Okay, sounds good. It's easy. It's easy to make a piece of it. I have nothing prepared, so we'll talk. Well, that's the very best podcast you can have is nothing prepared. I think prepared podcasts will sound prepared. Hey, everybody, and welcome to the Pre-Extended Investigation Podcast. I am Todd Conklin. How are you? it's so good to hang out with you. I mean that, that sounds weak and cheap, but it's not. It's totally sincere, as sincere as I can be. I'm trying to think what exciting things I have to tell you, which of course are many, but I think we'll hit a lot of them today. So you heard me kind of talk earlier about this potential workshop that we're talking about haven't, I can't even talk. And it's kind of an interesting story in that it was originally scheduled. And then because of some, I would just call them logistical details. I mean, if you ever want to know the dirt on it, the dirty dirt, you know, come see me, I'll give you the lowdown, blowdown on it. But because of some logistical complexities, complications, something, figure out a good word for him. It ended up not being feasible. But then I thought, man, we have Redonda. We have this incredibly compelling story of where error is criminalized, which I find super dangerous and super interesting. And we have all this plan kind of set up. We should go ahead and do it. So I just decided, well, if we're going to do it, I guess I have to do it. And so we're going to do it. So I made a few phone calls and Redonda was open for the last part of March. So we're really talking about March 31st and April Fool's Day, April 1st. And the conference will be in Santa Fe at the Hotel Santa Fe, because that's the town in which I live. Plus, it'll be, it's a good time to go. And I hooked up with Redonda and she was open and really kind of excited to do it. And I then called a friend of ours who I don't think honestly that she's been on the podcast, which I'm trying to think about this. And I don't know if Ann Liren has been on the podcast. She's from the Society for Patient Safety, SPS. And they're the guys that do patient safety for pediatric hospitals, really across North America. And so I called her and said, are you guys interested in this kind of meeting? Because I felt like it needed to have some medical horsies because I got zero, I got nothing. And so it all sort of spun up and it's happening. And if you've not worked with the SPS people and was at the Human and Organizational Learning Conference this summer. But more interestingly is just how much cool stuff they're doing. In fact, I think I'm going to actually do a recap podcast of kind of a little story that they tell, and I'll just kind of cover it. And that'll be interesting. That's coming up. I promise you that. But so Anne and I and Redonda got together and we just rolled with it. So that conference is happening. It is absolutely happening. And if you want to know more details on it, you can always just write office Todd Conklin at gmail.com. And that'll get you straight to Jay and the folks at Safety FM. And they can hook you up with what's going on. Now, it's not going to be too big. In fact, we'll talk about that. Maybe I should shut up a little and just take you right into the discussion. So today's podcast, Ann and I are going to talk about, ultimately what we're going to talk about is how in Redonda's case, an event is an unexpected combination of normal performance variation. And that idea is going to be really important to this conversation. And that's true always. Accidents are an unexpected combination of normal performance variability. That's how accidents happen. And that's almost always how accidents have happened. And if you go way back into the people who think about this, Hallnagel and Reason and those guys, that's kind of what they're going to tell you, is that accidents are an unexpected combination of normal performance variability. That's just how it is. And that's a really important part of this conversation. So listen, because Ann and I just had a little chat about this, because we were talking about this meeting, March 31st, April 1st, and we were talking about the potential for us to have this discussion. It's too important of a discussion not to have, and Redonda's at a place where she can talk about it. So without any further ado, let's listen to this conversation. I'm glad you're here. Hold on. You know, it's interesting, Todd, because when I think about the story, I've never met Redonda. I'm really looking forward to that. So can I interrupt you long enough to tell you a story? Yeah, sure. Okay. So, so I called Redonda and told her that this was on and I told her that the three of us were going to do it. And she said, oh my goodness, everything in my life has led up to this moment. And I thought, oh, that's what I'm about. I don't know what to say to that. And wow, cool. We should maybe get cookies or something. And she said, I'm so excited to get to hang out with the people from SPS. And she said, I've wanted to, but I've never met them. And I said, well, why haven't you met them? And she said, well, I don't know if they'd want to meet me. And I'm like, no, they do. Yeah. No, everyone wants to meet everyone. So this is a big, she's very excited to meet you. And so this will be great. It sounds like it's win, win, win then, because, yeah, well, that makes me feel great. And we'll just have a love fest in Santa Fe. But this case, so as I started to say, I obviously, along with everybody else who's paying attention to anything, heard about this case. And at first blush, the case is both tragic and exceptional. Yeah But what interesting about it as I think about it is that the more I learned the more tragic it is right Like there the you know obviously the loss of a human There's also the incredible damage to the career of what I'm beginning to understand is a passionate, caring, excellent nurse. Yes. There's the impact on the organization and its culture, its safety culture, and its organizational culture. And then this is the kind of case that has widespread reverberations. Nurses everywhere and healthcare people everywhere are hearing about this and having a reaction. So, yes, the more I learn, the more tragic. But what's interesting is, as I said, at first blush, it's exceptional. The more I learn about this case, the more I realize how unexceptional it is. and I think it's you know as I listen to the details and learn more about the details of it I do a lot of uh-huh yeah oh yeah okay yeah that's how it goes yeah that that's that's typical that's that makes a lot of sense seeing that before sure yeah yeah yeah and then there's the tragedy and so I think it's the combination of the fact that it's extremely tragic and remarkably unexceptional that makes it such a perfect opportunity for learning. And now if we add on to it, Redonda, who is just from all I can tell, just an amazingly lovely human who has the courage and to stand up in front of a bunch of people and share the story in an articulate way, I think we're all going to be pretty changed. I think so too. It's hard not to be touched by it. And you said something that's so important. You know, an accident is the unexpected combination of normal performance variability. So a patient safety event will always be an unexpected combination of normal things. So, and I think about this all the time. The accidents that I work with, it's not like aliens shot down an accident beam from Mars and something super unusual happened that has never happened before that, oh my gosh, And sometimes there are events like that, but they're super rare. I mean, really, really, really, really rare. Most of them are just normal variabilities that nurses and docs and physical therapists and welders and manufacturers, they just manage in real time all day long every day. And they're so unremarkable, Anne, that they don't ever hit the radar screen as something super unusual. I mean, they're just normal. What's amazing is when you put all the conditions together, which is what Redonda does really quite effectively in this story, you see all these individual conditions that had to exist in such a way so that this failure could succeed and succeed tragically. And I think that's a really interesting part of it. But to me, the payoff is in getting the opportunity to sit and talk about this event and really learn kind of retrospectively how we should be building systems that can help identify these conditions when they start to amass in such a way that things can happen. And that, I think, is a great opportunity. That's a huge part of what happens. And the chance to work with you guys and the patient safety efforts that you guys have done the last several years is so exciting to me just because you really use this in a tactical way. And you're making a difference in hospitals with little kids everywhere. I mean, it's kind of remarkable. Well, I'm pretty, thank you for that. And I am proud of the work that we're doing. I also know that there's just a tremendous appetite for exactly what you're talking about. Like, how can we think about this differently? How can we learn differently? Because we can't keep having these sorts of things happening. And it's even more frightening as a health care provider and person to hear about this case is even more frightening by how unremarkable it is. Because it's like, well, then, you know, by the grace of God, go I every day. What's the difference between? So how is it that we can learn? And so I think what one of the many things that I'm super excited about about this opportunity is learning from you kind of more of a framework for how to learn from cases like this and make the changes proactively in our organizations, put safeguards in place that are going to prevent tragedies like this from happening. And engaging that operational curiosity is really an important thing. And it's hard to do because things happen all the time. We've established that. And seeing this event as the potential opportunity to learn in the midst of all the tragedy, that's kind of a hard angle to take when every other pressure in the world is telling you either hide the information or make it difficult to achieve the farming of that information for liability. control and lots of other reasons, political, whatever reasons. And secondly, I think the opportunity to get better, you guys, this is what's so exciting about what you're doing with pediatric hospitals is you're making improvement a deliberate strategy. So we just have to get to a point where we're deliberately going to take two days at the end of March and 1st of April to talk about what do we do when things like this happen and how do we frame this and how do we tactically take this information so that it's factual and informational and has the potential to make us better while at the same time the hospital can manage it and do all the things they do. Do you think this meeting's better for medical people than non-medical people? What's your gut on that? Because to me, every meeting's good for everybody, but I don't know. Yeah. Well, I'm kind of in your camp that I doubt, I think I could probably like drag my mom along and she'd enjoy it. Exactly But so it I think that the case I you know I biased I biased Todd But I think that the medical people and maybe you know again exposed more to the on the pediatric side but they they ready to hear this They're ready to hear it in a different way. And, you know, there's sort of like an evolution in your in your ability to really promote real change. And I think that we're kind of like at step six in pediatrics out of how many, I don't know. But we've made our way a little bit. We're starting to, we've kind of been baptized in the new view, as you say. And we're seeing that the way that we've been doing it is clearly not right. And that we need to understand new approaches better. So I feel like I'm super excited about that group to hear about it. I hope that we also get representatives from adult medicine, because I think that the advantage that we have in pediatric medicine, at least in this country, is that we've got the vast majority of sizable children's hospitals engaged in the work together and sort of moving forward. And we can be kind of bold and nimble and just have people say, oh, those children's hospitals are doing some wackadoodle thing again and kind of get away with it. Those crazy nuts. Yeah, exactly. Those crazy. But the adult hospitals are locked in a little harder to like the old ways of thinking. I do know that I have learned so much from cases from other industries. I agree. So it feels pretty stingy to me to say this should just be for medical people, you know, because I feel like this is a, this is a, a, a, many, most, almost all of the cases like this that happen in medicine never get exposed to the light of day. So unlike like the airline industry, right. Yeah. Or something like that. Or construction. You're exactly right. I mean, let's make up a term. It would be mutually stingy. How about that? Mutually stingy if it were held to one industry. And part of that is because the opportunity to learn across industry is rich, rich, rich, rich, because it's easier to look objectively and say, oh, my God, that could be us. Oh, we're close to that. Right. So that opportunity is really good. Plus the fact, I think, the opportunity to bring other industry into this scenario would make a huge difference as well. Because I can tell you from my side, a lot of the things the hospitals do, or in Redonda's case, a lot of things that were being done were not unusual. But we would have a much more robust verification process just because we would. I mean, that's how we— Just part of your culture. Yeah, we would verify that much differently. Yeah, that's interesting. To me, the context of this case is so amazing that part of what I think is really cool is to come up with a way to really look at and capture those context pieces, those conditions. Because that's what you can start to look at and that's what you can learn from. Yeah. And I know that there's not a lot of time. So what are we, five weeks away or whatever? Yeah, yeah. I haven't looked at the calendar. So this one's kind of rushy-rush. part of the reason this conference is rushy rush is just because we're kind of reacting from not being able to have it earlier so it's a chance for everybody to kind of still have the conference and everything can happen well and part of it is because why wait we don't we don't need a lot of people at this so this is not one of those meetings where there'll be 500 people because we're doing it in Santa Fe because just in case you're wondering I live there and the food's good. And there's no bug. And we're bug free. So we're really looking at, you know, 50, 60, 70 people. So it's pretty small. But I would hope, like I would really hope through you guys, I've met a bunch of really interesting patient safety people from pretty big hospitals. I would hope they could sneak away and come to this. Yeah, that's what I'm hoping too. I'm going I'm going to try my best to shake the trees because they will, what I really like about the size of this too is that it can really be a conversation. You know, it's not going to be so big that you're just a big didactic thing that you're sitting in the back that we can actually have the opportunity to talk. And I would love to hear the perspectives and the insights of some of those people you're referring to. Because they're thinking about this kind of stuff. They're worried about it. Yeah, generally. They're trying to figure it out. And they'll be able to leave with some tactical ideas. Certainly some ideas for how to code information differently, how to collect information differently. And really what context to look for. The challenge that I think we're going to find, this is the part I'm excited about, is that to a great extent, the way Redonda told the story to the hospital gave the hospital everything it needed to pursue the outcome that Redonda got. And so when she talked about, I should have done this, I failed to do this, I didn't, I, you know, I should have, why I didn't do this, you know. And when people live in that counterfactual world of what failed to happen, then they're missing all the complexities that actually did happen. And so the story hospitals tell, or at least in this case, the story that's being told is the story of the event they wish they would have had and not the event that Redonda actually had. Actually happened. Yeah, that's interesting. And so it's much more difficult to improve when you talk about what didn't happen because you just tend to tell people, we'll do it better next time. What you really need to talk about is what did happen. And that opportunity, I think, is really exciting to talk about. It's a horrific event. I mean, it's a terrible thing. Terrible. But out of that, I think the potential to get better and the potential to motivate really an entire continent, maybe the entire globe, but certainly entire industries to think about things differently, that's pretty good. Because you're learning in SPS that thinking about it differently makes a difference. Exactly Exactly And it but you know it it hard It hard to get out of that that old framework I mean as you pointed out you know even Redonda her view of it is let me tell you all the things that I did wrong and all the mistakes I made And, you know, part of that is because she's just an incredibly lovely human. But part of that is the culture she grew up in, right, that we all grew up in in health care. And so it's not going to be that—it's not that easy for us to create a different frame. So I think, again, another reason why this really getting the chance to examine this case together, I think, is a unique opportunity and a potentially rich one. I think the other thing about the case that I find interesting is I have, I'm looking for, I have more questions about some of the things that are influenced people's behavior. And I, you know, yeah, I just, I, like, for example, I know that in many hospitals, what common pressures there are. And for like a super common one is throughput. And so discharging a patient. And so, and I remember, like, for example, the part of the case where she talked about how this patient was supposed to go home today, which again, adds to like the tragedy of it, right? Like she was almost better enough to go home. But that set off some alarms in my head because I know that when, that there's, that a very powerful goal in hospital operations is moving patients through. And so, and even you could, you know, there are parts of that that have to do with even the micro parts of her, of the patient getting the study and things like that and being off the unit. So it's, yeah, I mean, I'm just super excited to dig in a little further because I suspect that the group of us, when we put our heads to it, are going to expose some even more interesting aspects to it than maybe we might just kind of read in a book or, you know. Yeah, I think you're right. I think you're right. And just being a part of telling the story and being able to ask questions and fill in details. And yeah, I think it's exciting. I can't wait. I'm really excited to work with you, too. This will be fun. It is going to be fun, Todd. Well, you know, that is like 100% guaranteed. Yes. If there's a guarantee in this, it's going to be fun. We are going to have fun. Yes. Yes. It's the last thing we do, damn it. We're going to have fun. You got it. You got it. Well, thanks for talking to me. Hey, my pleasure. Anytime. I'm looking forward to talking to you some more and, most importantly, learning with you. Thank you for inspiring this, Todd. Really appreciate it. It just seemed like a ball was being dropped and we should not let it drop. That's what I kind of thought. Too great an opportunity. Yeah, let's not waste this away, especially because we're not looking for 9 million people. So, you know, we don't have to fill the stadium in Dallas. We just fill a little hotel conference room. There we go. So there we go. So sounds good. Thank you. Great. Great. Thank you. All right. So go have a great day. Go have a great trip wherever you're going. Yeah, whatever my adventure is. Yeah, whatever your adventure is. And I'll, I guess, I'm trying to think what else I need. Maybe if I just start by saying this is March 31st and April 1st at this place, that's probably enough information. Do we have a name for this? No, we should name it something. I don't know, something clever. We can think of it. I'll call Jay after this and see if we can make something happen. Okay. Sounds great. Because I do think we need a name, and he probably has a web address and all that stuff. He's probably got the fancy stuff. But, yeah, this is going to be great, Todd. All right. Thank you. Okay. Have a great day. Same to you. Have fun. Thanks for doing this. Bye-bye. You're welcome. Take care. Bye-bye. See what I tell you? Pretty good conversation, don't you think? I'm actually really excited. I've not met Redonda, so this will be kind of a cool thing. And I've not really worked directly with Ann. I've just worked next to her, beside her. It's probably a good way to say that. And so the opportunity, I think, for having really rich discussions. And the layout is a pretty smart layout. The first day we'll do kind of a fundamentals discussion because that's important to unify that vocabulary. Larry, then we'll hear the story. Then we're going to chart the story and you'll see how we're going to do that. That should be pretty interesting. And then out of that chart, we'll spend the next day talking about some tactics and some applications and kind of how we think about how the response happened and how we think about managing this response as we move into our organizations. And it doesn't mean it's it's certainly not vital that you're in medicine, although clearly that's going to be the topic, but I think the industry experience that you bring to the table will be pretty important. And it's a workshop. So, it's round tables and discussions, and it's a real chance to leave with some practical application and some new knowledge. I mean, that's the only reason I would go anyway. So, I think that's going to be important. And I also can guarantee that we're going to have as much fun as we can possibly squeeze in. I mean, I'm a big believer in that. So thank you, Ann. That was a great conversation. I hope I see you. I know that the deadline is really short. I'm sorry about that. It's just kind of how things played out. And so we don't have a lot of control in it, but we'll see how it goes anyway. I think it's got some high potential. So look forward to seeing you and you can check it out at officetoddconklin.officetoddconklin at gmail.com. I can't even think. I have no brain left. It's completely gone. And I promise you we can get you as much information as possible. It's just a couple of days, so it'll be in and out, and it's a pretty good time to be in Santa Fe. Until then, learn something new every single day. Have as much fun as you possibly can. Be good to each other. Be kind to each other. I think that's really important because I'm pretty concerned about the world right now. You know, be good to strangers. It makes a huge difference. And learn something new every single day. That's vital. Until then, be safe.
