Each year there are over 200,000 preventable patient deaths in U.S. hospitals alone,1,2 more than 3,800 every week. That is equivalent to two jumbo jet passenger airplanes crashing and killing all passengers, on a daily basis. On January 13, 2013, hundreds of prominent doctors, nurses, hospital administrators, medical technology executives and engineers, as well as patient advocates from across the world attended the inaugural Patient Safety, Science & Technology Summit. The goal was to create actionable solutions to today’s most pressing patient safety problems. By the end of the second day, the Patient Safety Summit had inspired a groundswell of hospital commitments to establish solutions to eliminate preventable deaths and medical technology company commitments of patient data accessibility in hopes to eliminate preventable patient deaths by the year 2020. “When we lost 3,000 people in the 9/11 tragedy, we created Homeland Security, the TSA, spent four trillion dollars on two wars and put our soldiers and innocent civilians in Iraq and Afghanistan in harm’s way. Yet we lose more than 3,000 people a week in U.S. hospitals alone, and no Patient Safety Security department has been created and the government has not declared war on these preventable deaths,” stated Joe Kiani, founder and Chairman of the Masimo Foundation for Ethics, Innovation & Competition in Healthcare, founder of the Patient Safety, Science & Technology Summit, and CEO of medical technology company, Masimo (NASDAQ: MASI). “With the Patient Safety Summit, we felt it was time to try something unique. We tore down the walls between the hospital, medtech companies, executives, doctors and engineers. We brought in the voice of the patient with powerful stories from patient advocates. We identified challenges that are causing preventable deaths and provided solutions to address the challenges. The solutions were clear, concise and left nothing out, for the sake of patient safety. We asked medtech companies to sign a pledge to make the data their products are purchased for, the patient’s data. We also announced that to return to the next Summit, each attendee had to make a commitment toward achieving the goal of zero preventable deaths. Former President Clinton also joined the challenge and from the reaction of the participants, the formula worked. We got nine medtech companies to make the pledge. We got more than 20 hospitals and hospital groups to make commitments to implement one to all of the solutions to get to zero preventable deaths,” Kiani continued. “But, to realize the dream of zero preventable deaths by 2020, we all have to get involved and we all have to commit. I urge all of my colleagues in our healthcare industry, from medtech companies to hospitals, from doctors and nurses to engineers and technicians, to join us today and make a commitment to zero preventable patient deaths by 2020, one hospital department at a time, one medical product at a time, one act of kindness and love at a time, especially on Valentine’s Day,” Kiani concluded. “To join us, please visit patientsafetymovement.org and make your commitment to Zero!” Commitments to Stem the Tide of Preventable Patient Deaths Many proactive clinicians dedicated to improving patient safety at their institutions, set the stage for action at the January 2013 Summit by establishing Commitments to Action. Hospitals, including Fletcher Allen Health Care (Burlington, VT), Hoag Memorial Hospital Presbyterian (Newport Beach, CA), Hospital for Sick Children (Toronto, Canada), Intermountain Healthcare (Salt Lake City, Utah), Johns Hopkins (Baltimore, MD), Sinai Health System (Chicago, IL), Miami Children’s (Miami, FL) and University of Miami Hospital (Miami, FL) committed to zero preventable deaths by 2020, by going after the challenges with action plans. Below are highlights of just a few of the actionable commitments made by the clinical community participants to reduce preventable patient harm and deaths within our hospitals. Preventing Respiratory Depression Deaths from Post-Operative Opioids: Michael A.E. Ramsay, MD, FRCA, Chairman of the Department of Anesthesiology at Baylor University Medical Center and President of Baylor Research Institute in Irving, Texas, made a commitment to educate clinicians about the unintended risks and delayed effects of some opioids administered post-operatively for pain management and work to research, deploy and refine new technologies that help to identify opioid-induced respiratory depression before a failure to rescue occurs. “Most clinicians don’t realize the delayed effects and unintended risk of death posed by the use of some commonly administered opioids designed to manage pain after surgery,” stated Ramsay. “My commitment is to change this by delivering lectures and teaching rounds in healthcare facilities around the world about the dangers of post-operative respiratory depression induced by the use of opioids for pain management. In addition, through my research in this area, I will continue to identify and help deploy technologies proven to prevent failures in care and further develop the clinical practices and technology protocols necessary to prevent unrecognized opioid-induced respiratory depression. These are all preventable adverse events with proper education and technology.” For more information about the Failure to Rescue challenge and solution, click here. Preventing Infections in Hospitalized Patients:Robin Betts, RN, MBA-HM, Assistant Vice President of Quality & Patient Safety at Intermountain Healthcare, made a commitment to reduce Catheter Line Associated Blood Stream Infections (CLABSI) at Intermountain – a 22-hospital system. With a target goal of reducing Intermountain’s CLABSI rate from 1.71 per 1,000 central line days and 1.25 baseline rate from 2012 to 1.06 during the third quarter of 2013, Betts is hopeful that this overall 38% reduction will positively impact (directly or indirectly) over 140,000 patients. “Blood stream infections from catheter lines pose terrible complications and danger for patients,” said Betts. “They increase the intensity of care, length of stay, cost of care, and patient exposure to unnecessary antibiotic therapy. Preventing infections in hospitalized patients is a national priority and aligns with the objectives of the Patient Safety, Science & Technology Summit to create a healing environment free of harm.” For more information about Central Line Catheter Infection and solution, click here. Creating a Proactive Culture of Patient Safety:Sharon Rossmark, System Vice Chair & Board Chair for Patient Safety at Sinai Health System, made a commitment to establish Comprehensive Unit Based Safety (CUSP) teams across the 3-hospital system. These teams will be established in each unit of the hospital to proactively assess risks and identify solutions that will improve patient safety and quality of care. Rossmark expects to have a fully operational CUSP team in every unit of the hospital within two years and anticipates that their patient safety vigilance will have a positive impact on more than 80,000 patients. “At Sinai, we live our vision of being the national model for the delivery of urban healthcare and pride ourselves on having a culture of quality, as reflected in our outstanding performance on CMS core measures,” Rossmark said. “This Commitment to Action, extending that ethos to a proactive culture of patient safety, is a natural next step.”Making Patient Safety a Global Effort: Edward Kelley, MD, PhD, Coordinator and Head of Strategic Programmes for Patient Safety at the World Health Organization (WHO), said patient safety is a global imperative. “Preventable patient deaths are a human tragedy that is global in scope. This year, the World Health Organization will develop an international effort on blood safety, which will involve raising awareness about blood transfusions and technological solutions to appropriate blood management. Moreover, in 2014 we will make medication safety the 3rd WHO Global Patient Safety Challenge, involving all 194 member states of the World Health Organization to improve the safety of medication practices and reduce unnecessary harm and deaths from medication errors worldwide.” For more information about the Blood Transfusion Overuse challenge and solution, click here. According to Dr. Peter Provonost, Sr. Vice President for Patient Safety and Quality at Johns Hopkins Medicine and Director of the Armstrong Institute for Patient Safety and Quality, “Despite significant effort to reduce preventable harm over the last decade, there is limited evidence that harms have been reduced across the country and globe. The Patient Safety, Science & Technology Summit, convened under the leadership of Joe Kiani, is informed by the model that allowed ICU infections to be significantly reduced across the U.S. It aligns all groups behind a common goal with a valid measure, it is informed by science and technology, and it is infused with humility of the task at hand, inviting all to help achieve the goal of zero preventable deaths by 2020.” Nine Medtech Companies Sign a Pledge to Make Patient Data Accessible Medical Technology Companies have made incredible advances in helping to diagnose, treat and monitor patients. However, according to Kiani, data ownership, information sharing, device integration and interoperability issues are hindering our healthcare system’s ability to keep patients safe. Kiani views the Summit as the first step in a movement of industry collaboration and “Co-Opetition” that will remove the information barriers that are plaguing patient safety. In this pursuit, Kiani penned and signed a pledge to patients vowing to make patient data accessible and open for sharing with other technology makers. Kiani, Dr. Pronovost, and former President Clinton issued a challenge to all medtech companies to do the same. Eight answered that challenge. Cercacor, Cerner, Dräger, GE Healthcare Systems, Smiths Medical, FUJIFILM SonoSite, Surgicount, and Zoll each made groundbreaking pledges to make patient data collected and displayed on their devices accessible for patients and clinicians – launching a movement designed to create a patient data superhighway, which with powerful predictive algorithms could help reverse the rising tide of preventable patient deaths in hospitals. Tom Gentile, President and CEO, Healthcare Systems, GE Healthcare, said, “GE Healthcare feels great responsibility to collaborate closely with hospital providers and industry partners to pursue zero preventable deaths. Our pledge outlines how the company is tackling this goal, for instance by expanding access to GE Healthcare technologies across the globe, supporting caregiver training and education, developing innovative technologies that accelerate clinical decisions, and delivering connected systems that work across the hospital.” ZOLL CEO, Richard A. Packers, said that making his pledge at the Patient Safety, Science & Technology Summit, January 14, 2013, strongly aligns with the company’s existing philosophy. “From a patient perspective, providing data from ZOLL devices and integrating the information to other devices is doing the best we can for the patient. It’s that simple.” Lenore Alexander, a patient advocate and founder of Leah’s Law Foundation, stated: “For over a decade, since I lost my daughter due to a failure to rescue event in a prestigious hospital, I have watched different organizations create patient safety meetings. While great minds were assembled, I could not feel that something tangible was going to come out of it. The Patient Safety Summit, from the onset was totally different, with the first few words stated, the Summit took a group of people who were not sure they could work together, let alone trust each other, to realize it’s time to break down the walls between the entire healthcare industry to work together. By the first break, hospital representatives and corporate CEOs were lining up to make their commitments to achieve the goal of zero preventable deaths by 2020. It was unlike anything I experienced. I was not alone – it’s what everyone I spoke to said about the meeting. I can tell you that this is the first time people can see the light at the end of this tragic tunnel. It is the first time in 10 years I feel like I want to get up in the morning.” “I hope that you will join us and help make preventable patient deaths a thing of the past,” Alexander concluded. Videos of the speakers and panel sessions can be viewed online at:https://patientsafetymovement.org/2013-patient-safety-summit/videos/ Photos of the 2013 Summit can be viewed online at: https://patientsafetymovement.org/2013-patient-safety-summit/photos/
- Daniel R. Levinson, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, Department of Health and Human Services Office of the Inspector General, November 2010.
- Kohn LT, Corrigan JM, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999, p. 1.
About The Patient Safety Movement Foundation
About the Masimo Foundation for Ethics, Innovation and Competition in Healthcare
Committed to advancing positive change for the benefit of patients, clinicians, hospitals and payers everywhere, the Masimo Foundation for Ethics, Innovation, and Competition in Healthcare is a U.S.-based, private charitable foundation that is focused on improving patient care, preserving patient dignity and reducing cost of care, through philanthropic programs and research initiatives that foster an environment of aligned incentives, highest level of ethics for those who take part in the care of patients, and healthy and honest competition. The Masimo Foundation also helps create pathways for new lifesaving discoveries and inventions, and improve access to cost-effective, innovative healthcare solutions. The Foundation’s emphasis is on transformative projects that seek to truly enhance patient safety and outcomes; helping to forge a world free of sickness, disease and inhumanity. Masimo Foundation supports third-party research, development initiatives, and clinical studies designed to expand the healthcare industry’s ability to provide better and more cost-effective solutions and protocols for healthcare delivery. The Foundation also gives special attention to causes whose goals are ethical – focused on doing the right things for the right reasons – and designed to foster innovation and create healthy competition, which the Foundation believes is the ultimate answer to improving care, improving access to care, and lowering healthcare costs in the United States and around the world. To learn more about the Masimo Foundation, visit www.masimofoundation.com.
The Patient Safety Movement Foundation
Phone: (858) 353-3581