World Patient Safety, Science, and Technology Summit 2022: Zeroing in on Medical Errors
People make mistakes. When those people are physicians, nurses, or other healthcare professionals, mistakes can lead to patient harm or death. Medical errors claim the lives of over 3,000,000 patients every year. Globally, avoidable mistakes by healthcare professionals are believed to kill more people than HIV, malaria, and tuberculosis, combined. Some estimates predict that one in 12 patients is impacted by a preventable medical error, but that number could be even higher as there is no central database tracking these figures in most countries, including the United States. This article recaps the Patient Safety Movement Foundation (PSMF)’s 2022 World Patient Safety, Science, and Technology Summit and shares how the conference addressed zeroing in on medical errors.
The PSMF believes reaching ZERO preventable patient harm incidents and deaths across the globe by 2030 is an attainable goal. With the right people, ideas, and technology in place, fewer mistakes will be made and the likelihood that medical errors cause harm or death can be reduced.
PSMF’s vision of eliminating preventable patient harm and death across the globe by 2030 starts with raising awareness of this critical issue. The World Patient Safety, Science & Technology Summit (WPSSTS) welcomes anyone who is passionate about ending preventable patient harm, those people who are ready to take action now, to save patients tomorrow.
After a two-year hiatus precipitated by the pandemic, the 2022 WPSSTS was held virtually on April 29 and 30. Originally scheduled for March 4 and 5, a notice on the PSMF website explained:
As the Omicron variant has continued to put undue stress on our healthcare system and its workers, the Patient Safety Movement Foundation has decided to postpone the virtual World Patient Safety, Science & Technology Summit (WPSSTS) to April 29th through 30th. On a mission to eliminate medical errors, this decision supports our efforts to prioritize the health and well-being of our healthcare workers who would normally attend this event. We want to thank you for all the work you continue to do day in, day out to provide quality patient care, and hope that you can use this time to take care of yourself. We are excited to see you virtually in April at the 2022 Summit.
The 2022 WPSSTS was co-convened by the American Society of Anesthesiologists, the European Society of Anaesthesiology and Intensive Care (ESAIC), and the International Society for Quality in Health Care (ISQua), and the World Federation of Societies of Anaesthesiologists (WFSA). This year’s sessions focused on key issues impacting the healthcare industry, including:
- Overcoming Obstacles for Applying High-Reliability Principles in Healthcare
- Embracing the Science of Human Factors to Unleash Safety Innovation in Healthcare
- Patient Advocacy: The Compass for Innovation
- How Regulation Can Support Quality and Value in Healthcare
- Healthcare Safety During the Pandemic
Over 270 participants gathered from around the globe, including hospital and healthcare organization board members, C-Suite executives, frontline clinicians, patient advocates, patients/family members affected by medical harm, insurers and other payers, industry leaders from medical device manufacturers, pharmaceuticals, medical supplies, software and data analytics, government officials, and students with an interest in patient safety and quality healthcare. PSMF offers on-demand registration throughout this month, allowing the summit to extend its reach even further.
Randall Clark, MD, FASA, president of the American Society of Anesthesiologists, delivered the opening keynote address and drew from his experience as an amateur pilot when he referenced the fail-safe approach to mitigating the impact of human error. Preventing all human error in healthcare is not possible, therefore, in the event of a failure, there must be systems in place that ensure the errors will cause no harm or at least a minimum of harm.
Peter Provonost, MD, Ph.D., Chief Quality & Clinical Transformation Officer at University Hospitals in Northeast Ohio, began his work in patient safety over 20 years ago and is well-known for his work in creating a five-item checklist responsible for reducing central line infections by over 80%. Dr. Provonost shared the “Leading with Love” framework for massive change in healthcare. “Despite all the great work that we’ve done, healthcare still harms too often; it costs too much, and it learns and improves too slowly.”
The Leading with Love Framework:
- Believing that this (safer healthcare) is possible so that we can infect that belief in others
- Belonging – creating a peer learning community, connecting people, sharing wisdom
- Acting / Performing and Transforming – doing what we know works on a consistent basis and using innovation to create new, safer ways of working
- Participants were challenged to write down their “I will …” statements as they considered the next steps for moving from reactive and transactional care toward more proactive and relational care.
Several true stories of patient harm caused by medical error were weaved throughout the summit. These narratives were meant to inspire change, rather than elicit sympathy. Having a patient, family member, or healthcare worker share the devasting effects of the medical mistakes they endured, was humbling and impactful.
A highlight of the summit was the presentation of the first Joe Kiani Humanitarian Award to President Bill Clinton in recognition of the role he played in the founding of the PSMF in 2012 and his ongoing support of the WPSSTS since its inception in 2013.
The summit also included announcements from organizations who have made their own commitments to reach the foundation’s vision of ZERO preventable harm and death across the globe by 2030. This year, the PSMF highlighted organizations deemed “HRO Champions” (High-Reliability Organization) for sharing their patient safety data in an effort to improve outcomes for all, including Parrish Medical Center in Titusville, FL; Hospital D’María in Veracruz, Mexico; Christus Muguerza Hospital Sur in Monterrey; Mexico; Kaiser Permanente Northern California; Hospital Materno Infantil Irapuato and Hospital de Especialidades Pediátrica León in Mexico, and Hospital Espanol in Mexico City, Mexico.
Reaching zero harm will require healthcare systems and their staff to acknowledge faulty processes and embrace the reporting of near misses to create long-lasting change. Health care workers are human and therefore, infallibility is impossible. What is possible is creating systems and processes that support clinicians and safeguard patients, within an environment of inclusivity and respect for all participants. Human error does not have to equal patient harm.
The use of healthcare simulation-based training for individuals and systems-focused clinical simulation to improve processes was mentioned during the summit, but not to the degree expected. I am a healthcare simulationist who appreciates the role medical simulation can play in educating, training, assessing, and evaluating healthcare providers, processes, and systems. Throughout the summit, I found myself wondering how more widespread adoption of healthcare simulation-based training and evaluation could accelerate the progress toward the attainment of ZERO.
More About the Patient Safety Movement Foundation
Each year, more than 200,000 people die unnecessarily in U.S. hospitals, with more than three million deaths globally, as a result of unsafe care. PSMF unites patients, advocates, healthcare providers, medical technology companies, government, employers, and private payers in support of this cause. From Actionable Patient Safety Solutions and industry Open Data Pledge to its World Patient Safety, Science & Technology Summit, and more, PSMF won’t stop fighting until it achieves zero preventable patient harm and deaths. The organization’s mission is to urgently unify people and collectively improve patient safety across the globe.
- Patient Safety Movement. (2022, May 1). Patient Safety Movement Foundation. Retrieved May 1, 2022, from https://patientsafetymovement.org/
- Pronovost, P., Zeiger, T. M., Jernejcic, R., & Topalsky, V. G. (2022). Leading with love: Learning and shared accountability. Journal of Health Organization and Management, 39(03), 388–393. https://doi.org/10.1108/jhom-10-2021-0383
Jeanne Carey is the Director of Simulation at Baylor University Louise Herrington School of Nursing in Dallas, Texas. She holds advanced certification as a simulation educator and has 10 years of experience in all aspects of simulation, including the development and implementation of new simulation-based learning activities, training of simulation facilitators, and recruitment and management of standardized patients. Carey and the LHSON Simulation Team created the Two-Heads-Are-Better-Than-One (2HeadsR>1) strategy for role assignment in simulation. She is active in several simulation organizations and currently serves as an INACSL Nurse Planner.