Episode 17: Engineering Systems for Safety

What can we learn from the havoc that the pandemic wrought on our emergency departments? How can we redesign healthcare systems for greater safety and resiliency? Join host Karen Wolk Feinstein and guests Dr. Chris LeMaster and Tina Vitale-McDowell, both emergency department leaders, for a dive into how systems engineering approaches can address some of the biggest challenges in healthcare safety and what we can learn from the lived experiences of our frontline workers.

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Episode Transcript

[00:00:00] Chris LeMaster: We don’t understand the differences between, say, simple systems and complex systems, which has a lot to say about how harm and adverse events occur.

[00:00:09] Tina Vitale-McDowell: You know, the idea that we’ve created a checklist and that makes, you know, everything okay, is irrelevant right now.

[00:00:18] Chris LeMaster: If you’re trying to understand why harm occurs or why an outcome is not the one that was desired, you really need that perspective, and you need to connect that group of people, those frontline experts with the operational leaders in the organization, the safety leaders, et cetera.

[00:00:34] Karen Wolk Feinstein: Welcome to the second season of Up Next for Patient Safety. We’re thrilled to continue to share conversations with the most interesting people, doing the most important work toward our common goal of making health care safer.

I’m your host, Karen Feinstein, president and CEO of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, which is a multi-stakeholder quality collaborative here in my hometown. We’ve been working to reduce medical error for over 25 years, and I will say at the start, we never believed the progress would be so slow.

However, I do know that revolutions come from hope and not despair. We hope these conversations will inspire all of us with hope as we hear from safety leaders of distinction. When it comes to healthcare system redesign, emergency departments should get first consideration. Ah, didn’t it seem obvious that the pandemic would wreak havoc on our ERs? As primary care practices and urgent care centers limited access, sick people had one place to turn. The pressure was unending, and as the ED nurses and physicians struggled to keep up with the volume, they faced another challenge. They couldn’t find beds in the hospital for the sickest patients. Why? Well, among other reasons, nursing homes were also besieged and often on lockdown. Hospitals couldn’t discharge fragile patients who couldn’t manage at home on their own.

So the ER was clogged as well with very ill patients who had nowhere to go. Then enter a new respiratory virus, RSV, to add to the mayhem. In some EDs, staff were treating people outside in tents, even here in the north and the dead of winter. So, weary and anxious staff resigned, retired and took extended leave as they felt inadequate to the task, and avoidable medical errors understandably increased.

So today we will be able to talk to a physician and nurse leader from two different California emergency departments. They’ll help us understand, number one, some of the best thinking from some of the best system engineers about how to redesign health care for safety and efficiency, and two, second, the reality of life at the frontline and the context in which we have to regard academic solutions.

So we’re so pleased to have both Chris LeMaster and Tina Vitale-McDowell here today. Dr. Chris LeMaster is the patient safety lead in the emergency department at a large hospital in California. For the last eight years, he’s helped to lead inquiries into near misses and adverse events with a focus on systems issues. His areas of interest include central line–associated bloodstream infections, diagnostic error, clinical decision support, and electronic health records, and the use of learning teams in health care.

Tina Vitale-McDowell is the director of an emergency department and another large hospital in California. She’s been an emergency department nurse for 23 years, moving into management right before COVID. Tina, that had to be a major challenge. She led the ED staff through the uncertainty of COVID, recognizing the importance of stories and experiences to support staff during a challenging time. She currently serves on several regional committees for both adult and pediatric initiatives, such as sepsis, patient handoff, and disaster management and works with emergency staff as a pediatric care coordinator. She champions pediatric readiness and safety regionally.

So, welcome both Tina and Chris. Thank you for all you do. So my first question is to Chris. You’ve convened an international group of safety experts from a wide range of disciplines, of which I’m honored to be part, who meet monthly to discuss frontier ideas for a healthcare system redesign that would advance patient safety. Can you share a bit about how you came to spearhead this group and what you’re hoping to accomplish?

[00:04:56] Chris LeMaster: That group, it started very organically, and it was actually in response to the Charlene Murphey death and the conviction of RaDonda Vaught in Tennessee for medication error. And part of what I was trying to do there is connect with a group of people who have some understanding of the underlying systems that were at play in that case. And you know, would it be possible to elevate that perspective? So that group began with a system safety engineer, Nancy Leveson, and one of her colleagues, a human factors engineer, a journalist and a few others. And one of the things that we really focused on was the design of the medication dispensing machines from a system safety engineering perspective and a human factors engineering perspective.

And then it just built from there and continued. So we’ve had many other discussions on various topics. It’s been really exciting and enjoyable. And I think the idea there is that we have a wide range of perspectives to think about safety because it is such a large, complex beast, and it’s virtually impossible for any one expert to tackle this problem alone.

[00:06:16] Karen Wolk Feinstein: Well, I will say having spent a good month with a group of anesthesiologists trying to understand what happened at Vanderbilt, there’s no doubt that the accident should have never happened. Good system design could have prevented something like this. So, Chris, I enjoy participating with the people you assembled.

Tina, you’re a valued member of this group because your insight and reality checks on life at the front line, not only are they incredible and sometimes startling and poignant, but they also bring us back to real life. So could you share a bit about the challenges that you and your team face on a daily basis that get in the way of providing the safest care possible?

[00:07:11] Tina Vitale-McDowell: Thanks, Karen. Yeah, I think there are maybe two or three things in particular. I can spend a lot of time talking about issues with access to health care and staffing and retention. I can talk a lot about, you know, changes in medical coverage, but I think what’s really at the core is a sense of what all humanity is facing. You know, we went through COVID, and we thought that our systems were more resilient, and we found out that they weren’t. And so, you know, we were faced with sort of this idea of these threats to our own mortality. You know, you’re seeing the great resignation. You’re seeing people wanting to find joy in life because they had this moment of, you know, my life’s gonna end. So healthcare workers, we took that on as well. So while we were giving care to patients, we were also experiencing those feelings ourselves. We had our own families that were suffering, you know, children that were injured with loneliness during the pandemic and, you know, our own health, our own access to care.

And we got sandwiched in between ourselves and the feeling of the struggles we were going through personally, and then being able to care for patients who were also going through the same thing ended up being this sort of sandwich in which we lost the connection. So we were both struggling at the same time. And that connection with our patients, the thing that is what’s valuable to all of us in health care, was lost. And I think that was really an important piece that feeds into patient safety and this idea of wanting to prevent harm, and I think we don’t go into it wanting to cause harm, but I think that this place that we’re in right now has made it really difficult for us to kind of step back into that healthcare provider role.

[00:08:56] Karen Wolk Feinstein: Well, I thank both of you. I don’t know how it didn’t take a toll to experience what you have. I know a leading doctor here who just had to take three weeks off. They just got to a point where the pressure was so relentless that they needed a break. So thank you so much. You both work at different facilities. But I like the fact that you’re working together to incorporate systems engineering design in emergency departments, and even in health systems as a whole. Could you give us some examples of how your organization and other organizations are using system design to improve safety?

[00:09:42] Chris LeMaster: Yeah, sure. I can start, Tina, and then you can go, if that’s all right. So we’re using a number of different tools, and part of what this group has been really helpful with is seeing that you don’t need just a single tool. And there’s, there’s great power in having, you know, many different things in your arsenal.

One of the things that’s been fantastic is something called learning teams, which is an approach that’s been used in the oil and gas industry and that really connects the hospital administrators with the frontline staff, who are the experts. The idea there is that when you’re trying to understand a process, and we can take a near miss or an adverse event, although it can be used for anything, it could be an operational success. To really understand that process, you need to understand the work as it’s done, and you can only get that from the frontline staff. This isn’t, you know, pandering to the frontline staff. They really are the experts because they are the ones who do it. If you’re trying to understand why harm occurs or why an outcome is not the one that was desired, you really need that perspective. And you need to connect that group of people, those frontline experts, with the operational leaders in the organization, the safety leaders, et cetera. And what you find is that there were system safety design issues that you just weren’t aware of. And this has led to some really interesting interventions that have helped with changes to our IT system, with the way that we screen for cancer, the way that we identify patients and avoid misidentification.

It’s been wonderful, and I’ve applied this both in the emergency department and in many other departments in the inpatient and the outpatient setting. It’s also very healing for the frontline staff who are participating because they’re empowered to lend their voice and be involved in system design changes.

[00:11:28] Karen Wolk Feinstein: So, Tina, can you follow up? Talk about ways in which you’re empowering your frontline team to provide safer care and make sure their voices are heard.

[00:11:40] Tina Vitale-McDowell: Yeah, I think, you know, as healthcare workers we’re not trained to be keepers of the system. I think we come in assuming the system is there for us to work, and I think we’ve all realized that the shift is really important for us to really understand, and I think it means providing that space. So one of the things that I’ve done with learning teams is when my staff is really frustrated about, you know, things that aren’t working or departments that are failing them and the resources that we need are not there, is spending the time together to really understand the work that they do. It takes away a lot of the stress and anxiety of everyday performance when you understand that there are challenges on the other side. Chris had mentioned this idea about work as imagined. I think, from leaders, we can’t live in that space at all. You know, the idea that we create a checklist and that that makes, you know, everything okay, is irrelevant right now. It’s been irrelevant, but it’s more irrelevant now when our resources are stretched, when we don’t have the capacity to be able to review policies and checklists and make them pertain to the complexities we’re facing currently. I think we’ve not built a lot of resiliency in our systems.

So there’s that piece. There’s bringing sort of the Gemba walk to everyone where, you know, we’re walking in other people’s shoes, and we’re understanding what their work is. It’s that psychological safety that doesn’t come from words. It’s not a poster that says, you know, “It’s safe to report here.” You can go ahead and do that. And what I’ve actually found is staff are more frustrated when they don’t know what the outcome is, when they’ve reported these issues over and over again and they have no idea about any work that’s being done for improving it. They feel powerless. So transparency is huge, and that’s one of the things that I’ve done with my staff is, you know, I’ve utilized the four Ds from Brent Sutton. You know, is it dumb, difficult? Is it dangerous? And tried to get their feedback on that. And we debrief often, and then I give them the feedback of what we’ve changed or what we need to do, and I think that’s been really important to empower the staff.

[00:13:41] Chris LeMaster: So, and you know, there’s good evidence to show that staff who don’t either know how to report events or don’t get feedback on those events, when that’s prevalent in a healthcare system, that hospital mortality rates go up. And part of that is ties into high reliability. If you’re a frontline staff person, you have a window into the reality and what all of the systems issues are that need to be addressed. We need to create a virtuous cycle where you speak up and that problem gets solved and you have the, you’re sort of conditioned, right? You have this feedback, you know, positive system design change, and then therefore you’re gonna speak up again. But when we don’t provide that feedback, it does the opposite. And then people stop, you know, they normalize these, these dangerous issues and then they don’t get addressed. And so this is one of the wonderful things that Tina does as she connects those folks to these larger-scale changes and makes sure that they’re involved so they know what’s happening and it really transforms the culture. Been wonderful to see.

[00:14:42] Tina Vitale-McDowell: I think the other piece is that globally in health care during COVID, there was all the sharing of ideas and sharing of practices and innovation and technology. And we really, you know, for the frontline workers, it might not have felt like it, but we lifted an entire system into another area, an arena that was never there before for good or bad. And I think that now we’ve all kind of retreated back into our own houses because we have to tidy them up. Our own houses are not kept as well as they were before. And that sense of sharing across healthcare systems has been lost. And I think that also impacts opportunities to focus on patient safety. If we had the ability to report and know that I’m not the only one that did that, or I’m not the only one that that’s to blame here, that this is sort of a common theme, like how amazing would that be if we were able to bring all of those things together and stop reinventing the wheel each time of recognizing common errors across the board?

[00:15:43] Karen Wolk Feinstein: Well, you know, I’ve seen healthcare leaders make big speeches and pay for billboards saying, you know, Our system really cares, right? We really care about patients, but I think it’s what you do as a leader, not what you say. So I had an incident of new surgical tape. It was cheaper surgical tape, but it gave big blisters. And the nurses tried to tell anyone who would listen, but they never got a response. And people, patients kept getting blisters, and after a while they start wondering, absent a real feedback loop, does anyone care? And I can’t imagine anything more demoralizing. So, I hear you Tina and I hear your team.

So one thing that’s been so interesting, Chris, is bringing in people outside health care to take a look at health care and hopefully they’ll have not only a perspective, but ideas about how do we relieve the stress so that there is less wasted effort and the systems are more efficient so the people could spend more time solving problems in the course of their work.

So you’ve both looked at some interesting incident causality models, STAMP, the system architecture modeling and CAST causal analysis systems theory. Just talk a little bit about how you might be using these techniques. How did other industries use them, and how can we adapt that to health care?

[00:17:22] Chris LeMaster: Yeah, that’s great. Yeah. The system safety engineering approach that Nancy Leveson uses, STAMP, and she sort of has two approaches there. One is called CAST, and that is a tool. It’s causal analysis using systems theory. It’s a tool used to think about an adverse event. Something’s happened and you’re trying to understand what the cause was. And the model uses feedback loops. So you’re looking for what they call “control structures,” these different elements in a system that influence how that system behaves. And they can say something about causality. One of the wonderful things about it is that it’s designed to think about how these feedback loops exist or don’t exist at multiple levels within the system. So, if you take for example, patient misidentification in the emergency department, the information that, well, let’s just talk about patients coming in by ambulance. The information that an EMS worker gets from a bystander or the patient or family is imperfect, so they may have the wrong name or date of birth. You know, to what extent can we influence how that information is gathered or communicate the ambiguity or the accuracy of that information when they arrive in the emergency department? But another piece to this is the triage nurse who’s taking this information in, if they’re typing the information that they’re hearing, that has a known non-zero error rate.

And so influencing that action can help address safety if we’re thinking about that as a control structure. And then the interaction between the nurse and say, the electronic healthcare record can play a major role as well if they’re searching for that patient. How do the search results show up? And is there something about that design that leads to patient misidentification? So, and, but you can keep going up, you can look at the way that the EHR, electronic healthcare record system and the healthcare organization interact, or the way that regulators influence these third party vendors that create them.

And so it allows you in one sort of map to see these different elements acting all at once. What we tend to do as humans is look for very kind of black and white simple answers and want to say that it was the nurse’s fault, or it was, you know, somebody else’s fault. You close the door, and you’d generate an action plan and be done with it. But this really allows us to be more nuanced in our thinking and it provides many additional opportunities to act.

[00:20:01] Karen Wolk Feinstein: Tina, any comment on that?

[00:20:03] Tina Vitale-McDowell: Yeah, I think the great thing about trying to implement these is, you know, from someone who is continuously given audits and root cause analysis reports to complete, utilizing this in a specific event and brining in these human factors engineers and bringing in the sort of human and operational performance components has really changed the way that I myself kind of respond to these. It allows me to look at the workarounds that my staff are doing instead of saying, Why did you not follow that? I can say, oh, actually that’s a better way to do it, and thanks for bringing that to my attention. So let’s look at that. And I think, you know, workarounds are just there. You know, you’ll hear two factions. One, it says, That’s ripe for patient error and you’re gonna cause harm. And then there’s another faction that’ll say, Actually, that’s actually brilliant, it’s showing us where the weaknesses are. And I tend to kind of move towards that a bit because I want to know where the weaknesses are. So this ability to not just do the one-person blame sort of response to an error has really, I think, provided some more resiliency in the ED, which is something we desperately need.

[00:21:23] Karen Wolk Feinstein: Why do you think that some of these strategies that, and technologies that are used in other industries that are high-risk and complex, why do we resist introducing them to health care? What holds us back?

[00:21:43] Chris LeMaster: God, that’s a hard question to answer. I don’t pretend to have a complete answer here, but you know, there’s a book called Still Not Safe, that was written a while back by Robert Wears and Kathleen Sutcliffe, that I think kind of explains this quite well. Part of it is that the people who are thinking about this problem in health care are largely healthcare clinicians and administrators, and we have a very specific way of thinking.

The mental models that we’re taught in medical school or nursing school or healthcare administration school, it doesn’t include understanding things from a systems perspective or a human factors perspective. We don’t understand the differences between say, simple systems and complex systems, which has a lot to say about how harm and adverse events occurs.

And so, those experts who could provide that perspective have been largely pushed out. And one of the wonderful things about this group that’s meeting monthly is that we’re hearing from a lot of those people and it’s, you know, teaching both Tina and myself a lot about how to think differently and try different approaches that have been really, really effective. And that’s been fun to watch.

[00:22:58] Karen Wolk Feinstein: And we really rely on Tina because, I know my early days, which now is 25 years old, of bringing outsider solutions. You know, I’m not a clinician. I sit up here in an office tower and think a phrase of fixing the world, and almost everything we introduced early on put more stress on the front line, asked people to stop, I mean, how bizarre in the middle of a shift, to solve a problem, to root cause? It just wasn’t working. So, I love the group. It’s interesting, it’s provocative, that you’ve convened, Chris, but I also like the fact that, you know, there’s pushback. There’s a sense that some of these ideas may work and some may not.

So I’ve also been intrigued at the idea of just bringing fewer people to the ER. So we have some EMTs here that are working hard on options to help people in their homes without bringing them to the ER, and you know, that’s a problem here because they don’t get paid unless they actually deliver a patient to the ER, which is a terrible, awful, no good idea.

But there’s so much you can do now, right? With teleconferencing and, you know, actually helping the EMT to stabilize the situation. The other is Amazon keeps asking me to do a real-time consult. Hey, am I worried about something? Just talk. What do you think about the idea of just bringing fewer people to the ER, having fewer people arrive at your door?

[00:24:38] Tina Vitale-McDowell: God, you’ve touched on so many things, so yeah, I think the telehealth, you know, the 24/7 ability to access your physician and hopefully stave off a visit to the emergency department. I will say, in action though, some of that we’re not ready for because we have to have the other systems set up to support that.

So if at three in the morning I call my doctor and he says, go get an antibiotic. Okay, well, can I get that now or do I have to wait till Thursday when there’s a pharmacist available to provide that? Do I have to drive 20 miles to the hospital to get that, or can I pick that up at my local CVS or something?

So I think that that these are all really good. I think these are, you know, this is part of where you start to, and, you know, looking at these analyses is like, look at the bigger, bigger, bigger, bigger, bigger picture. And there’s all these pieces, right, that don’t make it necessarily so smooth. And then you mentioned Amazon in this sort of value-based push, right?

So CMS is pushing us to provide value-based care, and I can tell you from the emergency department, my perspective is that we have physicians who are now being pushed into efficiency versus thoroughness. So that value-based sort of, you know, “don’t order this, order this” type of sense is being pushed because we have to get people through the department.

And so we’re getting this sort of efficiency and thoroughness conflict that I’m sure the providers would love to be able to do but can’t. And so they go home again at the end of the day and just didn’t do a good job. And so I think it’s very complex. I think moving that needle is gonna take different thinking.

I’m in it for the long haul. I want to do my part in the small space I’m in, but I think it can happen. Chris, I’m sorry, I’m speaking for all physicians at this point.

[00:26:25] Karen Wolk Feinstein: Tina, I love that you brought up pharmacy. So, we gave a grant once. It was an experiment to put pharmacists in the ED, and our guess was a lot of people could be seen by the pharmacists, have their prescriptions adjusted and go home. Actually, it worked. It was amazing how many people wound up in the ED, actually, because they were on the wrong meds or they should have been on something, they weren’t on, whatever. And I don’t know if that’s been your experience.

But here’s a real complication. Now, in all of the area around where I live, there are no longer any 24 hour pharmacies. And in fact, Rite Aid has gone to, wait until you hear this, daytime. I think it’s like 10 to 5:30 and not on weekends. Can you please explain to me how working people can adjust to this? They cannot get to a pharmacist. So are we all being pushed to mail order? And I do think that’s going to have an impact on the ER.

[00:27:30] Chris LeMaster: Yeah, absolutely. This, I don’t know, reminds me a little bit of what we were talking about earlier, that you need to have all these different groups involved in the design of these systems, right? And so part of the problem is that we have isolated siloed groups of people making decisions that make sense to them without thinking about, you know, this is a complex system, so what are the repercussions for other groups?

So, you know, I’d imagine that for a private company that wants to maximize value for themselves, that, you know, having shorter hours makes a lot of sense. It’s probably hard to staff a pharmacist overnight. There may be other downsides I’m not aware of, but obviously the patients that are impacted would have a lot to say about that. And if we were co-designing that together, we may come up with a different solution. It’s not set up that way, but if we’re thinking systemically, we need to, we, we certainly need to be including that perspective in the design.

[00:28:24] Tina Vitale-McDowell: It’s silly, because I can draw a direct line to more patients in the emergency department. You know, if we’re going towards mail and, and less sort of resources with less pharmacists, now we’re going to mail and UPS goes on strike and the postal system is having trouble, and now I can’t get my medication, so I take my car or the EMS and ask for a ride to the emergency department. So I can see a direct sort of line to some of these, which is what, to Chris’s point, it’s like we really have to think about the impacts when we try and fix one thing.

[00:28:58] Chris LeMaster: Yeah, I was seeing a patient yesterday who was saying that she ordered a medication in the mail or, you know, to be delivered, and it hadn’t arrived yet, and she asked me if I could refill it. So, there’s still a waiting period when you order something by mail and things can happen between when you order and when it arrives.

[00:29:17] Karen Wolk Feinstein: And I feel so bad. I know as a mom it would be Sunday my child would wake up with pink eye, right? And no problem then. I go to the pharmacy, I get drops and, you know, I could send my kid to school. Here’s the problem now there: our pharmacies aren’t open on the weekend. I’ve never heard of anything crazier. So, and Monday they open at 10 in the morning? I mean, you know, that mom isn’t going to work, and that kid isn’t going to school. And yes, I think we need to think about the whole system. You know, pressure here, you relieve the valve at the pharmacy and you put it on the ER.

So let me ask a last question. What do we have to do now before another pandemic or a series of mass casualties up and our emergency departments?

[00:30:12] Tina Vitale-McDowell: We have to keep our people, we have to keep the human beings at work in health care. In health care, we have to stave off the exodus. You know, how do you design for a traumatized group of people? How do you design changes and inspire them to kind of be the keepers of the systems? I think providing that feedback, giving them the ability to know that their reporting is worthwhile, recognizing that the workarounds are part of their ability to be resilient. I have a lot of words and cliches that I can throw out, but I think it just comes down to the people, the investment, the grit that it’s gonna take from leaders to stay with it.

I don’t assume that’s the change, but we are moving into a space in which, in order for our healthcare systems to survive, we have to kind of understand what’s coming down the pipe, and we have to keep our people. And so, you know, that’s reimagining the way we train our staff. That’s maybe looking at different ways of utilizing certain skill sets and being a little bit more dynamic. Yeah, I have hopes and lists, but I think it just comes down to the grit and staying put.

[00:31:28] Chris LeMaster: In my mind, part of this goes back to thinking systemically and what does that mean. There’s the story of the blind man and the elephant where, you know, each of the blind men in the parable are touching a different part of the elephant. And so the elephant seems like a wall to one or a tree trunk, or a fan, or a snake for the trunk. And the sort of overlying message there is that each of them is right, but all are wrong.

So if we’re looking at individual silos, those perspectives are valuable and they’re right. But we can’t address the problem as a whole unless we’re thinking about it systemically, and that sounds very abstract, but many of these tools allow for that. And the other piece is dialogue. Allowing these groups of people to talk to each other and mutually understand each other. Yeah, that the frontline nurse isn’t being lazy or not following policy. There are very concrete reasons that what they did made sense to them at the time. And then the other piece is that we can learn a lot from the pandemic that we just went through.

The STPA model is focused on identifying hazards and designing them out before harm occurs. And we can do what Todd Conklin calls the “pre-accident investigation.” So we know many of those hazards having gone through the pandemic and we can design out many of them for the next one. But it does require a systems perspective and many tools that exist outside of health care.

[00:32:49] Karen Wolk Feinstein: I’m very appreciative of the group that meets talking a lot about systems issues, system design. I do think we need to think hard about things that may seem unrelated, pharmacy hours, our ambulance payment system, the closure of so many nursing facilities as a result of the pandemic, how that impacts the emergency departments and the whole hospital.

So I am very appreciative. Thank you so much for bringing a provocative group together and helping us think through not only what some of the solutions could be, but also how do we put that into the reality of life at the front line. So thank you so much, Chris and Tina.

[00:33:37] Chris LeMaster: Thank you very much. We really appreciate your time, Karen. It’s been a lot of fun.

[00:33:40] Tina Vitale-McDowell: Thank you.

[00:33:40] Karen Wolk Feinstein: Up Next for Patient Safety is a production of the National Patient Safety Board Coalition in partnership with the Pittsburgh Regional Health Initiative and the Jewish Healthcare Foundation. It’s produced and hosted by me with enormous support from Scotland Huber and Lisa George.

This episode was edited and engineered by Jonathan Kersting and the Pittsburgh Technology Council. Special thanks to Lisa Boyd, Carolyn Byrnes, and Robert Ferguson from our staff. Thank you for listening, and please take action, whatever that is, to advance patient safety.