures, and I've got them listed here, from reclining, sitting, and standing. he goes from 142 down to 84. So we got a little positional hypotension here. Surprisingly, his pulse didn't change that much, which I found very interesting. So they do a CT of the chest due to his presentation, abnormal positional blood pressures to rule out a PE. They finished that at eight o'clock. They telephoned the report at 8.15, suspecting a very large PE. The report, unfortunately, is taken by the unit clerk, and I say, unfortunately, because you'll know why here in a minute, writes it down and puts it in the chart, and then goes home for the day. The written report comes up by fax. So they did call it, and then it's sent up. And you'll see here, this is a CT. Unfortunately, the arrow kind of gives it away on what we're looking at. Well, it's changed a shift. New ER provider comes in at eight, was not told about the pending report. She checks in with the patient at 8.30, no change while he's laying there and he's quiet, and so he's good. He's watching TV. No, I'm not having any troubles, feel good. Ordering provider was unaware the report had come back. And he happened to be with a motor vehicle accident patient who was really in trouble. It was quite a bad accident. So he wasn't made aware of that report, that the report was back. Nursing staff was crazy busy evening, and they were with other patients. And so they also were not aware of the report that had to come back. Ongoing unit clerk wasn't aware of the report, that it was actually sitting there on the fax machine. Change of shift, no communication, so they weren't told. 10 p.m., patient's getting bored. I wanna go home. I'm having no further symptoms. So the ongoing provider looks at the record and sends him home. Okay, follow up with your PCP. 1 a.m. the next morning, the wife calls EMS, finds a patient unresponsive on the floor. They do resuscitation, send him back to Parker, but that didn't work. Patient was pronounced deceased. They do a post-mortem. That's when they find that very large, it's called a saddle embolism, because it sits over the main bronchus just like a saddle would fit over a horse. And so that's when they found it. And for those of you who are very familiar with those, when this case happened, unless the patient's there and you can get them into diagnostic radiology or interventional radiology, it's not gonna turn out well. Here's the internal review. So they reviewed it internally, through their med staff and also QAPI. Several areas of concern were identified. No communication, that handoff communication did not happen. We did not follow our own procedures. That's a critical value. So that required provider to provider communication. No one checked the fax machine. You're supposed to do that. Every 15 minutes, go check the fax machine. And who's supposed to do that? Well, whoever wasn't really identified as a responsible person. And there really wasn't an assessment of this patient that could have, should have occurred in this case. Go back in, oh, rule out PE. Maybe I better check them out and see what's going on. So what do we wanna do? Look at those diagnostic test reporting. Who takes the reports? And when do you have to have that physician to physician interaction? That's why we have to look at that importance. Make sure staff feel safe when that physician needs to be approached. Now, again, the one physician who ordered it was in the midst of a motor vehicle accident patient. Is there someone else we can go to to say we got a problem here? Educate your staff. What are their expectations? Who should have been checking that fax machine? Don't say, well, who was ever around? No, that needs to be identified. So they got that cleared up. Who do we need to alert for any pending results coming back? This patient went for CT, rule out a pulmonary embolus. And then what are your discharge processes? Reassess the patient and look at the record. Make sure there's nothing you're waiting to come back so that we can get it taken care of. We got a hand at this hospital, sat down with the widow, explained it to her and told her what happened. Now the state had an early resolution program. The family asked for some good faith money. They wanted monetary resolution. Because again, this guy's pretty young. They did agree on an undisclosed amount. They worked and revamped their testing reporting process. They got input from medicine, nursing, radiology, of course. And then of course, lab, they added lab. So if it was an inaccurate or a way out of whack lab report, they could also be involved. This is what we need to do. And so if these critical values are there, who do we talk to? Just don't leave it with one person and make sure it is the physician or provider to provider communication. Cause it may not be a physician, maybe a PA, maybe a nurse practitioner, whoever, but that needs to be clarified. Who gets these results? So that was a very sad case. So before I move on, any questions in this case before I do move on, Lindsey? Any questions anybody has, you can be tapping those into the chat or to the Q&A option here. Yep, so I just said this is scary. And you probably all work in very crazy, busy emergency department. You can see how that could happen. You could see how it could happen. And that's why when we're rushed and just for circumstances beyond our control, it's sometimes hard to take that step back and think, wait a minute, what am I waiting for again? I had a comment here that says, I was an ER nurse for 20 years, I immediately went to PE. This probably happens more often than we know. Yes, very true. And PEs can be so insidious too. Those pulmonary embolism, because you're laying there, I feel pretty good. What am I doing waiting around here? And then you get up and it's over. I even had, we had a patient in our pain clinic who called us and said, you know, my calf, my leg is really bugging me and my calf is just killing me. No, we had nothing to do with the calf, okay? But he was somewhat recumbent. He couldn't get up and move around very well. So that leg was down there and it was a young guy too. And I'll be darned, he calls and one of the nurse takes the calls and says, oh, don't worry about it. Just, you know, kind of put the heat in there and just kind of do your dorsal flexion and extension if it helps. Fortunately, another nurse overheard that conversation and said, no, stop. Gets him on the phone and says, tell me what you see. What do you feel? And he says, well, it's kind of swollen and it really is cramping like nobody's business. And I said, okay. The nurse said, you've got two choices. You can either try and get in here on your own. I don't recommend it. Number two, call an ambulance and get to the ER because this doesn't sound good. So she immediately gets ahold of the physician and the physician also said that, yes, too. Let's get you into the hospital now. And sure enough, this person, this patient had a very large thrombus in that calf. Young guy, you know, not really a victim of an assault or anything like that, but it just showed up. So that's why sometimes we need to have those checks and balances on what's critical and what's not. So again, anytime I hear, oh, my calf is killing me and it's all swollen and doesn't look good, you kind of step back and say, don't touch it. Don't squeeze it. Don't massage it. Let's talk to your doctor. Because even the best nurses can sometimes miss it. I don't see any other comments here. Great, okay. So, you know, they did come to an agreement, did change some of the processes. Trust me, those two physicians just felt sick about this because they simply didn't know that that report was there. All right, I think this might be our last case. This is an issue of restraint and seclusion. One of probably the most cited areas for CMS when they're around as far as issues, deficiencies for restraint and seclusion. 48-year-old, she's coming in for a gastric bypass, weight loss. The band is inserted through an endoscopy procedure. Now, during the procedure, the patient unfortunately has an esophageal tear, but they don't immediately identify that. And that's common. They say that's a common complication that that happens. Very few days during the post-op care, they do identify the tear when they attempt to swallow. Immediately has dyspnea. Now, over a very short period of time, this patient becomes, she becomes sick, becomes dyspneic, has to be intubated and sent to the ICU. Over the next three days, she becomes septic. They put her in induced coma to try and decrease her oxygen demand and help her recovery. Now, I guess this is he, not she, excuse me. Over the next two weeks, condition stabilizes, able to take them off the ventilator. They start doing that. They do have to put the patient in a soft wrist restraint, those cloth ones, so they don't extubate themselves by accident. So another five days pass, they take them off the ventilator, still some confusion. And this patient was extremely ill with the sepsis. In fact, they reported hallucinations. So now hospital day 25, they put them to an intermediate care floor. All of these rooms are private, but only four of the 12 have video monitoring capabilities. They're very busy on that unit. They put them in a room halfway down the hall from the nurse's station, that's as close as they could get them. There's no video monitoring in that room. Family, friends, they take turns sitting with them during the daytime to help them reorient and keep them safe. They still remained confused. They're not combative, just a little confused with the illness. They're not pulling on the IVs, the oxygen tubing, nothing like that. Staff and visitors, they reorient them if they attempt to get out of bed or get up without assistance. Now they're concerned for his safety and lack of video monitoring. Staff asked for an order for an abdominal restraint at night. Family's aware of the request and why, and they don't have any objections. This family cannot stay with them because they also have young people at home, so they have to be home. Staff were oriented, they were all trained on the proper application with this restraint. First two nights, not a problem. Patient tolerates it beautifully. On the third night, midnight rounds, they're found hanging on the side of the bed and the restraints up around the neck. Cyanotic, a weak pulse. They do a rapid response. They get him back, ended up in a very light, vegetative state. They did find the abdominal restraint was properly applied. Over time, they do move the patient to a long-term care facility after he's there for two more months. Unfortunately, the condition did not improve. So here's our, any concerns, and I'm just gonna kind of throw these out. And I'll just go through these one at a time. Was the need for the use of the restraint identified? Do we have an alternative that might've been safer or better in this case? If no, how was staff trained? What was the component of that training? Did the person applying the restraint, did they document it to confirm? Yeah, it was done appropriately. And the checks? What was the rounding schedule for this unit? Was it every hour, every four hours? Rounding, in other words, go down and see what your patients are up to. We had no video monitoring in that room. Should we have done more frequent monitoring? Now, I've got some data here, and I'm gonna go through, and I'm happy to go back to those questions if you would like, Lindsey. But while you're considering those, again, did we do proper training for this patient? So restraint use, it's been, we see that now having a longer length of stay and undesirable outcomes, falls and advertent asphyxiation. Physical restraint, it's for patients. We see this, and this is what the study showed. They're at risk of falling, motor unrest, agitated behavior, and those who really have an intention of doing harm to self or maybe to suicide. And that is the link that I have there for you. So in a study of their deaths from physical restraint and the autopsies, three actually died of natural causes. One was a suicide, and 22 due to that physical restraint. All occurred when they were under nursing care, but not continually observed. And that was usually strangulation. In 19 of those cases, restraints were inappropriately or incorrectly fastened. So as far as the recommendation, freedom restraining measures, put together a restraint management bundle. So if it does happen, it doesn't have to be long and drawn out, just something very simple. Here are your steps. Give a framework to develop those processes. Maybe you can reduce it. Reduce the use of restraints, improve your safety and minimize harm. So before we move on, do you want me to go back to the questions, Lindsey? I don't think so. There are just a couple of comments here. Let's see. Yes, more rounding monitoring to alternative sitter. Anyone in any type of restraints needs frequent monitoring. Then a question here, were the patients in the video monitoring rooms in need of video monitoring? Yeah, yeah. That's a good question. Yes. Safety sitter would be a good option. Yeah. Yes. And one other question that came out from this, okay, who's qualified to be a sitter? You can have an aide or whoever, you know, a technician, whoever that is, be a sitter. As long as they know what are their responsibilities and what must they do if they have a concern. So that can be, and it can be a very basic training. Check with your state. There may be other requirements. In my state, as long as the person is trained in first aid, CPR and know how to call or reach out for help and are there continually like video monitoring, they can be a sitter. So CMS, they pretty clear on this. It should not be considered routine part of your fall prevention program because there's no evidence it prevents them. And a fall where restrained as we know in this case exemplifies it, it can result in severe injuries. And they've, studies have shown reducing the use of physical restraint can actually decrease the risk of falling. Restraining a patient because they might fall is not adequate basis for the use of them. So that's why we need to do that assessment. By the way, this patient was trying to get out of bed, got a little confused, thought, oh, I need to go somewhere, got out of bed and the abdominal restraint caught him and they couldn't wiggle their way out of it. Well, is there a reason, some physical medical condition that we have to prevent them from getting up and moving? Of course, the least restrictive intervention is best. History of falling without any clinical basis, again, not enough to demonstrate a need for one. Convenience isn't enough and you cannot use it as a substitute for adequate staffing. Maybe we need to reevaluate the patients, try and discontinue as soon as possible. Just having the family request, oh, go ahead and put her in restraint, she'll get a lot more sleep that night, that's not enough. Increase your rounding, someone said that, yes, absolutely. What do you assess when you're gonna go and look at them? They seem to be awake or they're asleep. Maybe sitters and again, train them. What do they need to look for in order to prevent that patient from being injured? So of course, the family was not too happy about this. They did not pursue any legal action. Hospital came right out and said, this is what happened, you need to know. This is what we've done. They did get cited by CMS because it was a reportable event so they had to report it and they got cited for an unsafe environment. They made major upgrades to these rooms. They had video monitoring installed in each and every one of those rooms. Now they didn't always use it or need to use it but they bit the expense on it and added it to each room. Staff were hired, they knew about video monitoring. They had specific places, a room with one or two staff depending on how busy they were to do nothing but video monitoring. And these didn't have to be RNs. They were, again, technicians who were trained like those you might use in coronary care. Escalation protocols, they put those into place, help the patient get out of bed or when they are. If a patient is trying to get out of bed and perhaps the sitter needs help, they had that escalation protocol in order to get help down to the room. Oh, I guess we have one more. Discharge planning, proper patient planning. So we have an 85-year-old patient, comes to the hospital, three-level spinal fusion. They live alone, remote farming area. Closest family member, two plus hours away. That's in good weather. Hospital is 60 minutes from this patient's home. And the next closest one is a critical access hospital, 20 minutes away. The hospital she was admitted to was a level three. So, I mean, it wasn't anything major. It was a good, it was good size, but it wasn't a critical and wasn't a huge hospital. So the daughter had DPOA, Bureau of Power of Attorney, for care and was also told, I'm their representative. She had told the staff, anytime you are talking to my mom about these issues, like planning, future care, et cetera, I have to be there because she forgets. So the daughter and the patient did request discharge evaluation be done and include us in this evaluation. They also talked to the physician and said, would you write an order for a discharge plan to be done and started? The hospital response, plain out, we're not doing one. That's it. No further explanation. They said, we want one. We need this evaluation. No, we're not gonna do that. So the daughter and the patient requested, okay, fine. Send me to a rehab hospital, maybe swing bed so I can have further recovery. Both wanted a meeting with the discharge planner because she lives alone. She's out there in the middle of nowhere and we can't get there that quick. And these are folks who have their own families and responsibilities. So again, they reiterated, I want an evaluation and a plan. Denied without any explanation. Nope, I can't do it. Surgery proceeded, no complications. She was scheduled for discharge home, second day post-op. So the post-op course and therapy, really two sessions of PT. Roll over and a 15 minute walk down the hallway, up and down three steps using a cane. Nothing else was done. No PT, no OT to see, okay, what's your setup at home? How do you get around? Can you fix your own meals? The PT, physical therapist told the patient, you're ready for discharge. You didn't qualify for rehab or swing bed. Oh, really? Okay. Homecare instructions were provided to the patient, but the daughter was not present when those discussions occurred. So when home assistant support, they also requested this. They, you know, we need these resources. They only gave them two. Homecare, well, they didn't really do that much. Vital signs, no transportation, no other services. They didn't help provide meals, didn't help cook meals, didn't do any evaluation. Elder services wasn't in her area, so she didn't qualify. St. John's didn't provide any other resources. So send them home with its daughter. That was it. Four days go past, patient has extreme pain. Eight out of 10, she was incontinent because she couldn't get to the bathroom in time. She had trouble maneuvering because she had to use that walker. Even though they used a cane with her, that's what happened. Her appetite goes down. We know when we don't eat, our recovery could be delayed. And she had a lot of anxiety, fear of falling, which is a very real fear for someone of that situation. So day five, she fell trying to get to the bathroom. She hit her head and right shoulder. This time she goes to another hospital. She has a concussion and a dislocated shoulder. So she has another two weeks inpatient at the other hospital. Now she has to have more PT for that shoulder. She has to have monitoring because of the outcome with that concussion. Make sure she doesn't have confusion. There's no bleed or anything more that's happening. Family did file a complaint with the state's, the beneficiary's families that service, the contractor and the state agency. The state arrived at the hospital two days for an immediate jeopardy survey. So what do you think CMS found when they came around? No effective discharge planning process in place. No qualified discharge planner. Social worker, absolutely no training, no education in that role. They didn't complete a discharge assessment as was required, especially when the patient and the representative said, I need help, you need to help me here. Okay, nursing care failed to provide adequate pain control. She went home eight out of 10 and we didn't get that done. Oh, it still goes on by the way. They didn't have adequate resources for her post-acute care. They were simply not appropriate. They weren't available in her location and what was there was woefully inadequate. The physical therapy department, they didn't properly assess the home environment. How many steps do you have? Well, this patient had multiple steps. There were two steps just into her house, but she had steps going downstairs to where other items like her kitchen was located, where further things she needed were down those steps and there were no handrails, by the way. There was also a concern with the physical therapist acting beyond their scope of practice, stating you're ready for discharge, we're gonna send you home. Here's the others. Policy and procedures they found hadn't been reviewed for four years. There weren't any current requirements as far as a discharge evaluation. When was it to be done? And there were three circumstances. Remember that one is when the patient, when you're admitting them and the nurses are assessing them, if they determine this person's gonna have a problem when they go home, that's one. Or the patient or the representative requested and three, of course, the physician. There were no leaders, when they talked to leadership, CEO managed to be out of town, could happen. The person who was in charge had no idea there were issues with their discharge processes. They hadn't done QAPI on their discharge planning. Director of nursing, no, we don't know anything's wrong here. We're fine, we're all good processes. Well, they're a little bit different when they talk to the staff. The staff said, our culture is quote, toxic, end quote. Those were their words. More than one had a quote, they called it the ruling class and I'm just using their words here. When it came time for patient needs, that's the way it's done around here. Staff nurses knowledge, they knew that this patient needed discharge planning, but they were overruled. They were told, we got it covered. You don't get involved with this, this is ours. No, no policy. They didn't know of any policies for when the patient wanted a discharge evaluation. They had no idea who to even contact. The daughter, when they were talking to the daughter, after the fact, they said, hey, we told this nurse twice, I need an evaluation. Says, well, I don't know who to report. I'll go talk to my charge nurse. That was it. The other thing that came out, this hospital was full and patients were being sent home so they could admit another patient. That was a well-known process. All right, any concerns here? And I'll start number one, discharge planning. Was it done? Nope, no discharge planning was done. Culture in this hospital. And I know we talk about culture a lot, but it's there. And this one was horrible. And these were coming from people who weren't involved directly with bedside care. These were other individuals, other departments were also reporting how bad it was. And no one dared say a word. Leadership, were they even present? CEOs, governing body, they are responsible for what happens in that hospital. And if they don't, they're accountable for it. So we know that in discharge planning, the hospital has to have an effective process that looks at the patient goals and their treatment preferences. This patient, yes, they want to go home, but they needed help. Where they go may depend on what do they need for their care? Is there a support network around? Can the patient, their caregiver, what are their goals? What are their preferences? They wanted discharge evaluation. They needed help. They needed this patient to go elsewhere so she could eventually return home. That plan has to be consistent with their goals. And then we must make sure it's an effective transition. We know it starts when the patient first walks in your door. Can they then, once they leave your control, your hospital, can they do what they did at home? Can they take their own shower? Can they fix their own meals? Can they get to and from the bathroom safely and in time? We need to reduce these preventable readmissions. They have predictive modeling that can help you. I also identify if they're at risk for readmission, then maybe we need to do more. Maybe do those callbacks, send them for home health visits. Maybe they do need to go to a skilled nursing or swing bed until we know, yep, they're ready to go home. Boost better outcomes for older adults through safe transition. Society of Hospital Medicine has this. They have a chart that can help you identify those who are at risk. Always include those folks in this planning. That just simply didn't happen here. Now, who's gonna take care of you when you're home? And studies involving these folks really can help reduce remission because they know what's expected. They're there, they can see it, they can ask questions, get those things answered. Even in TAG 806, we have to have that discharge planning evaluation so identified. And I've already identified three ways. The physician can request them, the representative or the physician. And that physician can ask for a plan too. Now, if you're gonna go back and look at these notes and the TAG numbers, there are many requirements. They are repetitive. CMS hasn't gotten around, unfortunately, to cleaning those out and making sure they're all very clear. So what's the likely need? This person's going to need them. Outpatient PT, she couldn't get there. She couldn't drive herself. Long-term care, rehab, make sure they're available in their region. And they weren't, they didn't. She didn't qualify because they weren't available. There was a memo back in 023 about discharge planning because they found many items were missing. That again, we have to focus on what the patient wants and include these folks. And we have to discharge and transfer where it is applicable, sending all information along. So here's what they found with this memo, that the information was missing that was communicated. When it is missing, anything who is prepared to take care of the patient, have no idea. They're not equipped to take care of them. And they even put in there, if you have an accrediting organization such as Joint Commission that comes around, they're alert for these issues. So those were the six areas of concern from this memo, durable medical equipment, communication with what they need at home, preferences for goals and treatment. That was completely ignored in this situation. So follow those CMS regs. If you're taking Medicare, Medicaid, you have to follow these regulations for all patients. Talk to the family, listen, work with them, ask them, what's your home set up like? How many steps do you have to and from? Where's your kitchen? Where's your bathroom? How about laundry? Do you have rugs that could trip you or slip? What's the distance to your kitchen? Do you have anything to hold on to? This patient did not, other than the walker. And what worries you about being home, especially alone? So any questions as we're going through this before I move on? I know I've got the outcome up here, but. Any questions here or comments in the chat? We encourage you to put those in now. If there's any questions in general for Laura, you can type those into the chat as well. So just since you already see this, the hospital was put on immediate jeopardy. They had to have monthly, monthly updates. They went, CMS went back in three months. One of the big concerns here was the lack of leadership. CEO wasn't around. Person who was designated didn't have any clue what was going on. And they were really concerned about, you know, who's telling who here? The physician wanted to have a plan. And what they found out after the fact was that he did. He went and said, I need to have a discharge plan done. Someone on the line says, no, we don't do that. We don't have the capability. We're fine. We're not going to do one. So he never broke the order. Yep, he said. And he did give somewhat of an inadequate response because CMS talked to him too. CMS and the major corporation that was over and owned this hospital also talked with him. And his response, because he did share it with the family, believe it or not, he said, well, I need this physical therapist. So therefore I don't rock the boat. That has now changed. St. John's, they weren't reimbursed for all of the care, including the surgery. The doctor was paid, but the hospital was not. And the family did file a demand letter for reimbursement after that second hospital. The original hospital paid that. St. John's paid that bill, made sure there was no bill for that second hospitalization. This matter did settle out of court through arbitration, so they were able to get it settled. And I did find out from the family's attorney that this hospital, there were a lot of changes that did occur. A lot of the leadership was replaced because of it. And they did have to shut down a couple of the floors because of nursing. They lost their chief nursing officer, so they had to get an interim in. And some of the surgeons, some of the surgeries that day that CMS was out had to be canceled. And the surgeons sent home because of the issues that they also identified during that visit. So that was pretty, it was a very involved visit. And I understand that there were many changes also made. All right, so from here, please follow your mandatory reporting. If you have a doubt, go to your legal counsel, go to your risk manager, find out, do I have to report this? Now, I'm gonna be honest with you, there are certain circumstances under certain state laws where let's say a female comes in and reports a sexual assault by a person they know. And said, don't report it, I don't want anybody to know this. You need to work with your legal counsel because in certain circumstances, you cannot report that if the patient says, don't do it. Just take care of me, I wanna go home. Secure the records for many alterations. Have those tight processes for your diagnostic test results. Make sure staff know what are their responsibilities. If you're leaving it open air, you're just going to invite problems. Those who are in restraints, we do need to watch them. And help the patient with those discharges. It will make your life a lot easier when they don't have to come back in because of something that wasn't done or was incompletely done. Thank you everyone for attending. I do have some of the information, those restraint bundles, those were one of them, those transition tools, AHRQ, Agency for Healthcare Research and Quality. By the way, a lot of these are free. That's what I always try to have available for you. So excuse me, I guess that's the end of it, just three of them. And so I'm gonna send it back to you, Lindsey, see if there's any additional questions or if they wanna put also in the comments, other cases or topics in the cases they'd like to hear, I'm happy to go research those out. Yeah, absolutely. And then they can also send that directly to me if you'd like. And you can see Laura's content information here on the screen. I'm gonna post some information here just really quickly for you all in the chat. Okay, so you should all, just as a reminder, if you have not joined us before for our webinars, we do have a routine process in place where you will receive an email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. And so because it comes from that Zoom email address, it very often seems to get caught in spam, quarantine, junk folders. So if you don't see that email in your inbox in the morning, I would first encourage you to check those additional folders. Maybe by around noon tomorrow, I would say give it until then to come into one of those folders or hopefully your inbox. And if it's not there and you would just like to go back and access the recording, we do record these sessions as on demand, meaning that you can use the same Zoom link that you use to join the live presentation to also access that recording. And just remember that the recording is available for 60 days from today's date. And we do have an additional security measure in place in order to protect Laura's intellectual property here. So when you click on that Zoom link, you'll need to just type in your information and that will prompt an email to come to us for approval. And we do approve those recording access requests once we validate them very quickly, typically within just a few moments of receiving the request. But we ask that you give us one business day to approve those requests. And then again, you'll have full access to the recording for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented today, but I did provide that there for you in the chat. So you can have that as a resource now as well. And then if you're joining us, especially as a member of the Georgia Hospital Association, please do pay special attention to that final link that will be included in that email tomorrow morning. And that is a link to the survey that you'll need to complete to obtain your certificate of attendance and receive your continuing education credit information. If you're joining us as a member of a partner state hospital association, please reach out to your contact within your association to obtain any information regarding CEs that your state is offering as well. And as Laura mentioned, if you do have any suggestions, possibly for future cases that you'd like to see her cover or just general questions, you can always submit those to education at gha.org. We'll be happy to get those over to Laura. And of course you do see her content information here on the screen. And we so thank you, Laura. I actually just got an email back from her yesterday that she had heard back from CMS where she had sent in several questions and got that back over to us. So we so appreciate you always going above and beyond to help serve our members and all of our participants. We so appreciate that from you. Okay, I don't see any other questions from our attendees. So thank you all so much for joining us today and thank you for participating and engaging with us. Thank you so much, Laura, as always for your time and information. I noticed lots of comments here just saying, thinking that these were great cases and great information that you shared. So we appreciate you very much. Thank you. I hope you all have a wonderful afternoon. Thank you, Laura. Thank you, everyone. Bye, thank you, Lindsay. Bye-bye.

Patient Safety

Medical Errors

Risk Management

Cultural Shift

Communication Improvement

Root Causes

Preventable Incidents

System Improvements

Patient Identification

Clinical Experience

Adverse Events