2019 World Patient Safety, Science and Technology Summit: Planning for Zero Deaths

New CEO of the Patient Safety Movement Foundation, David Mayer says every hospital needs to implement the 18 Actionable Patient Safety Solutions.

From day one of our Movement, our goal was to eliminate preventable patient deaths in US hospitals by the year 2020. With 2020 one year away, there is an urgency to engage every clinician, hospital administrator, patient advocate and medical technology CEO to help us. The 7th World Patient Safety, Science & Technology Summit in January allowed us the opportunity to celebrate our progress and successes, thank the many hard-working contributors, and highlight best practices we call Actionable Patient Safety Solutions (APSS). We stressed the importance of planning for ZERO instead of just wishing it will happen. One of the core messages this year was that we can’t change the goal date and that we need every hospital to implement all 18 APSS today.

What does planning for ZERO look like? Wecan look at the four hospitals that are 5-Star Hospitals, making commitmentsaround all APSS. CHOC Children’s Hospital in Orange County, California,University of California Irvine Medical Center, Parrish Medical Center inFlorida, and Hospital Español in Mexico City.

We can also look at the progress made bythe 4,710 hospitals around the world that have implemented at least one APSS.Cumulatively since 2013, these hospitals have saved 273,077 lives.

Planning for ZERO also means planning foras many things as possible to go right in every hospital setting. That was thefocus of one Summit panel that described this approach as a Safety IIperspective. So rather than a Safety I perspective of simply working to makesure nothing goes wrong, hospitals need to start shifting their focus to aSafety II approach of ensuring everything goes right.

A new APSS and a key component of planningfor ZERO (and sustaining that number) is making sure every person entering thehealth field is properly educated on patient safety early in their training. Atthis year’s Summit, Dr. Steven Scheinman, Dean of Geisinger Commonwealth Schoolof Medicine, introduced our APSS on Patient Safety Curriculum for Schools. Thiscore patient safety curriculum was designed so it could be adopted by anyeducational program in all healthcare professions (nursing, pharmacy,behavioral health, medicine, etc.). It was developed by an incredible team ofacademics, clinicians, patient safety experts and patient advocates to close acritical gap in student training. It is available for download on our websitewithout charge for any student and school interested.

Planning for ZERO also requires fulltransparency in the event of a harm incident, the topic of a Summit panel titled“Pushing Transparency and Aligned Incentives Through Policymakers.” Many yearsago, I was part of a team that helped create a program called CANDOR whichstands for Communication & Optimal Resolution, which represents a paradigmshift from “delay, deny and defend” to early communication with patients andfamilies leading to timely resolution and shared systems improvements. Sincebeing implemented at MedStar Health in 2012, CANDOR has reduced serious patientsafety events by about 65% and reduced the cost of care associated with serioussafety events (including medical liability) by more than $70 million since2012.

Another essential piece of theplanning-for-ZERO puzzle is the creation of a patient data superhighway. Bysecuring Open Data Pledges from as many healthcare technology companies aspossible (while respecting patient privacy laws), researchers and engineers cancreate predictive algorithms and decision support tools so clinicians canidentify an issue before it becomes fatal. With the recent signing of Baxterand Mindray, we now have 90 companies agreeing to share data.

I joined the Movement in January and Icouldn’t be more grateful for our many partners, individuals and organizationsalike, that continue to fight to save patient lives by reducing unintentionalbut preventable harm, overcoming systemic inertia and proving that a culture ofpatient and caregiver safety is possible, worthwhile, and a moral obligation. Ithink it was important to have our co-convening organizations - AmericanSociety of Anesthesiologists and the European Society of Anaesthesiology by ourside at our Summit. Anesthesiologists were among the first to show what’spossible when people don’t want to put up with the status quo, and thanks totheir determined efforts and those of the Anesthesia Patient Safety Foundation,the risk of death from general anesthesia has dropped to almost zero.

I am also grateful for the support anddirection of former U.S. President Bill Clinton, who has attended every Summitsince our inception. In his closing remarks he reminded everyone “to pleasestay active in this, please get more people active in it, and don’t give up.”

We are not going to give up. We are not going to move the goalpost. But with 2020 less than a year away, we need every hospital, every health professional and policymaker, every medical device company, every educator, to join us. You can make a difference. You can plan for ZERO.

Originally published in  Issue 2, 2019 of MT Magazine.