0:00:21.614,0:00:24.932
The nurse grabbed the recliner[br]and jerked me awake.

0:00:26.410,0:00:29.250
I heard "Code Blue"[br]and the room filled with people.

0:00:31.018,0:00:33.476
In that instant, I knew he was gone.

0:00:35.779,0:00:39.996
The doctors' words attempted optimism,[br]but their faces betrayed them.

0:00:41.555,0:00:43.702
The next hours were awful.

0:00:45.875,0:00:49.080
My sweet boy had become[br]a corpse hooked to machines.

0:00:50.995,0:00:54.227
I sat next to him,[br]begging him to come back to me.

0:00:54.971,0:00:57.476
But really, I wanted to flee.

0:00:58.019,0:01:00.522
I didn't want any of this to be happening.

0:01:01.614,0:01:04.522
I wanted to wake up[br]stiff and uncomfortable

0:01:04.522,0:01:06.922
in that ugly blue chair

0:01:06.922,0:01:10.287
and realize it all was just[br]a very bad dream.

0:01:13.312,0:01:16.114
But this was far worse than a nightmare.

0:01:16.954,0:01:21.385
My 20-month-old son had just died[br]in one of the country's leading hospitals.

0:01:22.769,0:01:26.920
On Thursday he was sick[br]and on Tuesday he was dead.

0:01:29.955,0:01:32.944
That night when he had been[br]admitted to the hospital,

0:01:33.056,0:01:36.816
white circles with wires were stuck [br]onto Gabriel's bare little chest

0:01:36.985,0:01:39.317
to monitor his breathing and heartbeat.

0:01:39.911,0:01:44.178
Every time he made the slightest [br]little wiggle, the alarms would go off.

0:01:45.093,0:01:46.248
And they're loud.

0:01:46.995,0:01:49.592
Every time we would almost be asleep,

0:01:49.809,0:01:52.820
the racket and worry[br]would start all over again.

0:01:54.797,0:01:58.583
We'd already spent sleepless[br]days and nights in my local hospital,

0:01:59.177,0:02:02.268
where he had been misdiagnosed[br]again and again.

0:02:02.747,0:02:06.461
But now, we were in a university[br]hospital for children.

0:02:07.561,0:02:13.229
Finally, here,[br]I felt safe and very tired.

0:02:15.452,0:02:17.874
And I'm sure the nurse[br]could see how tired I was,

0:02:17.961,0:02:20.013
and she wanted to take care of me too.

0:02:20.564,0:02:22.301
So she did the logical thing,

0:02:22.875,0:02:26.081
she turned off the alarms [br]on the machine next to his bed.

0:02:27.335,0:02:29.666
And I thanked her when she did it.

0:02:29.781,0:02:34.846
I was so grateful for the prospect[br]of silence and sleep.

0:02:36.592,0:02:40.470
Later, doctors and administrators [br]from the hospital would explain

0:02:40.472,0:02:44.548
that actually, unknowingly,[br]she had done a lot more.

0:02:45.428,0:02:48.004
She hadn't just turned[br]the racket off in the room,

0:02:48.592,0:02:51.084
she turned off all[br]of the alarms everywhere:

0:02:51.847,0:02:56.224
in his room, at the nurses' station[br]and on her pager.

0:02:58.511,0:03:01.218
Later, the manufacturers[br]of the monitors would explain

0:03:01.752,0:03:04.445
they didn't think anyone would[br]go through the trouble

0:03:04.645,0:03:07.645
of seven screens[br]to turn off all of the alarms.

0:03:08.552,0:03:11.598
So, they didn't include[br]a fail-safe to stop her.

0:03:13.038,0:03:14.999
They were wrong.

0:03:16.452,0:03:21.948
So, when Gabriel's heart stopped beating,[br]there was no sound, just quiet.

0:03:23.507,0:03:26.766
Nothing woke me until[br]several minutes had passed,

0:03:27.469,0:03:33.475
and I was being jerked awake, [br]and the room filled with people and panic.

0:03:36.969,0:03:40.692
Imagine if you were that nurse,[br]if you had done what she had done.

0:03:41.508,0:03:45.015
You're doing your job, [br]a demanding job, an important job,

0:03:45.263,0:03:48.247
and you do something[br]that causes someone to die.

0:03:49.421,0:03:52.906
A beautiful child dies because you think [br]you're doing a good thing.

0:03:54.810,0:03:56.401
Then your shift is over,

0:03:56.522,0:03:59.703
and you have to look his mother [br]in the eye and tell her good-bye.

0:04:00.351,0:04:03.584
And the next day, you're expected[br]to go back to your job,

0:04:03.824,0:04:06.455
carry on, go about your business,

0:04:06.732,0:04:11.755
all the while hoping and trusting[br]that nothing else terrible happens.

0:04:13.432,0:04:17.824
I could never do that job.[br]I'm not that brave.

0:04:20.444,0:04:24.364
My response to what happened[br]to Gabriel is not unique.

0:04:25.245,0:04:28.891
Like most people who have[br]experienced errors in medical care,

0:04:29.261,0:04:31.001
we want three things:

0:04:31.591,0:04:35.534
we want an honest, transparent[br]explanation of what has happened;

0:04:36.889,0:04:38.541
we want a full apology;

0:04:39.274,0:04:43.994
and we want to know and see[br]that changes have been made

0:04:43.994,0:04:48.086
to ensure that what has happened to us,[br]never happens to anyone else.

0:04:50.019,0:04:54.260
Unlike what we can see nightly[br]in television courtroom dramas,

0:04:54.388,0:04:56.792
people don't immediately seek lawyers.

0:04:57.541,0:05:00.121
We want answers, not money.

0:05:01.064,0:05:04.970
People hire lawyers because they[br]feel deceived and abandoned.

0:05:06.013,0:05:10.214
It is a very emotionally[br]and financially expensive last resort

0:05:11.420,0:05:13.016
that none of us want to do.

0:05:15.287,0:05:18.555
And the thing is,[br]we all make mistakes.

0:05:19.163,0:05:23.052
It's just that for most of us,[br]the consequences are pretty small.

0:05:24.465,0:05:27.650
I don't hit the submit button[br]in my online banking account,

0:05:28.316,0:05:31.120
and the power company gets paid late[br]and I get a little fee.

0:05:32.191,0:05:36.612
Or I forget that on Wednesdays[br]school gets out early,

0:05:36.964,0:05:39.740
and my daughter is annoyed[br]when I'm late to pick her up.

0:05:40.198,0:05:43.237
I'm annoying, so,[br]pretty used to that.

0:05:45.686,0:05:50.044
We all know that the power company[br]doesn't expect a whole lot from me.

0:05:50.144,0:05:53.609
And I hope my daughter knows[br]that though I may be late,

0:05:54.107,0:05:56.597
she also knows I'm[br]always going to be there.

0:05:57.540,0:06:01.209
But we expect so much more[br]from people in medicine.

0:06:02.620,0:06:04.901
We trust them with what [br]we value the most,

0:06:05.570,0:06:07.275
our lives and our loved ones.

0:06:07.906,0:06:10.650
And then expect impossible perfection.

0:06:12.242,0:06:15.908
We want the human element [br]when it means kindness and compassion,

0:06:16.530,0:06:19.775
like the nurse trying to get us[br]a couple hours of sleep,

0:06:20.233,0:06:22.775
but we deny it when it means[br]possible failure.

0:06:24.652,0:06:27.676
We're never going to have it both ways.

0:06:30.058,0:06:34.177
The day after he died, Gabriel's nurse[br]left that hospital for good.

0:06:35.404,0:06:37.202
I hope she was not fired.

0:06:38.323,0:06:39.850
Legally, I cannot be told,

0:06:39.850,0:06:43.102
but I know she never returned [br]to that children's hospital.

0:06:43.801,0:06:47.071
And I get it. I wouldn't be able[br]to go back there either.

0:06:47.879,0:06:52.174
And one of the pediatric neurosurgeons[br]who took care of Gabriel,

0:06:52.174,0:06:55.051
he later quit practicing [br]medicine altogether.

0:06:56.303,0:06:59.610
All of their expertise[br]and wisdom and experience

0:07:00.408,0:07:02.578
is no longer helping children.

0:07:04.054,0:07:10.105
That is another tragedy[br]and another very expensive system failure.

0:07:13.712,0:07:19.079
Unfortunately, hospital adminstrators[br]don't tend to respond to medical errors

0:07:19.425,0:07:21.497
with openness and transparency.

0:07:22.254,0:07:25.354
They react with a legal version[br]of fight or flight.

0:07:25.903,0:07:27.591
"Deny and Defend."

0:07:27.982,0:07:33.320
This means, keep your head down, shut up, [br]and let the lawyers handle everything.

0:07:34.436,0:07:38.311
This is a very dangerous[br]and expensive response,

0:07:38.846,0:07:41.385
that we all should be [br]concerned about.

0:07:42.461,0:07:46.577
It would have been easy[br]for the university hospital administrators

0:07:46.867,0:07:50.824
to blame the nurse, fire her, [br]and assume the problem had been solved

0:07:51.108,0:07:53.157
because the bad apple was gone.

0:07:54.379,0:07:57.386
It would have been typical[br]deny-and-defend behavior

0:07:57.656,0:07:59.815
for them to ignore my questions,

0:08:00.060,0:08:05.116
to go silent, and hope I couldn't gather [br]my thoughts enough to file a law suit.

0:08:06.502,0:08:08.326
It would have been a safe bet.

0:08:09.405,0:08:11.006
But they didn't do that.

0:08:11.296,0:08:13.142
They didn't prey on my vulnerability.

0:08:14.081,0:08:19.800
Instead, they investigated,[br]they explained, took responsibility,

0:08:20.060,0:08:21.560
and apologized.

0:08:22.620,0:08:25.135
Then they asked me[br]what else they could do.

0:08:25.975,0:08:27.846
It made all of the difference.

0:08:30.722,0:08:34.606
Transparency in medicine[br]can help heal our medical system,

0:08:35.551,0:08:38.426
and we all know that it[br]needs a lot of help.

0:08:39.754,0:08:42.903
By being open and honest[br]when the unexpected happens,

0:08:43.447,0:08:45.485
we can learn from our mistakes.

0:08:46.050,0:08:50.313
We can find the deadly system failures,[br]and we can act to fix them.

0:08:52.237,0:08:56.018
After the university hospital[br]investigated Gabriel's death

0:08:56.483,0:08:59.503
and the weakness[br]in the monitors was discovered,

0:09:00.534,0:09:03.110
all other hospitals[br]using the same equipment

0:09:03.236,0:09:05.586
were alerted to the vulnerability.

0:09:06.838,0:09:09.048
Maybe, that helped someone else,

0:09:09.874,0:09:11.134
I will never know.

0:09:11.134,0:09:14.254
But it still comforts me now.

0:09:18.204,0:09:24.082
After he died, the little plastic ID band[br]that was around his tiny wrist,

0:09:24.082,0:09:26.132
should have been slipped onto mine.

0:09:27.056,0:09:30.246
There was nothing more [br]that could have been done for him,

0:09:30.458,0:09:33.108
but there was plenty[br]that needed to be done for me.

0:09:34.432,0:09:37.352
I needed an infusion[br]of truth and compassion.

0:09:38.352,0:09:41.022
And the nurses and doctors [br]who took care of him,

0:09:41.244,0:09:43.177
they needed it too.

0:09:43.623,0:09:47.051
We all should have been given[br]ID bands and become patients that day.

0:09:50.150,0:09:54.544
Death is a full stop[br]for the patient in the hospital bed,

0:09:54.916,0:09:58.137
but it is only just a very [br]terrible beginning

0:09:58.272,0:10:00.043
for the survivors left in the room.

0:10:01.814,0:10:04.475
Hospitals should extend[br]their care to these people

0:10:04.832,0:10:08.227
because the impact[br]of these kind of experiences

0:10:09.169,0:10:11.664
is slow, painfull and toxic.

0:10:12.995,0:10:16.939
This is how transparency [br]can help the survivors.

0:10:19.370,0:10:21.243
And these kind of experiences,[br]

0:10:21.704,0:10:25.213
they demand that we relive them,[br]over and over again.

0:10:25.988,0:10:30.969
And those memories become [br]dense and strong, like thick black coffee.

0:10:31.993,0:10:33.942
And just like too much caffeine,[br]

0:10:34.644,0:10:39.019
that reliving keeps us up at night[br]and can make us a bit sick.

0:10:43.424,0:10:48.540
And the parts of these visions[br]and memories that we have,

0:10:49.199,0:10:51.872
the parts that don't [br]make sense and are unclear,

0:10:53.264,0:10:55.658
they become void, so we fill them in.

0:10:57.016,0:11:00.508
This phenomenon is translated[br]directly from Latin

0:11:01.189,0:11:02.950
as "making shit up."

0:11:05.567,0:11:07.770
We wonder if things could[br]have been different.

0:11:08.680,0:11:10.210
We feel guilty.

0:11:10.640,0:11:13.448
Maybe we place blame[br]where it doesn't belong.

0:11:14.814,0:11:17.185
This is how transparency is healing.

0:11:17.734,0:11:23.579
It finds truth, and it can take away [br]the infection of guilt and doubt.

0:11:27.263,0:11:30.782
Gabriel was treated[br]at two different hospitals.

0:11:31.817,0:11:35.175
He died because of mistakes[br]made at both of them.

0:11:35.795,0:11:38.869
Accidents that no one [br]wanted to have happened.

0:11:40.089,0:11:44.612
But how I was treated[br]after he died was no accident.

0:11:45.389,0:11:49.562
How they responded to those mistakes[br]was very deliberate.

0:11:50.975,0:11:54.776
Both had the opportunity[br]to learn from my son's death

0:11:54.920,0:11:56.601
and be transparent.

0:11:57.444,0:11:58.904
But only one did.

0:11:59.538,0:12:02.999
So, though I really wish I didn't,

0:12:03.870,0:12:07.136
I know both sides[br]of the transparency coin.

0:12:08.765,0:12:14.086
The university hospital didn't hide[br]behind legal maneuvers and dismiss me.

0:12:15.175,0:12:20.459
They learned, they explained and they [br]changed the procedures in their hospital

0:12:20.854,0:12:24.822
to ensure that all of the children[br]who were patients there were safer.

0:12:26.858,0:12:30.919
Now, they encourage me[br]to share my ideas,

0:12:31.542,0:12:33.067
they seek out my opinions,

0:12:34.007,0:12:37.286
and they value what I[br]have learned from Gabriel dying.

0:12:38.879,0:12:41.727
They give me the opportunity [br]to help people.

0:12:42.740,0:12:45.120
And that makes his life bigger.

0:12:48.425,0:12:51.415
But the local hospital ignored me.

0:12:54.429,0:12:58.334
By going silent, [br]they didn't just humiliate me,

0:12:59.441,0:13:01.812
they denied Gabriel his dignity.

0:13:03.993,0:13:06.083
And after more than eight years,

0:13:06.553,0:13:10.565
that wound is very far from healing.

0:13:14.627,0:13:17.547
I wish the story[br]I just told you was rare,

0:13:18.526,0:13:20.156
but it is not.

0:13:20.828,0:13:22.691
Errors in healthcare are common.

0:13:23.516,0:13:26.102
The exact numbers are hard to determine -

0:13:26.284,0:13:29.014
this is another side effect[br]of deny and defend.

0:13:29.799,0:13:31.822
But a shocking accepted number

0:13:31.822,0:13:35.772
is that 100,000 people[br]will die in the US this year

0:13:36.043,0:13:37.953
because of preventable mistakes.

0:13:38.983,0:13:44.147
This means, this year, there will be[br]100,000 opportunities to learn.

0:13:45.752,0:13:48.778
100,000 lives we should honor,

0:13:50.262,0:13:56.992
100,000 opportunities to choose [br]truth and compassion over deny and defend.

0:14:00.429,0:14:02.791
I know what I'm asking for is big.

0:14:03.994,0:14:05.793
I want a culture change.

0:14:07.202,0:14:09.590
Maybe I'm talking about a revolution.

0:14:11.077,0:14:13.368
And I know what the opponents say,

0:14:13.835,0:14:19.077
that transparency in medicine[br]would just be a field day for the lawyers,

0:14:19.873,0:14:22.064
insurance companies will never play along,

0:14:23.430,0:14:28.686
and the already busy hospitals [br]would just be distracted by it.

0:14:30.529,0:14:35.253
But case after case, study after study [br]proves the opponents wrong.

0:14:36.804,0:14:41.102
Transparency in medicine will [br]save us money and make us all safer.

0:14:43.038,0:14:45.927
Those are both good and nobel pursuits,

0:14:47.057,0:14:48.790
but it's not why we should do it.

0:14:49.944,0:14:52.351
We should do it because eventually,

0:14:52.351,0:14:56.181
we all are going to need[br]to wear one of those plastic ID bands.

0:14:57.795,0:15:02.434
Eventually, we all are going to need[br]the good, healing medicine

0:15:02.885,0:15:04.428
of truth and compassion.

0:15:05.716,0:15:06.877
Thank you.

0:15:06.877,0:15:09.907
(Applause)