Okay, okay, okay. I got 50 zillion million. Not really. I'm exaggerating a tiny bit. I got kind of a lot of response to talk about this SPS story. And so therefore I will, I think. Hey, everybody. Todd Conklin, Pre-Accident Investigation Podcast. How are you? So it's another week. Very exciting. I'm trying to think of all the exciting stuff I did this week. A little tiny bit of travel. I had some travel this week and travel is not getting more fun. darn it. I want it to be. I mean, it's my dream for it to get more fun. It's not, you know, I have real mixed emotions. Should I complain much? Because I think it gets tedious to complain about. So I don't really complain about it. And I'm tired of cold, but you knew that was coming. That cannot be a surprise to you. And actually, I'm really trying not to complain about that because, you know, I think that gets super tedious. What I ought to do is really talk about the feedback we got on this conference we're having at the end of March. March 31st, April 1st, Santa Fe. So remember, it's pretty small by design. And also because that's what the hotel, it's not like a big auditorium. It's just like a double conference room thing. And so it's, if you're interested, we'd love to have you. So we're, it's going to be limited, but I'm not very good at saying no. So I'll work hard to get everybody worked in if we can possibly work you in. I think it's going to be a remarkably interesting couple of days. So I know it is because you don't often get to sit down and talk about an event sort of that's happened in the past in the present. I mean, we're going to be in the present because that's all we got. But one of the interesting things about that is that we not only are going to really look at this event, but we're going to look carefully at the conditions that are necessary to make this failure happen. Remember, the whole premise is that accidents are an unexpected combination of normal performance variability. So that's exciting and coming up. But what really got interesting is when I started talking about sort of the little story that I became very interested in when it relates to this patient safety program, the Society for Patient Safety, the Pediatric Hospital, Children's Hospital's safety, patient safety program. Because, you know, I only have a couple rules. I think I've told you this before. You should never sit by the bathroom on an airplane. That is a very important rule. And two is little kids shouldn't die. I mean, they shouldn't. We should have a world that embraces little children, that all of us have a vested and shared interest in creating an environment where children can flourish and grow and develop and become amazing people, because that's who we're giving the world to, right? So, fair enough. So, they asked me to get involved, and I chose to get involved. So, that's the story that I think we should probably tell at the podcast today, just as you guys asked me to. So it was a couple of years ago, and I get this email, and it says, hey, can you come and be a part of our patient safety conference? We're an organization that is in charge of, not in charge of, but it's a consolidated group of many children's hospitals who are very interested in patient safety. And patient safety is really a tough nut to crack because there's just so many complex relationships. And hospitals are places where it's just, it's a really interesting risk relationship because people go to hospitals when they're really sick. And so not everybody survives the hospital because they went there because they're really sick. But some people get sick because of the hospital. And the patient safety complexities, lots of people have been doing really interesting, great stuff. Like David Marks, almost entirely. He wrote the book called Whack if you remember that from years ago He focused entirely on hospitals And hospitals they really they kind of they sort of Frankenstein They developed And you heard me talk about this before, especially with people who do patient safety. They're very complex operations that are sort of bolted together and good people have done diligent work to get them to do things, but they're really, really, really interesting organizations in that people who are good at running hospitals are not that good at patient safety, and people who are really good at running patient safety aren't that good at running hospitals. So there's a real delineation, and there's a lot of pressure between efficiency and thoroughness. It's a classic organizational relationship, and we're all sort of familiar with what that looks like, so that's kind of what happens. Well, I get this call and they say, we're going to have this meeting in San Antonio. Well, any meeting in San Antonio is worth having because San Antonio is the home of the puffy taco. And the puffy taco is a remarkably great thing to eat and the best ones. And there are many good ones available in many places. But San Antonio is also the home of really good food trucks. So you have to kind of talk around and find them and get them. And they're delicious. I mean, it's It's completely worthwhile. So I said, I'd love to do this meeting. It'd be great fun to do it. Let's have puffy tacos. And that was the deal. We're going to have puffy tacos, do the meeting. Everything's going to be great. I get to San Antonio and the facility's bigger than I thought it would be because I thought it would be like, you know, 50 people or 60 people. But there were hundreds and hundreds and hundreds of people at this meeting and it was really fun. And they started talking about this journey they had taken into the new proactive view of safety that they picked up from industry, from us. And they were pretty well versed in the new safety stuff that we talk about. And they had just gone out and tried it. And one of the things they tried was to actively engage learning teams. So taking pediatric nursing, especially in like ICUs, intensive care units, and getting them together. And they started to tackle a problem. Now, one of the things I learned really quickly is that their metrics change based upon the problems that they have, which I actually think is an important lesson for us to learn in industry. And so the current metric they were working on was something called extubation, not intubation. That's where you stick a hose in a person and breathe for them. Extubation is when the hose accidentally gets pulled out, or I guess maybe purposely pulled out. That would be extubation too. And they had had a really interesting challenge with this. And this challenge was perfectly suited, they thought, and I would agree completely, to actually use some of these new safety ideas. They call them proactive safety ideas, which is as good a name as any. And so they just did it. They didn't wait for anybody to sort of give them permission, which is kind of one of the reasons I like children's hospitals is they don't really wait for permission. They just improve. And because they weren't really waiting for permission, they just took off and did it. And what's interesting is that they began this unplanned extubation. That's where the hose, the baby moves and the hose pulls out, right? And then the baby can't breathe and the baby has a heart attack or even worse, the baby could die, right? They started this work in 2016, so pre-pandemic. And historically, this type of event, this type of accident, this type of harm, this unplanned extubation had been normalized in children's hospitals with rates over one unplanned extubation for every 100 ventilator days. So for every 100 days, they would have one of these events with horrible consequences. And in some hospitals, this equated to one unplanned extubation every few days in their intensive care units. So big hospitals would have a lot of these. And they kind of normalized to this number, and they couldn't really get a beat on it. And there lots of reasons why I mean lots of reasons why But ultimately little babies are kind of wiry and jumpy and roly and their skin is like paper So you can really tape anything to their skin and they're sweaty and oily because they're little babies and they're in an ICU. And so it was really difficult to get this tube to stay put. And the sweet spot for this tube was only a couple millimeters. So accuracy really mattered. Then they gathered additional data. This came later that said that African-American, that black children experienced unplanned extubation rates approximately three standard deviations higher than what the network had found for all the other races or ethnicities of the babies. So they found that this was happening a lot. And then in some children, it was happening a lot, lot, three times the standard deviation. So quite a few more times. And this problem sort of presented itself as a significant problem, an area of improvement, or as we would say, a hazard, a big fat hazard. And so in early 2023, the Society for Patient Safety, this conglomeration of children's hospitals, they began their journey towards thinking about safety in a new way. And they were really influenced by the concepts from HOP. And so because they were influenced from what we were talking about, we've been talking about this for years. As part of this work, the organization introduced the proactive safety tools that aligned with these following principles. Learning teams, walk-through talk-throughs, and then proactive safety huddles. So pre-jobs, simulations, and then learning teams. And what's amazing is that the entire network, all these hospitals across North America started to just test these new ideas because what'd they have to lose? They had a significant hazard that had significant consequences. So anything they did probably wasn't going to make it worse. And if it made it worse, they'd stop it immediately. Almost everything they do would help them get better. And so they deliberately chose a hazard area, and then they deliberately chose to gather information and to test, to try things out. And 99 hospitals tested, the example that comes up, learning teams. 99 hospitals put together learning teams. Then, because they started getting this data, because when you go out and ask nurses what the problem is, help identify the problem, and then help us identify the solution, you start to get information. They formed a cohort, a group of 72 of these hospitals to actually go out and test the safety huddles, to really look at where the highest risk for unplanned extubations existed. And between July 2024 and February 2025, this cohort reduced unplanned extubations in the neonatal ICU across the 72 hospitals by 20%, equating that to about 274 children that didn't die. it gets kind of harder to tell the story because I think we think our work is important. I don't think we don't think our work is important, but we don't often get a lot of payoffs like that because if we do our job really well, nothing happens. But in this case, these guys were able to equate these 20% improvement things to actually children that lived. And since SPS began this work, the rate of these unplanned extubations in all of the hospitals that share this data has decreased now by 60%. That's 12,500 children who didn't die. And as the rates have improved over the past few years the outcomes for black or African patients have improved at an even faster pace And that substantially narrowed that gap that times three standard deviation and brought everybody into normal. Because of this success, the success of the learning teams and the proactive safety huddles and understanding sort of how improvement happens, and how expertise lives operationally at every level of the organization. They're really looking at advancing these ideas and are. It's exciting and I think incredibly touching to see and hear examples of what this work does. And I bet you can just tell just from the story I told how interesting this is for a non-medical person who only has two rules, don't sit by the toilet and babies shouldn't die, to listen to this level of improvement, sustainable improvement. I mean, they've been on this a while. And what it's done is it's reacculturated and helped them redefine this problem. So their solutions actually were novel solutions that came from the worker, from the coalface, from the people who were touching the work. I think we call them blue line solutions. I know Bob would. Blue line solutions. And what's interesting is that they've made a difference. So you can kind of see why bringing people together for a meeting was important to me, really important to me. But I think what's more important to me is for us to tell this story to each other. Because the story I just told you, the data is all real. I'm not making it up. I mean, those are real numbers. Those are real little babies who didn't experience harm. And a lot of that is because of the work you're doing in your organization. You play an important role. And the ideas and the arguments and the discussions we have, the people who get angry and write mean emails, the people who try things and boldly go out to fail, but they fail quickly and they learn even quicker. All of that is a part of this story. All of that is a part of how this development happened. And I think that's a pretty exciting thing to think about. I think that's a big part of why we do what we do. So you can see that the chance to get together with people who do this for a living and talk about it, even in the midst of telling the story of a failure where somebody went to jail, that opportunity is a pretty good opportunity. opportunity. Too good to miss for sure. So that's the data from SPS around unplanned extubations. I can't even say that word. And it makes me kind of emotional. I mean, it really impacts me because I think that means the work we're doing has some real payoffs and makes a real difference. And I'm proud to have been on this journey with you guys because it's been fun and we've learned a lot. Think how much we've changed. Think how much we've learned and how much we've grown. It's a big part of the story, that's for sure. Well, that's the pod. Thanks for pushing me to tell this because I kind of thought I would skip it and not tell it, but I think it's worth telling. So thanks for making me do that. That's made a huge difference. Until then, remember the things we talked about, March 31st and April 1st. We'll see. There's probably space if you want to go. If not, we'll record some stuff and give you some notes and tell you what took place, because I promise you we can do that. Until then, learn something new every single day. Be good to each other. Be kind to each other. Take care of the strangers among us. Be good to the least of us. Learn something new every single day And have as much fun as you possibly can And until then I'll see you soon But be safe
