2009 Dr. Moorhead had an event that was life-altering. This event made him change the way he looked at things.

Dr. Moorhead:

I had a patient that I was working on that day under Ivy sedation. He was 72 years old and had a simple health history; he was an ideal patient. He had put off work for decades and he came in and said, “Doc, you gotta help me. I'm in so much pain I can't take this anymore." So, we had him in that morning and got the IV started after taking his vital signs, which looked perfect.

As I was watching the pulse oximeter, it started to go lower and lower

I reached for the oxygen and turned it on and it didn't come on- it did not come on.

We wore radio headsets in the office, so I radioed and said, “get the oxygen on quick!”

It seemed like an eternity before my assistant came back on and said “doctor, all the tanks are empty”.

Long story short, I did what no one should do during an emergency. I panicked.  I started lashing out at my staff which made things way worse.

Finally, one of them took me aside, looked me straight in the eye, and said, “doctor get it together. You're not accomplishing anything this way”.

Then, I realized I have a reversal agent and I gave him the reversal agent and he was fine. 

I was even able to keep the appointment, but I realized we had to do something different.  We needed a safety protocol. We needed a way to be able to error-proof the office.

And that's when I got interested in Standard Operating procedures (SOPs).

You can look at SOPs in other industries, like the golden arches of McDonald's. We don't go back there because it's necessarily great food, but we still go back because they have consistency no matter what time of day and no matter which McDonald's restaurant

We go to Starbucks and we order two pumps of this and no foam and whatever and all this complicated stuff and they nail it every time because they use systems.  Systems are super important not just for good coffee and good fries but also for life-saving events, potentially.

It is so super important that we have those.