[Script Info]
Title: 
[Events]
Format: Layer, Start, End, Style, Name, MarginL, MarginR, MarginV, Effect, Text
Dialogue: 0,0:00:21.61,0:00:24.93,Default,,0000,0000,0000,,The nurse grabbed the recliner\Nand jerked me awake.
Dialogue: 0,0:00:26.41,0:00:29.25,Default,,0000,0000,0000,,I heard "Code Blue"\Nand the room filled with people.
Dialogue: 0,0:00:31.02,0:00:33.48,Default,,0000,0000,0000,,In that instant, I knew he was gone.
Dialogue: 0,0:00:35.78,0:00:39.100,Default,,0000,0000,0000,,The doctors' words attempted optimism,\Nbut their faces betrayed them.
Dialogue: 0,0:00:41.56,0:00:43.70,Default,,0000,0000,0000,,The next hours were awful.
Dialogue: 0,0:00:45.88,0:00:49.08,Default,,0000,0000,0000,,My sweet boy had become\Na corpse hooked to machines.
Dialogue: 0,0:00:50.100,0:00:54.23,Default,,0000,0000,0000,,I sat next to him,\Nbegging him to come back to me.
Dialogue: 0,0:00:54.97,0:00:57.48,Default,,0000,0000,0000,,But really, I wanted to flee.
Dialogue: 0,0:00:58.02,0:01:00.52,Default,,0000,0000,0000,,I didn't want any of this to be happening.
Dialogue: 0,0:01:01.61,0:01:04.52,Default,,0000,0000,0000,,I wanted to wake up\Nstiff and uncomfortable
Dialogue: 0,0:01:04.52,0:01:06.92,Default,,0000,0000,0000,,in that ugly blue chair
Dialogue: 0,0:01:06.92,0:01:10.29,Default,,0000,0000,0000,,and realize it all was just\Na very bad dream.
Dialogue: 0,0:01:13.31,0:01:16.11,Default,,0000,0000,0000,,But this was far worse than a nightmare.
Dialogue: 0,0:01:16.95,0:01:21.38,Default,,0000,0000,0000,,My 20-month-old son had just died\Nin one of the country's leading hospitals.
Dialogue: 0,0:01:22.77,0:01:26.92,Default,,0000,0000,0000,,On Thursday he was sick\Nand on Tuesday he was dead.
Dialogue: 0,0:01:29.96,0:01:32.94,Default,,0000,0000,0000,,That night when he had been\Nadmitted to the hospital,
Dialogue: 0,0:01:33.06,0:01:36.82,Default,,0000,0000,0000,,white circles with wires were stuck \Nonto Gabriel's bare little chest
Dialogue: 0,0:01:36.98,0:01:39.32,Default,,0000,0000,0000,,to monitor his breathing and heartbeat.
Dialogue: 0,0:01:39.91,0:01:44.18,Default,,0000,0000,0000,,Every time he made the slightest \Nlittle wiggle, the alarms would go off.
Dialogue: 0,0:01:45.09,0:01:46.25,Default,,0000,0000,0000,,And they're loud.
Dialogue: 0,0:01:46.100,0:01:49.59,Default,,0000,0000,0000,,Every time we would almost be asleep,
Dialogue: 0,0:01:49.81,0:01:52.82,Default,,0000,0000,0000,,the racket and worry\Nwould start all over again.
Dialogue: 0,0:01:54.80,0:01:58.58,Default,,0000,0000,0000,,We'd already spent sleepless\Ndays and nights in my local hospital,
Dialogue: 0,0:01:59.18,0:02:02.27,Default,,0000,0000,0000,,where he had been misdiagnosed\Nagain and again.
Dialogue: 0,0:02:02.75,0:02:06.46,Default,,0000,0000,0000,,But now, we were in a university\Nhospital for children.
Dialogue: 0,0:02:07.56,0:02:13.23,Default,,0000,0000,0000,,Finally, here,\NI felt safe and very tired.
Dialogue: 0,0:02:15.45,0:02:17.87,Default,,0000,0000,0000,,And I'm sure the nurse\Ncould see how tired I was,
Dialogue: 0,0:02:17.96,0:02:20.01,Default,,0000,0000,0000,,and she wanted to take care of me too.
Dialogue: 0,0:02:20.56,0:02:22.30,Default,,0000,0000,0000,,So she did the logical thing,
Dialogue: 0,0:02:22.88,0:02:26.08,Default,,0000,0000,0000,,she turned off the alarms \Non the machine next to his bed.
Dialogue: 0,0:02:27.34,0:02:29.67,Default,,0000,0000,0000,,And I thanked her when she did it.
Dialogue: 0,0:02:29.78,0:02:34.85,Default,,0000,0000,0000,,I was so grateful for the prospect\Nof silence and sleep.
Dialogue: 0,0:02:36.59,0:02:40.47,Default,,0000,0000,0000,,Later, doctors and administrators \Nfrom the hospital would explain
Dialogue: 0,0:02:40.47,0:02:44.55,Default,,0000,0000,0000,,that actually, unknowingly,\Nshe had done a lot more.
Dialogue: 0,0:02:45.43,0:02:48.00,Default,,0000,0000,0000,,She hadn't just turned\Nthe racket off in the room,
Dialogue: 0,0:02:48.59,0:02:51.08,Default,,0000,0000,0000,,she turned off all\Nof the alarms everywhere:
Dialogue: 0,0:02:51.85,0:02:56.22,Default,,0000,0000,0000,,in his room, at the nurses' station\Nand on her pager.
Dialogue: 0,0:02:58.51,0:03:01.22,Default,,0000,0000,0000,,Later, the manufacturers\Nof the monitors would explain
Dialogue: 0,0:03:01.75,0:03:04.44,Default,,0000,0000,0000,,they didn't think anyone would\Ngo through the trouble
Dialogue: 0,0:03:04.64,0:03:07.64,Default,,0000,0000,0000,,of seven screens\Nto turn off all of the alarms.
Dialogue: 0,0:03:08.55,0:03:11.60,Default,,0000,0000,0000,,So, they didn't include\Na fail-safe to stop her.
Dialogue: 0,0:03:13.04,0:03:14.100,Default,,0000,0000,0000,,They were wrong.
Dialogue: 0,0:03:16.45,0:03:21.95,Default,,0000,0000,0000,,So, when Gabriel's heart stopped beating,\Nthere was no sound, just quiet.
Dialogue: 0,0:03:23.51,0:03:26.77,Default,,0000,0000,0000,,Nothing woke me until\Nseveral minutes had passed,
Dialogue: 0,0:03:27.47,0:03:33.48,Default,,0000,0000,0000,,and I was being jerked awake, \Nand the room filled with people and panic.
Dialogue: 0,0:03:36.97,0:03:40.69,Default,,0000,0000,0000,,Imagine if you were that nurse,\Nif you had done what she had done.
Dialogue: 0,0:03:41.51,0:03:45.02,Default,,0000,0000,0000,,You're doing your job, \Na demanding job, an important job,
Dialogue: 0,0:03:45.26,0:03:48.25,Default,,0000,0000,0000,,and you do something\Nthat causes someone to die.
Dialogue: 0,0:03:49.42,0:03:52.91,Default,,0000,0000,0000,,A beautiful child dies because you think \Nyou're doing a good thing.
Dialogue: 0,0:03:54.81,0:03:56.40,Default,,0000,0000,0000,,Then your shift is over,
Dialogue: 0,0:03:56.52,0:03:59.70,Default,,0000,0000,0000,,and you have to look his mother \Nin the eye and tell her good-bye.
Dialogue: 0,0:04:00.35,0:04:03.58,Default,,0000,0000,0000,,And the next day, you're expected\Nto go back to your job,
Dialogue: 0,0:04:03.82,0:04:06.46,Default,,0000,0000,0000,,carry on, go about your business,
Dialogue: 0,0:04:06.73,0:04:11.76,Default,,0000,0000,0000,,all the while hoping and trusting\Nthat nothing else terrible happens.
Dialogue: 0,0:04:13.43,0:04:17.82,Default,,0000,0000,0000,,I could never do that job.\NI'm not that brave.
Dialogue: 0,0:04:20.44,0:04:24.36,Default,,0000,0000,0000,,My response to what happened\Nto Gabriel is not unique.
Dialogue: 0,0:04:25.24,0:04:28.89,Default,,0000,0000,0000,,Like most people who have\Nexperienced errors in medical care,
Dialogue: 0,0:04:29.26,0:04:31.00,Default,,0000,0000,0000,,we want three things:
Dialogue: 0,0:04:31.59,0:04:35.53,Default,,0000,0000,0000,,we want an honest, transparent\Nexplanation of what has happened;
Dialogue: 0,0:04:36.89,0:04:38.54,Default,,0000,0000,0000,,we want a full apology;
Dialogue: 0,0:04:39.27,0:04:43.99,Default,,0000,0000,0000,,and we want to know and see\Nthat changes have been made
Dialogue: 0,0:04:43.99,0:04:48.09,Default,,0000,0000,0000,,to ensure that what has happened to us,\Nnever happens to anyone else.
Dialogue: 0,0:04:50.02,0:04:54.26,Default,,0000,0000,0000,,Unlike what we can see nightly\Nin television courtroom dramas,
Dialogue: 0,0:04:54.39,0:04:56.79,Default,,0000,0000,0000,,people don't immediately seek lawyers.
Dialogue: 0,0:04:57.54,0:05:00.12,Default,,0000,0000,0000,,We want answers, not money.
Dialogue: 0,0:05:01.06,0:05:04.97,Default,,0000,0000,0000,,People hire lawyers because they\Nfeel deceived and abandoned.
Dialogue: 0,0:05:06.01,0:05:10.21,Default,,0000,0000,0000,,It is a very emotionally\Nand financially expensive last resort
Dialogue: 0,0:05:11.42,0:05:13.02,Default,,0000,0000,0000,,that none of us want to do.
Dialogue: 0,0:05:15.29,0:05:18.56,Default,,0000,0000,0000,,And the thing is,\Nwe all make mistakes.
Dialogue: 0,0:05:19.16,0:05:23.05,Default,,0000,0000,0000,,It's just that for most of us,\Nthe consequences are pretty small.
Dialogue: 0,0:05:24.46,0:05:27.65,Default,,0000,0000,0000,,I don't hit the submit button\Nin my online banking account,
Dialogue: 0,0:05:28.32,0:05:31.12,Default,,0000,0000,0000,,and the power company gets paid late\Nand I get a little fee.
Dialogue: 0,0:05:32.19,0:05:36.61,Default,,0000,0000,0000,,Or I forget that on Wednesdays\Nschool gets out early,
Dialogue: 0,0:05:36.96,0:05:39.74,Default,,0000,0000,0000,,and my daughter is annoyed\Nwhen I'm late to pick her up.
Dialogue: 0,0:05:40.20,0:05:43.24,Default,,0000,0000,0000,,I'm annoying, so,\Npretty used to that.
Dialogue: 0,0:05:45.69,0:05:50.04,Default,,0000,0000,0000,,We all know that the power company\Ndoesn't expect a whole lot from me.
Dialogue: 0,0:05:50.14,0:05:53.61,Default,,0000,0000,0000,,And I hope my daughter knows\Nthat though I may be late,
Dialogue: 0,0:05:54.11,0:05:56.60,Default,,0000,0000,0000,,she also knows I'm\Nalways going to be there.
Dialogue: 0,0:05:57.54,0:06:01.21,Default,,0000,0000,0000,,But we expect so much more\Nfrom people in medicine.
Dialogue: 0,0:06:02.62,0:06:04.90,Default,,0000,0000,0000,,We trust them with what \Nwe value the most,
Dialogue: 0,0:06:05.57,0:06:07.28,Default,,0000,0000,0000,,our lives and our loved ones.
Dialogue: 0,0:06:07.91,0:06:10.65,Default,,0000,0000,0000,,And then expect impossible perfection.
Dialogue: 0,0:06:12.24,0:06:15.91,Default,,0000,0000,0000,,We want the human element \Nwhen it means kindness and compassion,
Dialogue: 0,0:06:16.53,0:06:19.78,Default,,0000,0000,0000,,like the nurse trying to get us\Na couple hours of sleep,
Dialogue: 0,0:06:20.23,0:06:22.78,Default,,0000,0000,0000,,but we deny it when it means\Npossible failure.
Dialogue: 0,0:06:24.65,0:06:27.68,Default,,0000,0000,0000,,We're never going to have it both ways.
Dialogue: 0,0:06:30.06,0:06:34.18,Default,,0000,0000,0000,,The day after he died, Gabriel's nurse\Nleft that hospital for good.
Dialogue: 0,0:06:35.40,0:06:37.20,Default,,0000,0000,0000,,I hope she was not fired.
Dialogue: 0,0:06:38.32,0:06:39.85,Default,,0000,0000,0000,,Legally, I cannot be told,
Dialogue: 0,0:06:39.85,0:06:43.10,Default,,0000,0000,0000,,but I know she never returned \Nto that children's hospital.
Dialogue: 0,0:06:43.80,0:06:47.07,Default,,0000,0000,0000,,And I get it. I wouldn't be able\Nto go back there either.
Dialogue: 0,0:06:47.88,0:06:52.17,Default,,0000,0000,0000,,And one of the pediatric neurosurgeons\Nwho took care of Gabriel,
Dialogue: 0,0:06:52.17,0:06:55.05,Default,,0000,0000,0000,,he later quit practicing \Nmedicine altogether.
Dialogue: 0,0:06:56.30,0:06:59.61,Default,,0000,0000,0000,,All of their expertise\Nand wisdom and experience
Dialogue: 0,0:07:00.41,0:07:02.58,Default,,0000,0000,0000,,is no longer helping children.
Dialogue: 0,0:07:04.05,0:07:10.10,Default,,0000,0000,0000,,That is another tragedy\Nand another very expensive system failure.
Dialogue: 0,0:07:13.71,0:07:19.08,Default,,0000,0000,0000,,Unfortunately, hospital adminstrators\Ndon't tend to respond to medical errors
Dialogue: 0,0:07:19.42,0:07:21.50,Default,,0000,0000,0000,,with openness and transparency.
Dialogue: 0,0:07:22.25,0:07:25.35,Default,,0000,0000,0000,,They react with a legal version\Nof fight or flight.
Dialogue: 0,0:07:25.90,0:07:27.59,Default,,0000,0000,0000,,"Deny and Defend."
Dialogue: 0,0:07:27.98,0:07:33.32,Default,,0000,0000,0000,,This means, keep your head down, shut up, \Nand let the lawyers handle everything.
Dialogue: 0,0:07:34.44,0:07:38.31,Default,,0000,0000,0000,,This is a very dangerous\Nand expensive response,
Dialogue: 0,0:07:38.85,0:07:41.38,Default,,0000,0000,0000,,that we all should be \Nconcerned about.
Dialogue: 0,0:07:42.46,0:07:46.58,Default,,0000,0000,0000,,It would have been easy\Nfor the university hospital administrators
Dialogue: 0,0:07:46.87,0:07:50.82,Default,,0000,0000,0000,,to blame the nurse, fire her, \Nand assume the problem had been solved
Dialogue: 0,0:07:51.11,0:07:53.16,Default,,0000,0000,0000,,because the bad apple was gone.
Dialogue: 0,0:07:54.38,0:07:57.39,Default,,0000,0000,0000,,It would have been typical\Ndeny-and-defend behavior
Dialogue: 0,0:07:57.66,0:07:59.82,Default,,0000,0000,0000,,for them to ignore my questions,
Dialogue: 0,0:08:00.06,0:08:05.12,Default,,0000,0000,0000,,to go silent, and hope I couldn't gather \Nmy thoughts enough to file a law suit.
Dialogue: 0,0:08:06.50,0:08:08.33,Default,,0000,0000,0000,,It would have been a safe bet.
Dialogue: 0,0:08:09.40,0:08:11.01,Default,,0000,0000,0000,,But they didn't do that.
Dialogue: 0,0:08:11.30,0:08:13.14,Default,,0000,0000,0000,,They didn't prey on my vulnerability.
Dialogue: 0,0:08:14.08,0:08:19.80,Default,,0000,0000,0000,,Instead, they investigated,\Nthey explained, took responsibility,
Dialogue: 0,0:08:20.06,0:08:21.56,Default,,0000,0000,0000,,and apologized.
Dialogue: 0,0:08:22.62,0:08:25.14,Default,,0000,0000,0000,,Then they asked me\Nwhat else they could do.
Dialogue: 0,0:08:25.98,0:08:27.85,Default,,0000,0000,0000,,It made all of the difference.
Dialogue: 0,0:08:30.72,0:08:34.61,Default,,0000,0000,0000,,Transparency in medicine\Ncan help heal our medical system,
Dialogue: 0,0:08:35.55,0:08:38.43,Default,,0000,0000,0000,,and we all know that it\Nneeds a lot of help.
Dialogue: 0,0:08:39.75,0:08:42.90,Default,,0000,0000,0000,,By being open and honest\Nwhen the unexpected happens,
Dialogue: 0,0:08:43.45,0:08:45.48,Default,,0000,0000,0000,,we can learn from our mistakes.
Dialogue: 0,0:08:46.05,0:08:50.31,Default,,0000,0000,0000,,We can find the deadly system failures,\Nand we can act to fix them.
Dialogue: 0,0:08:52.24,0:08:56.02,Default,,0000,0000,0000,,After the university hospital\Ninvestigated Gabriel's death
Dialogue: 0,0:08:56.48,0:08:59.50,Default,,0000,0000,0000,,and the weakness\Nin the monitors was discovered,
Dialogue: 0,0:09:00.53,0:09:03.11,Default,,0000,0000,0000,,all other hospitals\Nusing the same equipment
Dialogue: 0,0:09:03.24,0:09:05.59,Default,,0000,0000,0000,,were alerted to the vulnerability.
Dialogue: 0,0:09:06.84,0:09:09.05,Default,,0000,0000,0000,,Maybe, that helped someone else,
Dialogue: 0,0:09:09.87,0:09:11.13,Default,,0000,0000,0000,,I will never know.
Dialogue: 0,0:09:11.13,0:09:14.25,Default,,0000,0000,0000,,But it still comforts me now.
Dialogue: 0,0:09:18.20,0:09:24.08,Default,,0000,0000,0000,,After he died, the little plastic ID band\Nthat was around his tiny wrist,
Dialogue: 0,0:09:24.08,0:09:26.13,Default,,0000,0000,0000,,should have been slipped onto mine.
Dialogue: 0,0:09:27.06,0:09:30.25,Default,,0000,0000,0000,,There was nothing more \Nthat could have been done for him,
Dialogue: 0,0:09:30.46,0:09:33.11,Default,,0000,0000,0000,,but there was plenty\Nthat needed to be done for me.
Dialogue: 0,0:09:34.43,0:09:37.35,Default,,0000,0000,0000,,I needed an infusion\Nof truth and compassion.
Dialogue: 0,0:09:38.35,0:09:41.02,Default,,0000,0000,0000,,And the nurses and doctors \Nwho took care of him,
Dialogue: 0,0:09:41.24,0:09:43.18,Default,,0000,0000,0000,,they needed it too.
Dialogue: 0,0:09:43.62,0:09:47.05,Default,,0000,0000,0000,,We all should have been given\NID bands and become patients that day.
Dialogue: 0,0:09:50.15,0:09:54.54,Default,,0000,0000,0000,,Death is a full stop\Nfor the patient in the hospital bed,
Dialogue: 0,0:09:54.92,0:09:58.14,Default,,0000,0000,0000,,but it is only just a very \Nterrible beginning
Dialogue: 0,0:09:58.27,0:10:00.04,Default,,0000,0000,0000,,for the survivors left in the room.
Dialogue: 0,0:10:01.81,0:10:04.48,Default,,0000,0000,0000,,Hospitals should extend\Ntheir care to these people
Dialogue: 0,0:10:04.83,0:10:08.23,Default,,0000,0000,0000,,because the impact\Nof these kind of experiences
Dialogue: 0,0:10:09.17,0:10:11.66,Default,,0000,0000,0000,,is slow, painfull and toxic.
Dialogue: 0,0:10:12.100,0:10:16.94,Default,,0000,0000,0000,,This is how transparency \Ncan help the survivors.
Dialogue: 0,0:10:19.37,0:10:21.24,Default,,0000,0000,0000,,And these kind of experiences,\N
Dialogue: 0,0:10:21.70,0:10:25.21,Default,,0000,0000,0000,,they demand that we relive them,\Nover and over again.
Dialogue: 0,0:10:25.99,0:10:30.97,Default,,0000,0000,0000,,And those memories become \Ndense and strong, like thick black coffee.
Dialogue: 0,0:10:31.99,0:10:33.94,Default,,0000,0000,0000,,And just like too much caffeine,\N
Dialogue: 0,0:10:34.64,0:10:39.02,Default,,0000,0000,0000,,that reliving keeps us up at night\Nand can make us a bit sick.
Dialogue: 0,0:10:43.42,0:10:48.54,Default,,0000,0000,0000,,And the parts of these visions\Nand memories that we have,
Dialogue: 0,0:10:49.20,0:10:51.87,Default,,0000,0000,0000,,the parts that don't \Nmake sense and are unclear,
Dialogue: 0,0:10:53.26,0:10:55.66,Default,,0000,0000,0000,,they become void, so we fill them in.
Dialogue: 0,0:10:57.02,0:11:00.51,Default,,0000,0000,0000,,This phenomenon is translated\Ndirectly from Latin
Dialogue: 0,0:11:01.19,0:11:02.95,Default,,0000,0000,0000,,as "making shit up."
Dialogue: 0,0:11:05.57,0:11:07.77,Default,,0000,0000,0000,,We wonder if things could\Nhave been different.
Dialogue: 0,0:11:08.68,0:11:10.21,Default,,0000,0000,0000,,We feel guilty.
Dialogue: 0,0:11:10.64,0:11:13.45,Default,,0000,0000,0000,,Maybe we place blame\Nwhere it doesn't belong.
Dialogue: 0,0:11:14.81,0:11:17.18,Default,,0000,0000,0000,,This is how transparency is healing.
Dialogue: 0,0:11:17.73,0:11:23.58,Default,,0000,0000,0000,,It finds truth, and it can take away \Nthe infection of guilt and doubt.
Dialogue: 0,0:11:27.26,0:11:30.78,Default,,0000,0000,0000,,Gabriel was treated\Nat two different hospitals.
Dialogue: 0,0:11:31.82,0:11:35.18,Default,,0000,0000,0000,,He died because of mistakes\Nmade at both of them.
Dialogue: 0,0:11:35.80,0:11:38.87,Default,,0000,0000,0000,,Accidents that no one \Nwanted to have happened.
Dialogue: 0,0:11:40.09,0:11:44.61,Default,,0000,0000,0000,,But how I was treated\Nafter he died was no accident.
Dialogue: 0,0:11:45.39,0:11:49.56,Default,,0000,0000,0000,,How they responded to those mistakes\Nwas very deliberate.
Dialogue: 0,0:11:50.98,0:11:54.78,Default,,0000,0000,0000,,Both had the opportunity\Nto learn from my son's death
Dialogue: 0,0:11:54.92,0:11:56.60,Default,,0000,0000,0000,,and be transparent.
Dialogue: 0,0:11:57.44,0:11:58.90,Default,,0000,0000,0000,,But only one did.
Dialogue: 0,0:11:59.54,0:12:02.100,Default,,0000,0000,0000,,So, though I really wish I didn't,
Dialogue: 0,0:12:03.87,0:12:07.14,Default,,0000,0000,0000,,I know both sides\Nof the transparency coin.
Dialogue: 0,0:12:08.76,0:12:14.09,Default,,0000,0000,0000,,The university hospital didn't hide\Nbehind legal maneuvers and dismiss me.
Dialogue: 0,0:12:15.18,0:12:20.46,Default,,0000,0000,0000,,They learned, they explained and they \Nchanged the procedures in their hospital
Dialogue: 0,0:12:20.85,0:12:24.82,Default,,0000,0000,0000,,to ensure that all of the children\Nwho were patients there were safer.
Dialogue: 0,0:12:26.86,0:12:30.92,Default,,0000,0000,0000,,Now, they encourage me\Nto share my ideas,
Dialogue: 0,0:12:31.54,0:12:33.07,Default,,0000,0000,0000,,they seek out my opinions,
Dialogue: 0,0:12:34.01,0:12:37.29,Default,,0000,0000,0000,,and they value what I\Nhave learned from Gabriel dying.
Dialogue: 0,0:12:38.88,0:12:41.73,Default,,0000,0000,0000,,They give me the opportunity \Nto help people.
Dialogue: 0,0:12:42.74,0:12:45.12,Default,,0000,0000,0000,,And that makes his life bigger.
Dialogue: 0,0:12:48.42,0:12:51.42,Default,,0000,0000,0000,,But the local hospital ignored me.
Dialogue: 0,0:12:54.43,0:12:58.33,Default,,0000,0000,0000,,By going silent, \Nthey didn't just humiliate me,
Dialogue: 0,0:12:59.44,0:13:01.81,Default,,0000,0000,0000,,they denied Gabriel his dignity.
Dialogue: 0,0:13:03.99,0:13:06.08,Default,,0000,0000,0000,,And after more than eight years,
Dialogue: 0,0:13:06.55,0:13:10.56,Default,,0000,0000,0000,,that wound is very far from healing.
Dialogue: 0,0:13:14.63,0:13:17.55,Default,,0000,0000,0000,,I wish the story\NI just told you was rare,
Dialogue: 0,0:13:18.53,0:13:20.16,Default,,0000,0000,0000,,but it is not.
Dialogue: 0,0:13:20.83,0:13:22.69,Default,,0000,0000,0000,,Errors in healthcare are common.
Dialogue: 0,0:13:23.52,0:13:26.10,Default,,0000,0000,0000,,The exact numbers are hard to determine -
Dialogue: 0,0:13:26.28,0:13:29.01,Default,,0000,0000,0000,,this is another side effect\Nof deny and defend.
Dialogue: 0,0:13:29.80,0:13:31.82,Default,,0000,0000,0000,,But a shocking accepted number
Dialogue: 0,0:13:31.82,0:13:35.77,Default,,0000,0000,0000,,is that 100,000 people\Nwill die in the US this year
Dialogue: 0,0:13:36.04,0:13:37.95,Default,,0000,0000,0000,,because of preventable mistakes.
Dialogue: 0,0:13:38.98,0:13:44.15,Default,,0000,0000,0000,,This means, this year, there will be\N100,000 opportunities to learn.
Dialogue: 0,0:13:45.75,0:13:48.78,Default,,0000,0000,0000,,100,000 lives we should honor,
Dialogue: 0,0:13:50.26,0:13:56.99,Default,,0000,0000,0000,,100,000 opportunities to choose \Ntruth and compassion over deny and defend.
Dialogue: 0,0:14:00.43,0:14:02.79,Default,,0000,0000,0000,,I know what I'm asking for is big.
Dialogue: 0,0:14:03.99,0:14:05.79,Default,,0000,0000,0000,,I want a culture change.
Dialogue: 0,0:14:07.20,0:14:09.59,Default,,0000,0000,0000,,Maybe I'm talking about a revolution.
Dialogue: 0,0:14:11.08,0:14:13.37,Default,,0000,0000,0000,,And I know what the opponents say,
Dialogue: 0,0:14:13.84,0:14:19.08,Default,,0000,0000,0000,,that transparency in medicine\Nwould just be a field day for the lawyers,
Dialogue: 0,0:14:19.87,0:14:22.06,Default,,0000,0000,0000,,insurance companies will never play along,
Dialogue: 0,0:14:23.43,0:14:28.69,Default,,0000,0000,0000,,and the already busy hospitals \Nwould just be distracted by it.
Dialogue: 0,0:14:30.53,0:14:35.25,Default,,0000,0000,0000,,But case after case, study after study \Nproves the opponents wrong.
Dialogue: 0,0:14:36.80,0:14:41.10,Default,,0000,0000,0000,,Transparency in medicine will \Nsave us money and make us all safer.
Dialogue: 0,0:14:43.04,0:14:45.93,Default,,0000,0000,0000,,Those are both good and nobel pursuits,
Dialogue: 0,0:14:47.06,0:14:48.79,Default,,0000,0000,0000,,but it's not why we should do it.
Dialogue: 0,0:14:49.94,0:14:52.35,Default,,0000,0000,0000,,We should do it because eventually,
Dialogue: 0,0:14:52.35,0:14:56.18,Default,,0000,0000,0000,,we all are going to need\Nto wear one of those plastic ID bands.
Dialogue: 0,0:14:57.80,0:15:02.43,Default,,0000,0000,0000,,Eventually, we all are going to need\Nthe good, healing medicine
Dialogue: 0,0:15:02.88,0:15:04.43,Default,,0000,0000,0000,,of truth and compassion.
Dialogue: 0,0:15:05.72,0:15:06.88,Default,,0000,0000,0000,,Thank you.
Dialogue: 0,0:15:06.88,0:15:09.91,Default,,0000,0000,0000,,(Applause)