January 18, 2019By Lance Baily

7th World Patient Safety Summit Opens With Goal For Zero Medical Error Deaths By 2020

The 7th Annual World Patient Safety, Science & Technology Summit opened today in Huntington Beach providing two days of focused conversations and presentations specifically addressing Patient Safety. HealthySimulation.com is proud to serve as a Silver Sponsor of the internationally attended event and will be updating about the event with hashtag Organized by the Patient Safety Movement Foundation (PSMF), the 2019 event brings together hospital leaders, patient safety advocates, healthcare professionals, concerned journals, affected victims of medical error, and corporate executives — all dedicated to solving the world’s patient safety crisis. The event opened early with a special screening of To Err is Human, which you can now buy To Err is Human through Amazon now!

The Summit features keynote addresses from public figures, patient safety experts and plenary sessions with healthcare luminaries, members of the press and patient advocates, as well as announcements from organizations who have made their own commitments to reach the Patient Safety Movement Foundation’s goal of ZERO preventable deaths by 2020.

The 2019 Summit gathers international hospital leaders, medical and information technology companies, the patient advocacy community, public policy makers and government officials, to discuss solutions to the leading challenges that cause preventable patient deaths in hospitals worldwide. The event is co-convened by the American Society of Anesthesiologists and the European Society of Anaesthesiology.

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PSMF Chief Operating Officer Ariana Longley, MPH opened the event announcing that the almost 500 pages of 18 Actionable Patient Safety Solutions (APSS), developed by volunteer healthcare professionals working with PSMF, have been combined into a single downloadable resource.

Each APSS is developed by a workgroup comprised of patient safety experts, healthcare technology professionals, hospital leaders, and patient advocates. The Foundation is proud to connect as many stakeholders as possible to focus on how these challenges can best be addressed. The Foundation’s Board of Directors also contribute and review the APSS prior to their annual dissemination. You can learn more and access the APSS support content here.

PSMF founder Joe Kiani took to the stage to welcome attendees to the 7th annual event speaking on his gratitude for the volunteers who have dedicated so much to help the movement, but also his frustration that there are still so many barriers and egos preventing change needed by the entire world’s population.

Joe suggested that “simple ideas work” when it comes to medical error. Even just “apologizing” can have monumental impacts for family members who have lost loved ones, easing the pain. And such small changes can have huge financial impacts. With the PSMF’s strong commitment to zero preventable deaths due to medical error by 2020, he announced that commitments to patient safety have saved over 273,000 thousand lives since the organization began. He reminded the audience that “we have to be the best” suggested he desired that every hospital in the US should be adopting use the APSS. “Please don’t hope for zero, plan for zero” Joe exclaimed.

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He also shared that earlier this month Baxter signed the PSMF’s Open Data Pledge, making it the 89th company to demonstrate the importance of data sharing to improving patient safety. Companies that have signed the PSMF’s Open Data Pledge are committed to allowing access to the data generated by their medical devices to anyone, including researchers, software engineers and entrepreneurs, that seeks to improve patient safety. By sharing data generated by their products, in accordance with applicable patient privacy laws, these companies help further the development of predictive algorithms that can notify clinicians and patients of dangerous trends and thus enable earlier interventions.

Senior Vice President and Chief Scientific and Technology Officer of Baxter International Sumant Ramachandra MD PhD said the company “signed the Open Data Pledge as part of our ongoing commitment to help transform patient care and improve patient safety, [which] is paramount to our mission to save and sustain lives.”

Joe kicked off the first panel with Michael A.E. Ramsay MD, FRCA, Chairman and President of the the Dept. of Anesthesiology and Pain Management at Baylor University Medical Center and David B. Mayer, Executive Director of MedStar Institute for Quality & Safety to reflect on the progress of the PSMF.

Dr. Mayer suggested that “aviation never competes on safety”, and “imagine if we left a plane crash on the runway for 4 weeks” before evaluating what happened, and “where is that urgency in healthcare — we need to respond the same way the NTSB does.” Pilots are saying more and more that they are becoming “Risk Assessment Mitigators”.

He followed that focusing on patient safety “improves the quality, reduces risk, lowers the cost and provides better value. We’ve had less claims, saving over 100 million dollars in the past 7 years”. He continued that leadership is crucial to follow evidence based approaches that prove patient safety saves lives, adding “save the young and regulate the old”.

Jim Messina, CEO of the Messina Group chaired the Media Panel session, which was presented by:

  • Jayne O’Donnell, Healthcare Policy Reporter of USA Today,
  • Jamie Thomas King, Actor and Patient Advocate
  • Spencer Woodman,  Reporter of The International Consortium of Investigative Journalists
  • Shaun Lintern,  Senior Patient Safety Correspondent Health Service Journal
  • Elizabeth Aguilera, Health Care Reporter at CALmatters

The session opened with a gripping video story of Jamie who lost his newborn son to oxygen deprivation because the emergency c-section his wife need was delayed beyond safe standards.

Sympathizing, Shaun suggested that journalists have an important role to play in patient safety by exposing healthcare institutions that try to cover up medical errors to wider audiences. He shared the story of how investigative work uncovered a scandal at the NHS which lead to numerous new laws across the system. He suggested the next challenge is to get the right culture in healthcare, starting with an acknowledgement of the harm being done to patients in the industry.

Jayne shared that she wants to write more stories about the success of hospitals too, but most organizations don’t want the public to know about. But it doesn’t have to be all bad, she advised, and hospitals should publicize patient safety success stories by connecting journalists directly with patients willing to share.

Spencer shared his groups look at medical device companies to find systemic problems, starting with data sets first before going to patient groups to hear personal stories. He shared a recent story looking at data after seeing a lot of adverse effects for one type of infusion pain pump which was still implanted in hundreds of thousands of patients even though it had been pulled by the FDA. He highlighted this demonstrating that his story was the only article about the issue, showing how little journalism is done in the healthcare patient safety space. He suggested we all look at a new film “The Bleeding Edge” to learn more about the patient safety issues in the medical device industry.

Shaun reminded us that “there is a tsunami of patient anger coming to us, and because of social media we can all be swept away”. He hopes the work of journalists will help to challenge the status quo, and that the disconnect between the clinicians at the PSMF event and those back at their medical institutions is the what must be tackled next. Explaining further, Shaun shared that exposing outliers in performance in the UK at the NHS is bringing change. Not just for negative results, but also for positive stories after brave departments willingly share the improvements they have made after finding adverse issues.

Hospital Leadership Panel on Transparency

David B. Mayer, Executive Director of MedStar Institute for Quality & Safety, came back to the Patient Safety Summit stage this afternoon to chair the Hospital Leadership Panel which included:

  • Dr. Mike Durkin, OBE, MBBS, FRCA, FRCP, DSc Senior Advisor on Patient Safety Policy and Leadership at the Institute of Global Health Innovation, Imperial College London
  • Jack Gentry – Patient Safety Specialist
  • Allen Kachalia, MD, JD Senior Vice President at Johns Hopkins Medicine and Director Patient Safety and Quality at the Armstrong Institute of Patient Safety and Quality
  • Jon Schochor JD, Senior Managing Partner at Schochor, Federico, & Staton, P.A
  • Peter Lachman MD, MPH, MBBCh, FRCPCH, FCP Chief Executive Officer The International Society for Quality in Health Care (ISQua)

Dr. Mayer started by asking if hospital legal departments can win 90% of cases, what incentive is there for c-suite executives to take responsibility? “Even though 70% of claims and costs go to lawyers” he added. To start the process of moving beyond litigation, he said that healthcare providers have to be open and honest with themselves. Savings come later from better care, not from malpractice legal strategies.

He then shared about the CANDOR (Communication and Optimal Resolution) program, a foundational element of the comprehensive patient safety program at MedStar Health. CANDOR, along with a commitment to fostering a learning culture, the principles of high reliability organizations, and a systems approach to identifying, examining, and resolving weaknesses in our system are hallmarks of the MedStar safety program. CANDOR itself is a paradigm shift from “delay, deny and defend” to early communication with patients and families leading to timely resolution and systems improvements where appropriate.

Dr. Kachalia explained that disclosure is becoming more prevalent, and that in fact, in many cases after starting transparency programs, litigation costs go down. As a lawyer, Jon Schochor shared that it is not so much the medical error that brings patients and their families to lawyers. Rather, victims come to lawyers because the hospital system turns against them when they need the help most; ignoring them, or lying to them.

Dr. Lachman suggests that part of the problem lies with the system, where providers don’t like being wrong and are not taught to deal with failure. He believes that change will only come when healthcare acts like aviation, and focuses first and foremost on safety, with healing services a close second after that. Dr. Durkin explained that in the UK, it took patients, providers and government working together to report data to really assess the data for patient safety issues. Following this, a financial incentive increased risk safety assessments dramatically.

Medical error victim Jack Gentry, joined the panel to share that although his heart breaking experience at MedStar left him quadriplegic, the immediate communication and apologies from the doctors, risk management team members, and hospital executives helped him start his healing process. By being open and transparent not only with the patient and the family, but also amongst themselves, is the most important aspect of such errors — so that something can be learned from the unfortunate circumstance.

Dr. Lachman poised an interesting perspective to maximize transparency: Ask the patient victim of medical error what they think should happen? He agreed with other panel members that an open and honest system starts with immediate responses to errors, by providers to institutions and victims.

Visit the Patient Safety Movement Website to Learn More!

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