It's casing Ontario. I'm gonna go to the flying J. Gonna grab some fuel. Gonna park. Gonna go inside. Gonna have a shower. Gonna be nice and clean. Gonna feel good. It's parked there tonight in southern Ontario. If you're wondering, my lip is a little swollen today. No, I didn't get punched in the face. No, not today. I bit my lip last yesterday. I've been playing with it all evening yesterday and then I woke up and it was, you get it. I did not get punched in the face. Don't worry. That only happened once. You should have seen the other guy. I'm gonna go to a cabs gazing at my shower. My reload that was scheduled for tomorrow got cancelled. I told you that yesterday. But the good news is it got rescheduled. But it's loading the day after tomorrow. So I'm gonna have a reset, an unscheduled reset on the road. I'm gonna deliver this load tomorrow afternoon. Well, sorry, not tomorrow. I'm delivering this load tomorrow. I was supposed to reload the day after tomorrow, but now I'm only gonna be reloading the day after the day after tomorrow. So that's our good news and bad news. I'll be sitting around for a day in southern Ontario. Maybe I'll go find a theater theater and catch a movie. I don't know. We'll see. I haven't had a day off like this on the road in a long time. Maybe I'll just sit in the truck here and organize stuff and clean stuff. Maybe I'll just sleep. I don't know. The options are endless. Let's get... Oh, excuse me. Let's get on the road. Let's get some miles behind us. We have 600 miles to go today. It's about a thousand kilometers, so it's gonna be a full day. We're gonna be driving pretty late. We'll see how far we get. I do have to get there by tomorrow afternoon to unload though, so there's that. Got to wear my Scottish hat when I say that. I still have it. So I have one. Of course I do. I'm not giving that away. That was an awesome gift. That was from Tracy and Wadi in Scotland. Got to practice my Scottish accent. One day, one day in the far future, you know, I don't like talking about it, but Diesel's not going to be around forever. He's retired right now at home, but one day when he's gone and, you know, we're ready to move on a little bit.  Got to practice Scottish accent. Let's not think that far in the future though. Diesel's still got like 15, 20 years. He's only, what, 12? Turning 12 this year? No, he's turning 11. Is he turning 12? Oh my goodness. Okay, stop talking about it. Let's go. Oh, CB on. Easy, easy. Even though no one else up here will use this CB, whatever I have mine on. Lights are on. The truck is ready to go. All warmed up. Hopefully I'm not stuck. And I'm not. I'm going to check my trailer. It is attached. Nice. Brakes work and brakes release. Fantastic. Fantastic. What a good day. What a good day. I think I got my coffee down here. Yeah, we're ready to rock. Or if you're French, we're ready to lay rock and lay roll. It is all chained down and tight.  Oil is good. Engine's good. Tires are good. Lights are good. Another day of trucking. Let's go. This freight ain't going to deliver itself. Nice little town up here. There's not much up here on Highway 11, but it's a much flatter drive. Excuse me, I'm so sorry. Pardon me. A little gassy this morning. It's okay, old blue. I took the blame. It was me. I take Highway 11 because I want to be nice to old blue. These reels are pretty heavy behind me. They're not the heaviest load I've hauled, but they're heavy enough. And Highway 17 is 50 kilometers or 30 miles shorter, but there's massive hills that you got to climb. Lots of hills. Hard on the engine, having to pull that hard all the time. Highway 11, it's a little bit further around, but it's flat, right? Easier. Makes me feel better anyway. Who's this? Claude Giroux. Oh, hometown of Claude Giroux.  Every town in Canada has like a little shrine to the NHL hockey players that were born there and grew up there. So every Canadian NHLer has their own little signs and stuff in their hometown. Take hockey. Very serious. Very serious. I wish I had more time to watch it, but you know, life goes on. You got to work. And we don't have the channel. Though I think I can get it through Prime. I think I can get Hockey Night in Canada through Prime or Paramount Plus or something. I saw it there once. I was like, wow, no way. Saturday nights, Hockey Night in Canada. I got to confirm that yet though. That used to be a staple in every Canadian household. On CBC, what was it? Channel 6, Hockey Night in Canada with Dawn Cherry and Ron McClain. Dawn Cherry is an absolute legend. It's actually a pretty big town up here. Ontario has a lot of people. It's the most populous province of Canada. Most of them, most of the people live down in Southern Ontario where we're headed tonight, around the Toronto, Ottawa area. That's where actually the majority of Canadians live. The brutal weather of Manitoba, only the toughest of us. Flying Jay's just down the road. I'm going to shower first. I have two shower credits available. This is how their parking lot is set up. It'd be more of a hassle to go fuel up and then go all the way around and park. I'd rather just quickly park, go shower, and then we'll fuel and then go. Then I just have to do one loop. One loop of their parking lot. You'll see. You have to start considering building a bypass around town. It's a pretty busy street. It's gotten a lot busier since I started driving. I've noticed that last time when I came through here too. It's a lot going on. A lot more people up here than I think we realized. This guy was going here too. The pumps are on the left here. You've sort of got to do a loop around the yard to get fuel. And then if I want to park after I fuel, I've got to come back out here onto this busy road and then loop back around in the centre. Just be easier if I park, go fuel, no park, go shower, then fuel. Round and back in beside that guy who knows then. Road in here. It feels like it, right? It's all the snow is just packed in here. Actually, you know what? I changed my mind. I changed my mind. My reserve's right. I changed my mind.  Right beside where this guy's backing into. Right beside this guy with Mr. Volvo.  Once I've done my shower, I can literally just drive straight forward into the pumps. Hopefully there's not a long line up and I can just grab an FD1 and get fuel and go. Very nice. Oh, there it is. There it is. All right. Okay, so what I do now? The building's right there. I go into my app. Those of you who drive out here know this very well, but those of you who don't drive might not know. The way I reserve a shower is right through their app. Promote in the parking lot. Three available.  Boom, shower reserved. Now I have 10 minutes to get in there and get into the shower or it resets and they give it away to someone else. Isn't this kind of interesting?  It's cleaner. But the only thing, the only thing clean on there is dirty. Maybe that's just my eyes. They're all dirty. It's all dirty. Who am I getting? Automatic lights. Nice. I was wondering where the light switch was there for a second. No, these are magic lights. You just walk in, they turn on. It's for fancy people. This is what we're working with. Okay, that's all you get. We are showered up, fueled up, fed, got our coffee, load is tied down nice and tight. Let's go to Southern Ontario. See what they've been up to. Haven't been there in a while after this pickup. I'm going. I'm going for it. I'm going to send it. Ontario 11 East for 113 kilometers. Lots of traffic coming in here. This is the place that we stopped at last time. Right across from the Husky, remember? Petro Pass has a gravel parking lot. Husky has a paved parking lot so everybody always fills up. Husky first. A lot of truck stop. Off on the right. Sign lit up. Gillers truck stop. For some reason their sign isn't lit up, which makes it a little difficult to see. All right, these big guys, the first size load headed back. That'd be an interesting ride back from Ontario. It's under 12 feet wide. I think 11 foot 8. So I've decided we're asking Pickering Ontario to stop there all the time. And if that place is full by the time I get there, there's another one down the road in the next town. It's your destination on the right side, 1715 Alliance Road. I think I'll be safe here. At least here I know no one's going to hit me or run into me or anything else. I'm out of the way. There's no signs that say I can't park here. I'm parking. I got to go to bed. So we'll be up in the morning again. We're going to go deliver these reels tomorrow. And then we're going to head to London, Ontario flying J where I'm going to do a reset. I have to wait till the day after. Okay, wait a second. Tomorrow I deliver these reels. The next day I was going to pick up my new load, my oversize. That's not happening. Now it's happening the day after tomorrow. So the day after the day after tomorrow. But it's after midnight already. So technically now it's the day after tomorrow. Either way, I'm going to be sitting in London, Ontario for a day just hanging out. Grab a shower, wander around a bit, maybe go for a walk, watch the Netflix, watch a lot of YouTube. We'll see what happens. Worry about tomorrow when tomorrow gets here. We'll worry about the day after tomorrow and the day after tomorrow gets here. Right now I'm going to worry about going to bed. Thanks for joining me today. Please hit that like button if you do like my videos. I appreciate that. I have a lot of videos. I have them all in playlists on my channel. You can go check them out if you like. All the way back to 2011. We started counting and doing our seasons. I think in season, we're in season 10 now, which is the 10th year of daily vlogs since I started counting. But I did start doing daily videos somewhat in 2011. So we've been doing this a little while. This is our 12th year. No. Yeah. Wow. Wow. I'm going to have to go and check that out. I was a bit of an inside joke. I'll have to explain it in another vlog. It's not my joke. It's Britt's joke. Most of my jokes are her jokes. Just so you know, I steal a lot of her funny content because she's a lot funnier than I am. And so she's always cracking jokes and then I take them and say them on the vlog. So disclaimer, a lot of my humor comes from my wife. So I'll see you guys tomorrow. Don't forget to hit the bell. Turn on all the notifications so you don't miss when my next vlog comes out. And we'll see you tomorrow.


Okay, well hello everyone and thank you so much for joining our webinar and the title of today's webinar is recognizing unsafe care what it is and how to report it. Next slide please. And so before I jump into the objectives, I will very quickly introduce myself. So my name is Sarah Miller. I'm our director of partnerships here at the patient safety movement foundation and we're very excited again to welcome to you to this month's webinar and in a few slides we will introduce our panelists, but I will start off by jumping into the objectives. So the first objective for today is defining the term medical air and discuss the most frequent types of patient harm. The second is understanding the difference between negligence and human error. The third describing the typical process for reporting unsafe care. The fourth is discussing how to escalate concerns that are not adequately addressed even after they have been reported. And then finally, the last one is examining ways that patients and families can get involved in driving organizational improvement. Next slide please. So just a quick housekeeping items for those of you that are on the live webinar today, we will be providing one approved credit for BCPA. It will take about five to seven days to process. So if you have any questions at all, please feel free to email clinical at patient safety movement.org with any questions regarding your CE. So with that said, we will jump into introducing our panelists so I will be facilitating today's webinar, but it's my great pleasure to introduce our moderator Marcy Romero. So Marcy would you like to introduce yourself. Yes, thank you so much, Sarah.  My name is Marcy Romero. I'm a registered nurse. I am a nurse at the University of New Mexico Hospital in Albuquerque, New Mexico, and I am the manager for the patient family advisory committee. I've been in this role for about a year and I am passionate about including the patient voice and the delivery of healthcare. The patient perspective is so important to everything that we do and in fact we cannot move forward without it. So with that, I am going to introduce our panelists here. I am going to begin with yourself. Peter Capitain and Peter, I'm sorry if I said your last name wrong, comes to us from the Netherlands and as a patient advocate as well as a CEO and inspired to live. An organization with an international reach that connects patients, researchers and clinicians in the fight against cancer. Currently, program manager and advisor for complex and politically difficult problems where he organizes, congresses and lobbies the matrix of public authorities that's difficult work Peter. Healthcare organizations, insurance companies and health research institutes. Peter's sole aspiration. I love this is to create awareness and hope through showing people to live their lives happy and healthy in harmony with cancer. Peter, thank you for all that you do. Carol, Carol, you have an impressive bio Carol graduated from Colorado State University go Rams with a degree and speech communication. She received a master's degree in patient safety leadership from the University of Illinois, Chicago, and a second master's degree in healthcare ethics from Creighton University. Carol has worked in healthcare for 30 years. She was an adjunct professor at the University of Illinois in Chicago for 10 years, teaching and their master's program for patient safety. Currently, Carol is the senior director of education for MedStar Institute for quality and safety, and she is also the director of education at the executive master's program for clinical quality safety leadership at Georgetown University. Pamela Garn is involved in patient safety work across the country. She sits on the leapfrog patient and family caregiver expert panel for quality safety and experience at Children's Hospital Colorado, pediatric substance outcomes collaborative at Children's Hospital of Colorado, clinical excellence council for Colorado Hospital Association, and the board of directors for the collaborative for accountability and improvement. That is a mouthful Carol, her passion resides in transparency and communication after medical health care communication, and the power of storytelling that after the aftermath injured by providers patients and families when medical her transpires. And last but not least, I introduced Robin Betts who is an R and like myself, and a leader and clinical assistant and the implementation of safety improvement. She has dedicated her professional life to patient safety quality and high reliability systems to elevate patient safety and quality and health care. She has a distinguished 38 year health care career as a pediatric and NICU nurse nursing informaticists and executive leader of quality risk management and patient safety. As vice president for quality clinical effectiveness and regulatory services for Kaiser Permanente, Northern California, Robin helps further advance Kaiser Permanente's nation leading excellence in quality and patient safety, mental health services, and overseas health plans and hospital regulatory functions, including compliance licensing and member grievances. She sets the vision for patient safety and quality in pursuit of clinical quality excellence. So with that, let's begin. I'd like to begin by asking our audience to go ahead and use the chat box and define the term medical error for me please. And while you're doing that, again, use the chat box to find the term medical error. I'm going to give you a definition from the Institute of Medicine of Medicine and as well to our panel so Institute of Medicine defines medical error as the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. There are two types of errors, right. We have errors of omission and errors of commission errors of omission occur as a result of an action not taken. For example, not leaving the bedrolls up for a patient that is at risk for falling, or let's say not using the proper safety protocols when transferring a patient using a prance transfer device, maybe a lift errors of commission occurs the result of the wrong action taken. So an example would be providing medication to a patient where it was documented that the patient had an allergy to that medication, or operating on the wrong body part. I think it's important with that being said that we know that not all medical errors result in harm, right. And likewise, when harm does occur it's not always the result of the medical error. Often the medical error is a preventable adverse event, and they can occur in a number of settings. So Peter, from your perspective, I'm curious as a patient advocate, do you believe the majority of patients have a clear understanding of the definition of medical error. The answer is, it depends, of course, always be aware that I look at the world from the cancer patients perspective. So, coming to the moment that you have your diagnosis, I think most patients do not have an understanding of medical errors, which is quite logical because the day before you were not a patient yet. Looking at the two definitions omission and commission. I think even cancer patients who are shortly ago diagnosed have a feeling what a wrong action taken might be, because they feel it quite in quite short term. They do not know omission errors, which is quite normal in cancer patients life that they have that the result of actions not taken because quite a lot of treatments are not available for patients within a country, or external of the country. Well, it depends. Most patients when they are only in a short, short term, a patient do not know anything, but become aware of the situation and cancer patients live. And that's of course, a good thing, longer and longer and longer and then they become aware of what is possible what is what is an error and what is not an error, which is a failure which is not a failure. So do you think in order to make an impact globally that that patients should be more well equipped with knowledge so have that knowledge beforehand. Do you think that would help aid in the reduction of medical errors. Definitely. Yeah, but but but again, when you become a patient on day one you do not know anything so you need help. And for that, I mean, I always make a difference. My definition between a patient and a patient advocate the patient is, well, does not know any anything from the start patient advocate should know they, and they should assist patients in the way they should in well preventing them from having not the right treatment and make them aware that there are medical errors that should be prevented that if they happen they can assist in, well, do the things that are necessary to prevent them in the future. Absolutely, you know, it makes me think of what you said, like for example, if I were to go to a car mechanic. I don't know a whole lot about cars, and I certainly wouldn't know what to ask for and diagnostic terms, right. And so but the certainly once your car breaks down and you have to, let's say replace the transmission, you might do a little bit of education, and if I could remind everyone to please go on mute. That would be helpful. Thank you. All right. And so I recently, as you know I'm the manager for PFAC, and I recently had an advisor have the privilege of presenting with our residents of the Department of Internal Medicine. And one thing that she brought up was the mental and emotional impact that sometimes medical errors have on patients that really providers don't think about. Carol, 87.3% of patients and the recent patient safety movement foundation poll reported that they knew nothing, or had heard nothing about medical errors within their local community within the last year. How important is it for clinicians and patients to speak a common language in an effort to reduce medical errors. So Marcy, it's really important because as we know in healthcare, healthcare has its own language, big words, acronyms, and there's a real push out there with organizations, not just across the healthcare, but across other industries, and it's called plain language. So in other words, in healthcare, we tend to use words like expire, when what does that mean to different cultures to different people, someone died. The other thing is, is in using plain language, then patients and families can understand more about what is going on in their care. And they can speak and articulate back to the provider so that it's a bidirectional communication. So it's really important that, you know, we're talking and communicating where everyone is on what they say the same sheet of music. Exactly, we're singing from the same hymnal. And what you said about, you know, bidirectional, they agree and it makes me think of teach back and how important that relationship is between the provider and the patient. And I'll be honest, as an RN, providing patient care, there have been times when I had thought that I explained something very clearly, when in fact, I had not. Carol, you know, I completely agree with what you said and with that being said, I will change the focus to patient education. 2019 report published by the Betsy Lehman Center for Patient Safety estimates the annual cost of medical errors in the state of Massachusetts alone. I thought this was fascinating to be $617 million. The state of Massachusetts alone. Again, this member does not reflect the emotional and mental impact that's placed on patients and providers so Robin. I'd love to hear from you from your perspective, what's the biggest barrier to providing comprehensive person centered education on quality improvement so the patients can understand this whole process or at least the tip of the iceberg. Yeah, I think that's such a great question. Health cares has a long standing history of designing for the patient instead of with the patient. And so in general, we are more comfortable directing care, instead of partnering in that care. The concept of patient and family centered care emerging two decades ago when the Institute of Medicine published crossing the quality cast. However, there is a lot of great maturity patient family advisory councils have been formed, but they largely remain existential to the safety and quality organization structures where we kind of reach into them when we want their input. Instead of embed them and having them be representative on our quality and safety committees to both hold us accountable for quality and safety and to provide insights into solutioning for safety. So there is a maturity and many organizations are somewhere along the spectrum, but we still have a long way to go. And I agree. I think it's exciting to see organizations not only form P fax, which we know have been around since the 1970s, but also to inform P fax with QS so patient family advisory quality and safety councils, and including patients in the beginning of a process rather than creating a process, and then going to them and saying hey what do you think of this. In fact, it saves a lot of time when you include them at the beginning because they will notice things and they will have input which as a healthcare professional. We want that. I think about transparency, and it can be scary, right, especially when we're being transparent about flaws, or something that we're normally not transparent about what you just shared, you know about the collaboration, I think is spot on. So Peter, again, and I know everyone on this panel has a lot of experience so please feel free to chime in but Peter, I can tell that you're extremely passionate about improving health outcomes for patients and families. And I want to play the doubles advocate for a second. I've been told by patients at times, and that they want to put all of their trust in the doctor, right. So why, why should I be involved, the doctors the expert. You know, I, he, this person here she has all the education, they're the ones that went to school. I'm just going to trust the doctor. What's wrong with that scenario. If you have a broken leg I think you should rely on the expert to repair that broken leg. But in many diseases there are choices to be made. And it's not always the right thing to treat until the end. Sometimes patients do not want to be treated at all they choose for a good quality of life for the rest of that life that might be three months, six months a year, two years. That means that, yes, the doctor might be the expert on that disease, but the choice is a personal perspective. And then the quality of life is determined by the patient. So the ends, the outs, the pros, the cons of different scenarios in treatments should be decided by the patient based on good information. And yes, the professional can give that information, the patient herself can also find a lot of information about it. And in the end, in a good discussion is the decision of the patient, what the right treatment is so yes, the expert is necessary, but it's not the only one who determines what the right treatment is. Robin, do you have anything you want to add? Robin, I see your hand. Yeah, I, any high, there's a concept about higher liability signs. So these are a highly reliable organization is an organization that consistently delivers on quality they have very, very deep effects. And one of the principles of high reliability is deference expertise. These organizations defer to the experts no matter where they reside in the hierarchy. In healthcare that may mean a patient or family member who is a content expert regarding some of the normal baseline. And they often are the first signals that our patients or their family member is getting into trouble and so listening to them is imperative. Absolutely Carol. Oh, Marcie is I think we have to also think about this from a cultural and generational. I agree.  They're very technical savvy new younger generation that are doing a lot of homework they go away and they ask questions. But there's also cultural issues where certain cultures would never question someone they feel is at a higher level or higher authority. You know, we can teach and we need to teach and we need to make people speak up. But we also have to be aware of where people are in their lifespan and how they've been brought up. All of those other things play a factor into why some some patients and families do not speak up. Absolutely. Absolutely. Thank you for bringing that up. I am glad someone brought that up and I also saw a comment in the chat that stated that the patient is the expert on themselves and absolutely. And I believe it's probably it's not probably it is the role of the health care provider to empower the patients to to empower the patient to take control of their health care, because it isn't always natural. It doesn't always come natural, especially when it's foreign. Right. And so, and I think about access to access to information. Not everyone has equal access to information. So, thank you. The one other thing I'll add because this goes a lot with Robin's expert in different expertise. We can often see when our loved ones are decompensating way before a lab test, because we know them we know those behaviors, and we know ourselves. So understanding again to listen to the patient and family because we might not be able to say oh we think they're septic, but we can see the changes and say something's wrong something's not right. You know, listen to me I don't know the medical term I don't know the technical term, but I know this child, and this is not their normal behavior. I think I'm sorry I'm sorry. I just, I just love that but what what makes deference text is so important to a highly reliable organization is because they, they are able to intervene early before things exacerbate. Accepting the information from the patient or family member, that's giving you that early signal allows us to intervene early instead of react in a situation where there's a complete decompensation. So it's just such a beautiful concept I love Carol's comments to about high distance power that can be cultural it can be age and and upbringing as well and so it's such an important factor to consider as we in healthcare need to have sensitivity to that. Oftentimes those social determinants of health have a have a definite play in this. I'd like to play a rather provide some troubling statistics, which I'm sure many of you know. It's estimated that between 210,000 and 440,000 individuals died from medical error yearly, which makes medical error the third leading cause of death in the United States behind heart disease and cancer. Now globally, there are an estimated 3 million people that died each year, and to put those numbers in perspective, that is more an HIV tuberculosis and malaria combined. It is the equivalent of three jumbo jet crashes every two days. Could you imagine. So Peter. In your opinion. How have we gotten to this point. And what have been major milestones that we have. And what have we learned from other industries. Well, to start with the last one I think to prevent medical and medical errors. We learned a lot from from the, from the aircraft industry, and, and a very, a very big tragedy happened in 1977 when it was the biggest incident in, in, in, in aircraft was was on the island of Tenerife, where over 500 people died. And that was kind of an impulse in, in, in making good controls and checklists, which were also used, of course, not from the technical perspective from a different technical perspective, which were also used in healthcare. And one of the biggest thing that was introduced was, you could say a kind of a second opinion that if someone says this is it, someone else has to say, yes, you're right. Doing surgery, the surgery has to say, this is the way we have to do it. And another one says, yes, you're right. And if of course the other one says, no, you're not. There's a discussion which cannot be taken too very long during surgery. So we learn from, from different industries. But by the way, I also think that other industries will learn from healthcare. Absolutely. I agree. And the double check, right. So I'm thinking about, and healthcare is a nurse, you know, having having another nurse double check and medication administration let's say of insulin. And so those would be things that we have learned from, from that industry. Another, another comment that I just saw come through that I, that I absolutely agree with, we have to consider where patients are in, in their journey. And so many of our patients come into the setting. And I think of, I think of patients just being diagnosed with cancer scared, right? Nervous, anxious. Right now, I think of the COVID pandemic. A lot of times they're not able to bring in visitors with them. So they're alone. And, and how, how do we empower patients that are in that, in that mode. Patients again, another chat, communication disabilities. I mean, we're thinking our difficulties, we're thinking about all of these factors and, and we can't forget them when we think about patient safety and getting this message across. I'd like to talk about the reporting of medical errors because I think this is really, really important. Robin. Can you tell us about the normal process for reporting medical errors, and who's the most likely person to report a medical error. Typically, medical error is reported through what we call event management systems or event reporting systems and they're really a requirement of hospitals and care delivery systems in America and in other national health systems. And now, and it's the responsibility of everyone, anyone who sees something or, or is actually an actor, and it could even be a near miss. The idea is that you as leaders create a culture where we want to hear from you. Please tell us even when you almost made a mistake so we can learn early and mitigate before harm occurs. So a great safe culture would see lots of near miss reporting and see their serious safety events go down at the same time so they have increased detection. But there are other ways to increase detection. You can do proactive monitoring of potential care gaps. You can also use codified triggers based on things like medical billing or other codes in the medical records such as a code that says return to or the patient return to the or that could generate a trigger that populates a work list of an identified resource who would then evaluate and make recommendations to do a deeper dive and say is there's something we could learn here and share with the rest of the organization about why this person had to go back to the or. And then not waiting till something happens in your own institution, but learning from literature and the industry because many of us are publishing our findings and our improvement methodologies to mitigate and eliminate harm. Right. And how do we share all this information. How do we, how do you know if there's so much so much information out there sometimes it's overwhelming. Yeah, there's wonderful organizations that we that are involved in the safety and quality science. For instance, there's a huge database where we submit a bunch of data about surgeries, all of our surgeries, and we share that and all that data is aggregated with thousands of other hospitals that are doing surgery. And we look at our performance trend and benchmark against each other. And so we know who the best performers are we can reach into them and talk to them and get advice. We do a lot of publication. So, whenever my team is engaging on an improvement project, I always ask them to let it to review scan the environment. What's been going on who's been doing what and then reach into those that have published, but we don't reinvent the wheel but we actually take that learning and laterally deploy it across our own organization. Absolutely. Harold, do you have anything to add I. Yeah, so Marcy it's interesting right now because you know we've had these PSOs these patient safety organizations out there for years, based on art, and a lot of them have not been successful. And I can tell you right now patient safety movement foundation Jewish healthcare are really trying to establish like the NTSB the national trans transportation safety board a healthcare patient safety board that for finally all the data will come in that we're looking at everyone's data hopefully at some point, then we can see those smaller nuances, but the patients and families also have access to this and are part of this. We need the same side as type of regulatory body for healthcare, like we have for transportation, if we're going to ever really make healthcare safer. I agree. And that's why I think it is so important that that patients are become educated that they that they start to learn some of the ins and the outs of quality and safety so that when this does happen to them, or, you know, God forbid that they know the actions to take right. And so I hear you talking about throughout this conversation human factors, and I think that that is important to consider as well. And, and, and reporting, right so when a provider experiences an error miss reporting that so that we can learn from it and not make those same mistakes again. So let's talk about the BIPOC or BIPOC and LGBTQ plus communities. We know that medical errors disproportionately affect these communities we've talked about this a little bit, and it negatively breaks down communication between the provider and the patients. We know that from our the number one reason for medical errors is a breakdown in communication. We haven't taken oath to treat all patients equally. Yet we know this isn't always the case. How, how do we ensure how how do we ensure that the impact on patients isn't greater than it already is how do we come together to help solve this problem because it is, it is growing quickly. And I think about the IT right and access and, and how an even reporting mechanisms for patients. Are we leaving people behind right now. So I'll take us first step at this Marci and I think there's several things is one. We're seeing more organizations doing training on cultural diversity language pronouns. She all of these things to not to further harm patients, you know, if you're transitioning and someone is calling you by the wrong name or the wrong, wrong pronoun. Those are small micro aggressions to those individuals. So, you know, we know that on the human factor scale education is one of those lower level things, but we have to start somewhere. So it used to be multi prong. So for instance, research used to be in white men, and then women were allowed to be part of research and now we realize that we have to look at age we have to look at different ethnicities. You know, that's one part how we address people. And then the other thing is, is that, you know, we have harmed certain groups. If you go back to the Tuskegee airmen and the way we did research with them and syphilis and Henrietta locks. There's a trust issue out there with certain different cultures and populations, and rightfully so. So how do we break down those barriers and I think where it's really showing right now is vaccines. You know, we need to get everyone vaccinated, but we have to have that trust again. I'm curious, who do, who do patients normally report to. Do we know that the number one person that a patient when they experience a medical error, who is the who's the first person they're going to share it with family. Right. And then what happens, and then and then what do they do. They're afraid to say anything if they're still in the hospital. They're afraid that they won't get the kind of care that they should. There's not a great mechanism for patients and families to report how it often comes out is when they get their prescani survey or something else where they feel that they can really put everything out there. But they, it's very difficult in the hospital, because you're already in a vulnerable state. Now you've been harmed and you feel even more vulnerable. Right. I think, I think about going to a restaurant and you get bad service, and you don't want to complain, because you don't want your food to come back, you know, with something in it. And so my husband always say mercy, don't don't complain. Medical medical error that's way worse, you know, you have the sphere of complaining because what if, what if then they don't treat me well which of course that never happens. And that never intentionally happens a provider always wants to provide exceptional care for their patients. And I think that we are scared as patients sometimes to ask those important questions. I've been a patient myself numerous times admitted to the hospital and I am, I am a healthcare professional. I know the questions to ask and I was scared to speak up for myself. So I can't imagine how our patients feel, who should they go to I saw when I saw a comment that they would report a medical error to PCP primary care provider. And I think that's, that's excellent and I would hope that the primary care provider would then file something saying that this happened and we now need to learn from this. Who do you recommend that patients report to most hospitals hopefully have a patient advocate. Yeah, and that would be a great individual to work with. They generally have a risk and quality department and there's always the administration that you can go to. If argumentation is responsive, which that would be unfortunate because I think we know enough about safety science that there should be some systems in place to support members through the patients through that process. But there are other escalations through regulatory agencies and, and unfortunately with hate for them to have to take legal action. That would be a disappointment I would call that a failure. So, there are a lot of opportunities I think there's opportunity to level flat early, and really in that case, so that they feel comfortable speaking up. You know, some of the things that have emerged in healthcare in my organization is we actually do. Shift handoff reports at the bedside and include the patient and appropriate and allowed by the patient family members in the discussion and we clean again a lot of information from those content experts. There's even more multidisciplinary rounds are conducted in patient wars and if appropriate, they'll bring the families into those discussions as well during the admission process. There's a lot of opportunity for the patient and family to be oriented to how they can escalate their concerns and participate in those daily roundings when they are so that they are there and ready to participate. There's also clinical handoff routines. As you know, during COVID we created virtual opportunities for families to participate in those discussions. And I think, you know, and another emerging thing are the visual boards in the room that include information for the patient, but also some of the patients that are helpful, such as including the patients individual goals, they're short and long term goals. Including the patient and family members in event investigations when safety events happen so that we understand from their perspective, the sequence of events and get their insights as to what they think. It's different or enhanced to prevent the event we've instituted that an organization and we've made system changes based on input from the lens of the patient and their experience in a harm event. Inclusion. I like that word. I'd like to take it even further Robin is the patients and families need to share their narrative. I've heard of one thing you should do. So that's, that's part of when it comes for the event review.  Everybody else is like a revolving door they see snippets of the movie, they never see the whole picture. They aren't getting it. We're not learning, but then it's closing the loop. So not only do we have it here and I understand that very few organizations literally have the patient and family in the full organization conversation because there's still fear the providers won't feel comfortable whatever, but we're not closing the loop at the end. We're not going back to those patients and families and saying, Here's what we talked about. Here's what we came up with. Do you agree with that? Or what do you think or what did we miss. And if we don't close the loop at the end. We're still missing things because again they think about a different you filled in certain pieces, they may be like, Oh, no, no, that didn't happen or that did. And here's what we could have done better. So it's not just the upfront. What are we doing here. And then how do you let them that they want to be part of the process improvement. Be part of that because for many people that's a healing opportunity. It's also an opportunity where they know something's been done. They're doing it in honor of a loved one that may have lost their life so there's there's multiple reasons to let them be involved in that work. It's very humbling for the for the healthcare provider as well I can speak to the institution that I work at and I'm proud to say that we recruit our advisors that sit on our patient family advisory committee from grievances and and from result grievances and that's not always an easy conversation to go into, however, that is the only way we're going to learn, and even more so, including them in the root cause analysis like you said of what what exactly went wrong and I think patients need to know that they can ask to be included, you know that they can they can speak up and like you said Robin speak out to re judge when advocate or an administrator, and really say that that I want to be involved in this process, and you may get to know, and then you take, you take the next steps right because I saw a comment about ambulatory care and I'm going to shift the conversation, because I think this is important we've been talking a lot about inpatient, and we know that the majority of medical errors actually occur in the outpatient setting. Again, often related to diagnostic errors and miscommunication. Why is that that is that that's where we need that that's the first stop, right. And so if we can stop medical errors, hopefully from occurring here, then the patient, hopefully never ends up in the hospital. And the ambulatory setting and specifically the primary care setting. I'm thinking Robin about education. I'm thinking, I'm thinking like you said those whiteboards and I think that's great. I think that's fantastic I think about transferring that from inpatient to the outpatient side I speak about this a lot a dream of mine would be to go to any ambulatory clinic and see clinical measures posted for patients and staff to see, right, but it's only useful if we talk about it with our patients, those whiteboards are only useful if we include our patients in them, I can't tell you how many times I see, I say a patient rights and responsibilities hanging up, and it's not visible. It's not somewhere where the page it's visible to the patient but are they really going to be looking there. Maybe not. How important isn't to include things like that in the ambulatory setting that the one of the nice things like for me I work in an integrated care delivery system where we were a health plan so we provide the insurance and we have the help and care delivery as part of our company and then we have hospitals and yes, that's a care. So we're able to use our systems and shared learning and adapt them to the ambulatory space and so you're exactly right it needs equal attention our event management system includes the ambulatory space and engagement and we have the adapting for that space because the types of injuries or events that happen in the ambulatory space are sometimes the same but need modification based on the types of risk. And so just being cognizant of how do you adapt it, but it's very feasible to translate all of this and it is done. But I don't, but but I think in the standalone ambulatory space is probably not done with the rigor that we would like.  You know, physicians have to see so many people are, let's face it our payment system drives a lot of this and we have a perverse payment system. So we have to sort of fix the payment system and this is more relative to the United States. Other countries don't have this because they have a single payer system. Another thing is, is, you know, we've really just started talking a lot more in the last several years about diagnostic error, you know the work that hard to sing and Traver and others are doing in this space is really calling out. What are all those biases that play into it where's the communication breakdown. I think it's probably one of the fastest growing areas that we need to invest money into and keep researching. Because we do know, you know, we know technology has not solved all these problems we thought, having electronic medical records and triggers and you know all of this.  So, you know, I know a lot of people are looking into it. I know we don't have a perfect solution yet. But I think that's the next for a first patient safety. I think I don't know Peter can speak to be it because it Scandinavia as some of the most advanced safety systems and, and the way they're legal, their med legal is designed as well, facilitates a more open and comfortable dialogue for the providers. I don't know if Peter has any insights into that. There's not much in Scandinavia, we are close to Scandinavia, but I do not know much about Scandinavia. But I think yes there is a difference between the United States situation and your situation and within Europe there are different between the Eastern and Western part of Europe as well I think Scandinavia and the Netherlands are more or less the same. There is a lot of overtreatment because of the payment system in healthcare in the Netherlands as well. And I'm pretty sure that is also the case in Sweden or Denmark. There is a perfect situation in that. Yeah. I'm listening to this conversation as there is a kind of a big elephant in the room about medical errors and there was the not diagnosis because of COVID. I may not know the data from from the Nettles but I do know the data from the United Kingdom, where in 2020, 2 million diagnosis have been postponed, which it's, which will cause thousands probably more than 10,000 people dying because of a too late hospital death is kind of a medical error as well. Absolutely and the strain placed on on hospitals and healthcare professionals is not helping the situation either. I think it's, you know, I think it's important we have about 15 minutes left and I want to make sure that we have time for for Q&A with our audience. Let's talk about diagnostic errors. What are some other common types of medical errors that patients can experience or should be aware of? Well, that is what what what I call we do not execute what we already know. I mean, if there are several ways of treating patients with, for example, lung cancer. In the Nettles, we have a little less than 100 hospitals and it really makes a difference in what hospital you are diagnosed because the hospital that diagnosis determines the treatment and not all the treatments are of the same quality. But they are given because that treatment is available and that treatment is being reimbursed in that hospital. So, and I consider that as one of the biggest medical errors that that that exists, we do not execute what we already know. I agree. And that speaks to what Carol said, you know, with diagnostic error. Absolutely. Absolutely. I think about medication errors. I think about wrong site surgeries. There's quite a few, you know, that we could go on and on and it's so important I think for patients to be aware of that. And to give one example of that, I know we were quite a lot with a company called IQFIA, one of the biggest clinical research organization, and they have data with for lung cancer. I know it. Let's say there are two ways of treating three ways of treating people with lung cancer, medication A, B and C. Well, they can see that the result of A is lousy B. Well, it does something and C is the best, but they see in that data that A and B are still given to patients. And this is the data that that that can be analyzed and can be published, but who is the one who dares to publish this data. And then of course, if it's published, who is the one who dares to take up a stand and say, hey, this is not something that we like to continue. Right. I think it's, you know, I think it's up to each and every one of us. And so, so with that, I am going to turn this over to our audience members and see if we have any questions. Let me. And I can move this. Okay, fantastic. I'm going to open the chat box. Okay. Generally, what is the first step that large integrated health systems take to begin including patients on the care team and taking the time to listen to their voice. I would like to answer this question. I think we talked about it earlier. I think, you know, the first is probably to establish your service culture and your values, and really, you know, establish that and have that burning platform. In my organization, we create caring moments because every moment matters. And some of the values include respect and compassion safety is first. And so, we can link everything to that and then begin to think about how do we integrate the patient into the patient voice into our work so like my organization and many others we have that side shift handoff and I talked about multi disciplinary rounding. During the admission process really orienting to patients to where they can elevate their voice including signage that gives them the information so they don't have to remember to how they can elevate or escalate or have the discussion. I think sometimes it helps even to have some scripting for writers that helps them get out of their kind of checklist mode and then give them that that scripted guidance so that they remember to ask the questions or ask that patient's opinion. And then, you know, just in every way we try to look where we can include including what we call human standard design. When we start an improvement process we get when we're designing, we include all the stakeholders, whether it be a clinic doctor or the hospital and the nurses and then the patients and then when we look at equity, did we design for those disparities and that's the maturity we're getting to now do, did we look for disparities in our baseline data that said hey we've got a problem here and as we're designing, we're actually designing to bridge the gap between where we have equitable disparity and so those are some thoughts I don't know Carol has anything to add. Well, I think you have to have leadership first that's going to support it. Leadership risk management legal because I can tell you the battles, you know you can have people at the front lines I want to do it, but if you're still betting heads because it's a denying defend or they don't want the patient voice. There needs to be a culture that says we want to engage our patients we want to learn with them from them, all of those different things. I think the other thing is, is that you're seeing more and more patient advocates that we feel like we've softened our voices, because it was our way to get in the door, you know, and I think there's enough patients out through P facts and things that really now, we don't have to soften our voices anymore. We really there's enough of us now that we can speak up, and I can see. I'm going to let you say something Stephen because I can see you believe in that like I feel like we've got that tipping point. Absolutely. I saw in the chat, there is a remark about the patient bill of rights should be posted as well. Our organization inspired to live in 2014 2015 we built together with a dozen of other organization patient advocacy organization, the cancer patients bill of rights and we handed it over to the European Parliament. And well that was really a statement that we could make. And of course that's a long term trajectory to bring it into practice, but shortly after that we together with the organization that I mentioned before. We made a statement that that how to implement the cancer patient bill of right what to do and every time knock on that door of your own Parliament European Parliament, whatever you are. And what Carol says I think really a good example of how patient advocacy can be very effective is the act up movement for the HIV AIDS patients in the 90s of the former century. They were very successful. They knew what they were talking about that's very important that you know what you're talking about. So you have to know things about. My expertise here have to know about molecular biology have to know about healthcare you have to know about treatments, how to design drugs etc etc. And if you know what you're talking about you have to be very active because otherwise they won't listen to me. And I think that the way you said about, there was a comment about P fax and, you know, I think that most organizations are starting to come along with P fax right and the really meaningful work that our advisors can do. And I would even take it a step further with the patient bill of rights or patient rights and responsibilities and say something that you want to match did was our patients actually wrote the patient rights and responsibilities are P fax. And so there's some ownership in that it's not. It's, it's nothing about me right without me, and that is really, really defining that so. Absolutely. Let me see if there's any further questions and I am actually going to try to stop sharing my screen here from a minute. Oh, absolutely. Okay, it looks like no problem. I got the message. Okay, so here's another question. Let's see how do we stay away from always being concerned with the revenue and healthcare great question and going back to caring for human life. Great question. Great question, but a great question. Yeah, I don't. Please, please go on. Yeah, you know it's a difficult question it assumes that everyone is still looking at dollars I actually get people kind of look every day to do the right thing they went into healthcare for a reason, and it's rare. So that is solely in it for some sort of revenue producing. You know there is a need to be solvent right so we can keep our care delivery system open in our community so we have to be excellent stewards of the finances that we that will manage. I think that there's probably some models that are better than others. You know, for me coming to Kaiser was unique because our, our system is designed that we carry the risk, and we actually don't make money when our people are sick so, or when they have surgery and so we are whole world is focused on optimizing health. And there's no pressure for our institutions to try to have more market share of the total hips and knees and those kinds of things so this is a new culture for me, however, more and more for instance the American College of surgeons in fact one of my hospitals was for one of the first hospitals validated for their geriatric care program, and they provide criteria and guidance to partner with the patient in decision making through really clear transparency around all the risk and options for surgery. We opted this in our organization, because we found that we are really transparent with our patients that in some cases 60% opt not to go to surgery and try other therapeutic so there's not a rush to that that that surgical experience so I think that there's, you know, growing awareness and I think that Peter spoke to what is the patient want and how much care do they want and how willing are we to hear their voice and partner with them in those hard decisions so they get the amount of care, and the level of care and intervention that they want based on their personal goals and needs. So it's evolving but I think the heart during the right place. I can't say it's perfect. I also think about nursing care models that that organizations can adopt, such as like compassionate connected care, or even candor right using candor when communicating with patients or encouraging patients to share their lived experience has a document where patients you know are prepared to answer these five questions prior to going to their appointments and so I think those are all useful tools as well to think about the human side of of medical error. So fantastic. I'm going to see if we have time and also you know aligning incentives, right, we have to encourage health organizations to start aligning their incentive incentives it has to happen. I agree Carol. Now we have a voice and, and I think p backs have a stronger voice to, and we'll have a much stronger voice when we all come together providers and patients and cultivate collaboration so this was very enjoyable I think you all for a robust conversation and I think the audience for being so engaged, and thank you patient safety movement foundation for this opportunity. I'm going to turn it over to Sarah. I see you're back on and you need me to end this let me know and I can do so. Perfect well I just wanted to close this out and say thank you again Marcy for moderating thank you to all of our panelists for such a great conversation. Thank you that joined a little bit late I just wanted to provide a few more housekeeping items just a simple reminder that if you are joining the live webinar we do have one C e credit for DCPA credit so again it will take about five to seven days to process if you have any questions at all. Feel free to email clinical at patient safety movement dot org. And then finally, if you enjoy this webinar and you want to continue hearing all of the great webinars and educational content that we have to offer just keep in mind that we do provide this free of charge. So obviously as a nonprofit we do rely heavily on donations from individuals like yourself so we really want to just ask you to consider helping us continue to keep these going and donate on our website at donate at patient safety movement dot org. But again thank you so much thank you to all of our panelists if you guys have any questions at all feel free to email us but we encourage you to just continue doing all the great work that you're doing and keep up the great work. Thank you.


As a reserve sailor, I am many things. I'm a mother and I'm a provider. I'm an office manager at a well-known corporation. Thank you. I'm a Chief Petty Officer in the Navy Reserve. While I may not always be in uniform, I'm always a Navy football fan. Go Navy! Be Army! Woo!


Oh, this show today? There's a question. How do I balance my priorities without being overwhelmed? I'm overwhelmed. And is it okay if my college student moves back in after graduation? And do I need to cut off my parents after I get married? No cutting off parents, maybe to the moving end. We'll see what all the sisters think. Stay tuned. Welcome to Sister to Sister. You have joined a beautiful, intelligent women of God. We are women of God.  So we'll see how this is today, because the questions that you write, we answer from our hearts and from a biblical point of view. In most cases, I'm not sure today, because there's two that are contentious to me. This first one, listen, someone wrote, is it necessary for your relationship with your parents to change once you're married?  Husband. But I talk to my mom every day. Okay, so you can probably imagine how I feel. How do you feel, Flo? I don't know about my feelings, but I think they need to really take a look at what leaving and cleaving means. Leaving and cleaving doesn't necessarily mean abandoning. I don't need to abandon my parents. You honor them. And that's why I'm able to honor you, because I learned that at home. So I think when you have a situation like that, first of all, let me back it up. When you get married, the scripture clearly says that we are to leave and cleave. Now, I think the challenge comes in as, what does that look like? What does leaving look like? Leaving does not look like me dishonoring, abandoning my parents. The relationship may shift. For example, I was a daddy's girl. So there are things that I would run to my father for. And thank God for the women in my family that could give me Godly counsel. Believe me, it saved his life a few times. So, you know what's true. Which is what? But I do think that we have to watch, we do this with friends, not just parents. I can't call Corey and tell her all of what's going on in my marriage, and shame me, my husband on covering him. My wise woman built her house. But how do I learn to be a wise woman from the other women in my life? You know? And so I think that that's part of the challenge. And so I think good boundaries and a loving attitude is part of that answer. And so you tell the husband?  Yeah, there you go. Yes, I think that. Exactly. I pray a little bit this morning. I need a little bit. Okay, a little bit. A little bit. Get it off for it. That sounds a little bit like the husband is feeling like he's not a priority and that communication needs to happen. I think that you need to find a way to convey to your husband that your love for your parents in no way diminishes your love for him. And that you need to make sure that your husband is feeling like a priority and that he is a priority in your relationship. And I mean, I think there's some unanswered questions here. Are you talking on the phone every hour? Are you running to your parents complaining about your husband? Are you asking your parents inappropriate questions? Going to your parents for things that you should be going to your husband for? I think there's a lot of unanswered questions here that you need to make sure that that leaving and cleaving is happening and that your husband is your new family. And that's a hard thing to do. When you first get married, it is very difficult. You have had that relationship with your parents and now there is a shift and that is now with your husband. It's a new relationship. And so there does have to be, I don't wanna say a cutting off, but it is a shift in a change that does not mean you dishonor, but there does have to be a change. We literally moved to another state and that was the best thing for our marriage. It was difficult, but it's what needed to happen for our marriage. Well, I didn't move. How about like the person's background? Like if you come from a family-oriented background and you marry somebody who doesn't know, you know, then that can bring challenges of its own. My big fact, here we go.  I forget what I was gonna say about that, but I didn't leave the town I was born in so I'm a little different and I was with my parents and they were my best friends. They were everything to me. You guys know that, I've said many times. I do wanna say this about what I did and you're right about sharing. Your husband is not your parents, first of all. Don't replace your husband with your parents with your husband. He is not your parent, okay? But I do have to say this, what I found that occurred naturally and it just might be the ethnicity. I don't know what it is. I included my husband in those conversations. I went to dinner at my parents and we had those conversations. Include him in some of them because what's Proverbs 31 say? The heart of her husband trusts her. My husband trusted her. I'm not gonna be yapping about him or complain. I'm gonna go right to him. He knows me. I'll go to you before I go to anybody else about what bothers me and you come to me. So include your spouse with your parents and my mother, my dad, my husband love my mother and my father. He became like their son. And then I was like, okay, where am I? So you get to that point. It's a beautiful thing if it works together. I know how close you are with your parents. Well, yeah, I mean, my mother-in-law lives down the street and she calls each of us both separately every day, probably, and my mom and dad don't call that much, but we are very close with them. They are our best friends.  And that doesn't mean there's no boundaries. I do not call my parents and rip on my husband. There's a trust there. They have his back and they don't allow me to.  She will fight for me. You know, there are healthy boundaries in play. Not that we don't. Sometimes I'll get a meshed. But thank God for the rich, bountiful family that God's given you. And we're all blessed with that. Before I got to that point, maybe you all didn't have this. I included him in the conversation, Roxy. I did. He just didn't hear it, but I included him. And I included him so much, that's how I got my understanding about how I was supposed to carry myself as a wife. You understand what I'm saying? I just wanted to share that. I like it. I like it. Now I'm going to go to kids. We were talking about parents. Now I'm going to go to kids. And here's the question that you wrote to us. Thank you. My college student is graduating and intending to move back home with me. My husband doesn't believe she should, but that she should go off and make it on her own. See, I told you it was contentious today. I agree it would be better for her to go on her own, but I don't see the harm in her coming back. Amy, what do you think? Well, okay. So I've got two like college age kids, you know? One could stay as long as he or she wanted. And the other, it could not work at all to stay in that, because it would be constant contention, right?  But I think that home is a place that kids should always feel welcome to come to. Not to stay for the next 25 years, maybe, maybe not depending on your situation, but that we really are a launching pad. And I thought about the funny story about Jesus and Mary and it's really very humorous. He hasn't done no miracles. She knows he's the son of God. And he's guys, he's about almost 30. And he's at home. He's just now in the chapter before launching out to get his disciples and to gather the team to go do the work of the Lord. And they're at a wedding and she's like, yeah, it's time for you to do a miracle.  And she's like, do whatever he says. Like it's time. So there's this essence of launching your kids out to do the will of God also. Do you remember the movie called Failure to Launch? It was Matthew McConaughey and he wouldn't leave his mother. Okay. Hello to my son. No, it's okay. What do you have? Okay, back it up. Somebody, somebody. I'll save her somebody, save her. I have two adult children as well. And what my husband and I have agreed upon at this point in time is that there will always be a roof over their heads and food on the table. That that is, you know, always going to be there, but our house is always going to have house rules as well. And we're not going to enable easy living for the rest of their lives. So there's going to be food. There's going to be a roof, but you know, they've also seen that if you're not actively being educated, you also need to actively be supporting yourself. So that has worked out. Hello, somebody. I love having them there. This is such a sweet time. I love having our family dinners, like the conversations. I mean, it doesn't happen all the time, but like when we're together, it's just such an amazing new place that we're at.  There might be something they need to learn in a different relationship, not in the parent child. If God is calling them back in, exhibit A, me. I didn't leave till I cleaved, I guess. I was going to school and working. I was productive, of course, Corey. So I think you'll be okay with that. Sometimes there's something they need to learn in that interim. He said for a bit, or she said for a bit. Be open to the Lord. What is it now in the season and their life that I could transfer that I couldn't before? Is it finances? Is it relationships? Is it adult? So be open to what God has, because this culture, I'm so tired of culture dictating, they're 18, they gotta go. That's the American culture. Go look at all the other countries. They're living at home because they can't afford it. They're taking care of their elderly. They're respecting and honoring. So don't get tied up to the culture that you're missing a time with your child. That's so good. And I have one more question, and I'm gonna go to the wisdom of flow, which is what I do when I'm not sure what to do. And here it is. And you wrote this to us also, how do I balance the priorities in my life and not feel overwhelmed? And I know you have many balls in the air all the time. How do you do it? I have to say that my balancing comes from first feeling overwhelmed. So you have to allow yourself, it's a process. And when I feel overwhelmed, then I realize that something's out of order, straight and narrow is the way, right? Yeah. So I love having accountability partners. And I don't like guest people around me. I really, really, really don't, just don't. And there's something about like the word says, instruct a wise man, he'll become even wise.  And how that ties into this for me is having people in my life, some people will say to me, Flo, you're doing too much, you need to slow it down. Or they'll show me where I might not always see it, but it shows up in some of the work that I'm doing that I'm not, as some would say, fully present. Because I got too many things going on. So I, for me, the balancing comes in when I see, I must first be realistic about I am out of balance. And I think it can be very deceptive, even if you're good at juggling things, you may think that you're doing it well. You may be doing five things, but are you doing those five things well? And that's the thing, like the prayer of J-Bass, enlarge my territory. So you may have five things on your plate, but when God enlarges the territory, if I was doing a presentation with a plate of food here, on a smaller plate, those things really look jumbled together. But on a larger plate, they all have their own identity. That's good, Amy, how do you do the priorities because you're raising children still? Yeah, so we just had to have a come to Jesus meeting because I have a whole lot going on in my own life, Buck has his whole busy, Gloria has her whole, we each had our own very full busy worlds. So we said every Monday night, we would always have family dinner night and we tried to do it other nights, but Monday night, don't book anything for family. And then thank God for Rabbi Daniel Lapin because he just wrote a book about being holy you. And he said, break your life down and these faith, family, friends, finances and fitness. So we sit there and we talk about, okay, how are we with our faith and our spiritual walk? Okay, what about our friends? Is there anything we need to address, talk about? It just sort of gives you like a well-balanced picture. So you're not like all hobby, no God, all family, no work. It's like it kind of helps you keep the wheel spinning right. So that's kind of what we started to like. I like it. Roxy, you have lots. Oh yeah, and the scripture says, teach us to number our days, that we may give you a heart of wisdom. I think sometimes we do too much out of pride. Yes, yes. Come on, that's so good. I won't say no because I'm too proud. You think I could do so much. You think I'm so great. I'm a Proverbs 31 woman. I could do it all. That is pride, okay? We're gonna slash it up a little bit on the 31 lady. Not her, but us trying to be her. Because God has appointed a time and a place for everything. So what I've done in my schedule, I have learned to start saying no because there's a frustration, there's an overwhelming. Am I called to do it? Am I supposed to do it? Is this the time? Put it off till later and it'll come back. Don't think you can't let it go because that's pride. And the other things, let things go. You don't have to wash the sheets every week. Wash the pillowcases. What? Compromise. Yes, you do. Okay. Teach your children. Here's what I have to do. I have to take a break. Go ahead. So that the people can get their coffee and come right back. So we'll see you in just a minute. Good job. Okay. Hi, welcome back. You know, we continue to talk. Yes, we do. When you're not here. And I wish you were, because it was really good. And we are contentious a little bit. Yes, we don't always agree, which is okay. I love, if I can, I know we got time, but I love the point that you bought up because sometimes it really is pride. And it can be pride that, you know, it's not just pride, it's not just pride. You know, somebody thinks that we're great and sometimes it's pride that we think that we're so great. And so if God gives you, he might lay something on your heart, a vision, something to be done, but it may be for somebody else to do it. Yes. Right. And if you didn't catch the beginning of the last show, that was talking about balancing our priorities. So we, we're trying. We're trying. She's trying. We're just going on. But listen to this question. You know, this is really good because I think this relates to you. So you wrote it to us, but I know a lot of you feel this way. My son grew up in the church. My daughter, my son accepted Christ, totally turned away from God. Does that mean that he was never saved in the first place? Hmm. Cory. Well, first of all, I don't think that we should be hanging our hat on the Sunday school salvation card and then just kind of wiping our hands of it and saying we're all good. Okay. I think, you know, a lot of Christian parents out there do that. And I think there's a danger in that. Okay. I also don't think that we should be determining what is or isn't in our young adults' hearts. Okay. That is not for us to determine. I cannot tell you how many times, not a month, not a week, but in a day that I stand on the promise of Proverbs 22, 6, train up a child in the way they should go. And when they are old, they will not depart from it. Good one. The Bible does not define what old is. Okay. I stand on that promise so much. The Bible does not define what old is. That could be when they're in their 20s. That could be when they're in their 90s and they're on their deathbed. But I stand on that promise. It is so hard to see your children's struggle, to see them go through a faith crisis, to see them struggle through things. But we have to remain faithful in our prayers, in our beliefs that God will remain faithful in his promise that the truth that we raised our kids up in, the truth, God's truth is truth. And that they will not turn away from it when they are old. I love it, Corrine. I know that you heard, your heart heard what Corrine said. Amy, what do you have? Yeah. I wanted to be very specific with this one because it is a very strong concern for parents. And doctrinally, the ones saved always saved. So I wanted to bring up these few specific points. Of course, John 3.36 says, whoever believes in the sun has eternal life. Period. Whoever believes in the sun has eternal life. Salvation is received and maintained by faith in Christ alone. It's not what you do. It's what Christ did for you. You can't sin your salvation away, but you can renounce it. It's something, it's this salvation, what Jesus did. It's not something you lose that you can choose to reject it. And I think it's important to know that that darkness cannot overpower the light. There's even qualifications in the scripture for you to renounce and to walk away from your faith. So you have to be so, so adamant, so heart-hearted, so cold-hearted to walk away from your faith. The tension with this question is the balance between the law and grace. There's a tension there because you can't do all works of the law and I earn my way to salvation. And it's not all grace.  So it's something to consider prayerfully and with scripture, but never lose hope in your children. I love it. Flo, I know that you're thinking about this. Well, I was glad she came back and brought some more clarity to that. And I thank God for some more studying that because there were times we had stuff like this before and anyway, praise God. So, but let me just stay with the child. I believe that each of us have to know God for ourselves.  Well, when they hit 16, it's a whole another thing. And so he's the God of Abraham, Isaac and Jacob. And if you study it out, they all had to have their encounter with him. So you don't, I can't will you salvation. You know what I mean? They have to have their encounter with God themselves. And I know for a parent, it can be disheartening to see things. And many of parents have cried and come for counseling and are gripped by fear when they see that. Cause I mean, you're concerned about your child going to hell, but I do believe strongly in the power of prayer. And I do believe that children have to, we all have to write our own testimony. And so, you know, I think she did a good job, a balanced job on that great debate. It is a great debate. One saved, always saved. And, but at the same time, stepping away from that and just looking at this particular question about the son, I would encourage the mother to stand fast and do all that she knows to do in fasting and praying. Can you close this out with a scripture on this? What do you have? Yeah, well, it goes both ways. I just want to say this about it. I don't know if one saved, always saved, or eternal security. That's a debate we're going to find out in heaven. And we should debate it. But you're going to have to remember, mom, Jesus left the 99 righteous sheep. They're all sheep. They're not goats. They're sheep. They're part of the flock. And he went after the one that went astray. That's right. He put him on his shoulders and he brought him home. Have hope until the very end because Jesus will bring him home. Oh my goodness. What a wonderful, wonderful thought to leave with our people today because I think this one saved, always saved. My son used to go to church. He doesn't anymore. It tugs at our heartstrings and it tugs at a mother's heart. So what everybody said today is have faith, have hope.  And on that day there, we're going to close this up. What a great show and so many good things to debate. We could go on and on and on. I just love my sisters and what they bring to the table. But what we love most of all is the word of God. And we always end our show with the scripture. And today's scripture is from 1 John 1 9 from the NIV version. If we confess our sins, he is faithful and just and will forgive us our sins and purify us from all unrighteousness. This is a verse for everyone. It's for the college student moving back in. It's for the newly married couple that are struggling with parental relationships. It's for the maybe the older person that has just heard that verse for the first time. It's for the young adult that maybe has fallen away from the truths that they have learned their whole lives. And you know who else it's for? It's for the child in Sunday school. A child like me who went to church twice a week and grew up in a Christian home. And as I stood in my bathroom, one night my mom was helping me get ready for bed. She brushed my hair as I stood on the bathroom sink. She asked me this question. Corey, are you a Christian? And I answered yes, because I knew that was the right answer, but I had no idea what that meant. And she explained to me that if I confess my sins, if I believed in Jesus, that I could be saved.   Corey, thank you. This is why this show is pretty amazing. And we end with the scripture, which is really amazing. And it goes like this. As iron sharpens iron, so does the countenance of a man or a woman sharpen the other because Christians make each other better just like the sisters. See you next time.


Good afternoon everybody. Welcome to stage A, stage A, stage C, stage C, wrong stage. Can I introduce you to Dan who's going to talk about what Walt Disney and what was meant to be the future? Hello, I'm Dan and this is Epcot It's the second of a Walt Disney World theme parks, and I think it's the most boring theme park in the world So I thought I'd tell you all about it It's themed as a permanent world's fair More volume It's themed as a permanent world fair It's split into two parts a world showcase with pavilions for every country and a future world The world showcase has pavilions for different countries little pastiche recreations of different places There's a United Kingdom which has a pub efficient chip shop and most importantly of all a merchandise shop selling keep calm and carry-ons mugs In the bottom of the park you have future world you can tell it's future world because it has a monorail There you can do exciting things like visit a hydroponic garden That's pretty much it And there's kind of two main reasons why I find Epcot frustrating The first is a world's fair acts as a snapshot for a specific year specific point in time and Epcot's a snapshot of 1982 I'm not particularly interested in going on holiday to 1982 But secondly is the name Epcot stands for the experimental prototype city of tomorrow It was never meant to be a theme park in its original design It was meant to be an entire city built by Walt Disney Walt Disney decided that American cities were incredibly broken. They were full of crime poverty and that he was the one who could solve this He'd kind of seen run down amusement parks and gone well I can build one of those better and built Disneyland He'd seen animated kids films and thought I could do that better and it built better animated films So he thought a city is pretty much the same problem So to do this he bought a patch of land in Florida. It's an area twice the size of Manhattan It's probably the distance of Bristol to Bath from one end to the other It's kind of 54 times the length of Western Supermere Pier for scale And his plan was that he would build a theme park at the top to lure people in build a city in the middle and An airport to the south with a monorail collecting them all to buy this land he used a number of shell companies and lawyers Kind of who weren't associated with a Disney company to anonymously buy this land without anyone figuring out what was going on He used the Company that later went on to launder the money for the Bay of Pigs invasion kind of X CIA people Really underhand stuff. He even had to buy the mining rights for land because that was owned separately from the landowners And this meant that later on after he built his theme park Someone could turn up the drilling rig and just go for it in the middle of the park So his plan was to build a from scratch modernist utopia. It would be concentric in the center There would be sit shops restaurants offices all under a glass roof fully air conditioned Separate from the elements. He would run his own public transport infrastructure He'd have monorails for long-distance travel Podcars that would take you wherever you wanted Underground would be where the cars are hidden underneath that a service tunnel with the lorries for deliveries to places You'd never have to encounter traffic as a pedestrian on the outside He would build parks and schools in a green belt and then outside that would be suburbia with the houses where everyone would live And you wouldn't own your house. You'd rent your house from Disney Disney would kind of choose what electrical appliances you had so he could experiment and try the best things for your home They built a massive model to simulate it. They'd kind of Got them quite far on the planning stages They even got as far as to announce it to the public with this half an hour long film kind of selling the citizens of Florida on television this utopian vision for the future and But sadly a few days after announcing the project what Disney was diagnosed with lung cancer He was a heavy cigarette smoker and the city was never built Instead they went ahead with just building the theme park Which they still outfitted the modern The most modern technology they could this is the contemporary hotel It's a prefabricated concrete a-frame structure each of the rooms is a different module that been Cramed in and swapped out to complete so that no maintenance is carried out on site And you can tell it's futuristic because it's got a monorail running through it The entire theme park is built on the first ground of a massive structure called utilidors There are a series of concrete corridors service structures so that staff can get around the park without being seen on the ceiling of these tubes called Avax they suck pneumatically the rubbish from rubbish bins around the park so that nobody sees the staff emptying the bins They even run their own power grid and their own telephone network If you've ever tried to get BT to install a landline You'd probably realize it's quicker to build your own phone company And they can do this because technically they're a city Even though Epcot never got built the legislation got passed which formed The re-decreak improvement district It's a special legal structure roughly equivalent to a city council and it contains two cities including this city of Lake Buena Vista This means it has all the powers and rights of the city It can run a police force. It runs ambulance services fire service. It can open a court It can run a jail. It can appoint judges. It can run hospitals It's even got permission to run its own nuclear power station And it's also got the responsibilities of the city so it has to hold elections But the way it's structured is only landowners in the area can take part in the elections Which are 16 Disney employees who are given special little houses purely for the sake of voting this means that Disney never has to deal with a Government that isn't in its interests which is helpful because it applies for planning permission from itself So when Disney passed away they searched his office and They found he only owned one architecture book in all his planning to build a city and it was a book by Victor Gruen Victor Gruen turns out to be the inventor of the shopping mall. There's kind of perfect glass-covered air-conditioned city Already exists. We already have these utopian cities. It's just it turns out they don't fix the problems of cities By building a glass dome over a roof and opening some Nandos That's pretty much all I have sorry I should say what Disney World did later on go ahead and build its own town It was a kind of Basically a suburban sprawl of villas But they built it not because they wanted to build an utopian city But because the land that they owned was so vast and it becomes so valuable because of Disney World It meant that someone could buy the entire of the Disney Corporation Sell off all of the film assets not care about those not care about the theme parks and just built hotels and houses and make a massive profit so they built an entire town and annexed it off into Orange County outside of its own jurisdiction to prevent someone creating a takeover of the Disney Corporation for real estate purposes It's a quite a ridiculous structure Anyway, thank you


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Ladies and gentlemen silent mic. We got another little workout video a training session at the one and only barbara gate Just showing you guys the real Harlem shake I don't know if you guys remember that you might be too old, but that's that's the the new age There it is. There it is the Harlem shake look it up. That's the real Harlem shake not the little viral one I'm at Barbara gate hidden a little bit of upper body and lower body of my man Bart Kwan my really good friend and owner of Barbara gate So Bart is competing. He has a meet I think only about two or three weeks out I'll basically all the employees of barbara gate are competing in it, which is super cool I actually have a wedding to go to that day Otherwise I would go down there and show my support because literally the entire staff people that have never competed before Everybody's trying to throw down So I just basically hopped in with Bart. He was hitting some squats and as many of you know Look at that talent. Can you look at that balance? Bart wanted to switch squat rack so he could be closer to me because I was doing the belt squat I walked the entire gym no hands 45 pounds in my in my hands barbell on my neck rack to rack Rack to rack. I didn't know he I don't think he helped me. Oh, maybe he did I thought he didn't help me and I racked that thing perfectly on my little baby traps But uh, so I'm not squatting or deadlifting I'm basically just giving my back a break and more importantly my mind a break as I've been dieting I'm feeling literally the leanest and meanest most basketball I've ever been around 200 to 205 pounds and it's been a great mental break for me to just kind of do whatever I want to do I still have some structure in my workouts, but I'm doing cardio. I'm going for bike rides. I'm doing a little extra cardio I'm going in on the gym on the off days because I feel like it because I want to do extra cardio Because I want to do extra arms or whatever might be and it's been a really good break for my brain Not to solely be focused on the numbers that I used to hit or when I'm peaked or my best You know fiver at max or whatever might be in a variation of the squat bench or deadlifts So I will return to powerlifting. I have zero doubts in my head I will hit bigger better numbers at lower body weights than I've ever hit in my life But for now I'm enjoying the process. I've talked a little bit on Instagram for those that are Not following me there is Salamico 2k's but I talked about the many projects that I got going on And we're just laying the foundation for these things So it's a little bit of a struggle period mentally for me because progress can't always be seen You're constantly working and grooving on these things, but the results don't come You know the patience is where it really comes into play. I'm a super impatient person You know, I'm always eyes on the prize kind of deal, but it's very difficult at times So I'm doing a max effort pitch shark and bars. Just he's really holding on to me You know, I don't know if you guys have ever been hugged by an angel But this was I did two reps I basically did two reps and any any Coddled my my behind my goocher and allowed me to really push through that's the progressive overload We're looking for but so we got a lot of projects going stress is is is high in kind of the business life sense But in the gym and things it's good Bart was trying to get a real workout.  I'm doing my parkour Hardcore parkour plus some pitch shark after this. I actually do get a decent workout in it was just in the beginning It was like probably six or seven in the morning something stupid I drank too much caffeine and started messing around but I think Bart hit a heavy single and then some back off sets of five I just did some sets of five to eight on the pitch shark And they're pretty much called it for the lower body. We did end up getting a nice upper body pump I think we need a bunch of chin ups Bart's super good at them. So it's good to do those with him It makes me push myself a little bit. I did some dumbbell incline press some side lateral raises and just a little bit of arms When I'm traveling just try to get a pump try to feel good It was a mess at the gym appreciate you guys give this video thumbs up New videos coming every Tuesday Wednesday Thursday a Saturday a Sunday I will be back on twitch as soon as I'm back from Texas check out mama's boys podcast on iTunes two new episodes a week I think you guys will really love it the feedbacks been great. I appreciate all you guys catch you in the next one


of the Apgu. So it was spelled so many different ways. People would spell like Apguhui, Apguwi. Some people think that Gui is Apguwi, which goes from Gui breeder. I don't know. I don't have enough experience with Gui breeder's Gui. The Apgui I was familiar with was a more, I wouldn't say short, but yes, it was more squatter than most plants people are used to dealing with. It had this beautiful almost watermelon blueberry-type turf that was very hard to describe, and it was true breeding for it. Almost everything I crossed it to, or that it was crossed in, took on the Apgui smell, and I could see how people could get very overwhelmed by it because it's very distinctive. You could also describe as like cantaloupey berry. It was unique, and I tended to love it. It would pass on beautiful resin traits. It had good potency, not the best yield, but I think overall it's one of my faves off this list.