The 2019 World Patient Safety, Science & Technology Summit celebrated the remarkable progress being made around the world to save patient lives from preventable harm, introduced two new Actionable Patient Safety Solutions (APSS), highlighted new commitments and discussed strategies in making sure every hospital incorporates every APSS before 2020.
For the seventh year in a row, former U.S. President Bill Clinton presented the keynote address. He commended attendees on the 273,077 lives saved over the last seven years and asked participating clinicians, hospitals, and healthcare technology companies to recruit others to join them. During his speech, Clinton stated:
“I’m grateful that the movement just in the last year alone saved more than 90,000 lives. I’m grateful for the 4,700 hospitals at home and around the world that are part of this effort. I’m grateful that 89 technology companies have committed to share data to develop algorithms and predict dangerous trends. And I hope there will be more. I’m very happy that this is increasingly a global effort. My most important message is to please stay active in this, please get more people active in it, and don’t give up.”
After his speech, President Clinton sat down to discuss with Founder & Chairman of the Patient Safety Movement Foundation Joe Kiani the state of the world today and the dangers of apathy, global warming, and the opioid epidemic.
During his State of the Movement address on the Summit’s first day, Kiani reviewed the progress made to date, reminded attendees of the 2020 goal, and urged every hospital to implement all of the Actionable Patient Safety Solutions (APSS). He stated, “To err is human but to not put the proper patient safety processes in place is inhumane.”
Other Summit keynotes included speaker Daniel J. Cole who presented on the challenge of delirium from the perspective of the American Society of Anesthesiologists (ASA). The panel on delirium was moderated by Dr. Michael A. E. Ramsay and the panelists—Dr. Pratik Pandharipande, Lee Fleisher, Adrian Gelb, Dr. David Scott, Dr. Daniel Arnal Velasco, and Audrey Curtis—discussed how delirium can be prevented in half of the estimated 2.6 million patients affected by it in the U.S. each year.
World-renowned patient safety expert Dr. Peter Pronovost provided another keynote on going from healing in the hospital to being healthy at home. And Prof. Kai Zacharowski, Director of the Department of Anesthesia, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, and incoming President of the European Society of Anaesthesiology (ESA), shared his perspective from the ESA, urging critical care medicine intensivists and anesthesiologists to join forces to combat patient safety problems.
New Actionable Patient Safety Solutions (APSS)
The 2019 Summit introduced an important APSS in Medication Safety: Drug Shortages. By addressing drug shortages in the healthcare system, caused by such factors as business decisions, manufacturing problems, and product discontinuation, hospitals can mitigate possible delays in treatment protocol and the increased likelihood of medical errors due to subpar substitutes.
In addition, Dr. Steven Scheinman, Dean of Geisinger Commonwealth School of Medicine, introduced the 17th APSS on Patient Safety Curriculum for Schools. The new APSS is a core patient safety curriculum that can be adopted by educational programs for all healthcare professions (nursing, pharmacy, behavioral health, medicine, etc.). It is being released after nearly two years of development by a workgroup comprising academics, clinicians, and patient advocates dedicated to improving patient safety through educating the young. The curriculum will go beyond care of individual patients to address systems of care and close a critical gap in student training when they are introduced to patient safety.
Kiani stated, “We can’t hope for zero preventable harm and deaths; we need to plan for it and put the proper patient safety processes in place. Patient safety experts from around the world have done the heavy lifting and created proven solutions. These APSS are available to every hospital and thousands have implemented one or two APSS, but sadly, only four hospitals have implemented all of them. We hope to see every hospital implement every APSS in 2019.”
In addition to the Delirium Panel described above, several panels featuring noted experts in their respective fields explored in depth critical topics in the areas of technology, transparency, and the media across both days of the Summit.
- Healthcare Technology Leadership Panel
Medtronic’s Chairman & CEO Omar Ishrak moderated a panel to discuss how hospitals are leveraging open data to create interoperability. The panel consisted of Dr. Donald Rucker, National Coordinator for Health Information Technology, U.S. Department of Health and Human Services; Ed Cantwell, President & Chief Executive Officer, Center for Medical Interoperability; Anders Wold, President and Chief Executive Officer, Clinical Care Solutions GE Healthcare; Jan Kimpen, Chief Medical Officer, Philips; and Katherine Kay, patient advocate. Kathy was a “good catch” and lives to tell the story of how interoperability saves lives.
- Pushing Transparency and Aligned Incentives Through Policymakers Panel
This policymakers panel, moderated by former Surgeon General Dr. Richard Carmona and featuring Congressman Harley Rouda, discussed the need for aligned incentives toward furthering transparency. The panel also consisted of Larry Smith, Vice President, Risk Management Services, MedStar Health; Aidan Fowler, National Director of Patient Safety, Deputy, Chief Medical Officer England, NHS Improvement, Department of Health and Social Care; and Scott Morrish, patient advocate. Scott lost his son Sam preventably due to Sepsis in England.
- Leading Causes of Preventable In-Hospital Deaths Panel
Moderated by patient safety champion Dr. Tami Minnier, this panel examined the flipside of how patient safety is typically viewed. Instead of a Safety I perspective, where the focus is on creating an environment where “as few things as possible go wrong,” the panel highlighted the Safety II perspective that emphasizes ensuring “as many things as possible go right.” Panelists included Carole Hemmelgarn, patient advocate, whose daughter Alyssa died of C.diff; Dr. Helen Macfie, Chief Transformation Officer, MemorialCare Health System; Thomas J. Kallstrom, Executive Director and Chief Executive Officer, American Association for Respiratory Care; and Clifford Hughes, Immediate Past President & Chairman of Board of the Accreditation Council and International Society for Quality in Health Care.
- Hospital Leadership Panel
A panel of experts joined by patient advocate Jack Gentry discussed transparency from the legal perspective. The panelists encouraged transparency, just resolution, and immediate root cause analysis after each harm event.
- Media Panel
Journalists from USA Today, Health Service Journal, The International Consortium of Investigative Journalists, and CALMatters were joined by Jim Messina and patient advocate Jamie Thomas King. Jamie shared the heartbreaking story of losing his youngest son, Benjamin, in 2016 and being propelled into the world of patient safety. The panel urged hospitals to be open and share their stories of medical errors and medical successes.
Keynote addresses and panel discussions are now available on the Patient Safety Movement’s YouTube channel
During the 2019 Summit, Joe Kiani officially announced that David B. Mayer, MD, will serve as the Chief Executive Officer of the Patient Safety Movement Foundation, effective immediately, and Michael A. E. Ramsay, MD, FRCA, was named Chairman of the Board, effective after the 2020 Summit.
Dr. Mayer was one of the architects of CANDOR, which focuses on transparency, immediate root cause analysis, and education. When implemented at Medstar, CANDOR reduced serious patient safety events by 65% and reduced the cost of care associated with serious safety events (including medical liability) by more than $70 million since 2012. Dr. Mayer also serves as the Executive Director of MedStar Institute for Quality and Safety and previously served for almost seven years as MedStar Health’s Vice-President for Quality and Safety. He was selected by the International Society for Quality in Healthcare (ISQua) as an International Quality and Safety Expert and has been presented with the 2013 Founders’ Award from the American College of Medical Quality and, in 2016, with the Patient Safety Movement Foundation’s Humanitarian Award.
Dr. Ramsay is the Chairman of the Department of Anesthesiology and Pain Management at Baylor University Medical Center and President of Baylor Scott & White Research Institute. Dr. Ramsay is also a Professor at Texas A&M Health Science Center and holds a clinical professorship in anesthesiology at the University of Texas Southwestern Medical School as well as in the Department of Periodontics at Baylor College of Dentistry, Texas A&M University. Dr. Ramsay is the developer of the Ramsay Sedation Scale, a measurement designed for interpreting the depth of sedation for patients in the critical care unit. This scale has been adopted around the world. He has published over 200 peer-reviewed articles and numerous chapters in textbooks. He was a member of the Sedation Analgesia Guidelines Task Force of the Society of Critical Care Medicine. Dr. Ramsay was the 2013 recipient of the Patient Safety Movement Foundation’s Humanitarian Award.
The Summit’s first-day program ended with recognition of those who have made the greatest contributions in 2018 toward achieving the PSMF’s goal of zero preventable patient deaths by 2020. This year’s Humanitarian Awards recognized the lifesaving achievements of the following leaders in patient safety:
- Steven Moreau Humanitarian Award Winner: William C. Wilson, MD, MA, Chief Medical Officer, UCI Health
Each year, the Steven Moreau Humanitarian Award recognizes a hospital administrator whose zeal for improving patient safety in their hospital is clearly evident. Under Dr. Wilson’s leadership, UCI Health in Orange, California, became the first academic medical center to obtain a 5-Star ranking under the Patient Safety Movement Foundation’s 5-Star Hospital Ranking Program. In 2018, UCI Health’s commitments saved 16 lives. Dr. Wilson has worked to fully engage UCI Health’s clinical staff in creating a culture of safety for their patients and families.
- Beau Biden Humanitarian Award Winner: Julie Morath, RN, MS, President & CEO, Hospital Quality Institute (HQI)
This award is normally presented to a government official who has improved patient safety. However, Julie Morath’s efforts have helped spread transparency across the entire state of California and created a model for other states to follow. Under Morath’s leadership, HQI and CHA have encouraged voluntary reporting on five hospital-acquired conditions: CLABSI, SSIs, sepsis, VTE, and maternal safety. In a year’s time, she was able to get 92% of California hospitals engaged, and 55% of them are publicly displaying a dashboard on their websites.
- PSMF Humanitarian Award Winner: Tore Laerdal, MSc, Chairman and CEO of Laerdal Medical, Executive Chairman of Laerdal Global Health, and Executive Director of Laerdal Foundation
Under Tore Laerdal’s leadership, Laerdal Global joined the Patient Safety Movement Foundation’s network in 2017. Every year since, Tore has shared Laerdal Global’s progress implementing simulation-based training to advance patient safety across 80+ countries. Laerdal Global has partnered with other organizations, such as the American Heart Association, American Academy of Pediatrics, U.S. National League of Nursing, and British Heart Foundation, to work on solutions to address neonatal safety, airway safety, optimal resuscitation, maternal care, and feeding tube placement. In 2018 alone, Laerdal Global partnerships saved 30,500 lives.
Capping off the two-day Summit was a special evening musical performance by the two-time Grammy nominee Belinda Carlisle. She shared that patient safety is close to her heart as she too has lost both family and friends due to medical errors.