 Okay, well hello everyone and thank you so much for joining our webinar and the title of today's webinar is recognizing unsafe care what it is and how to report it. Next slide please. And so before I jump into the objectives, I will very quickly introduce myself. So my name is Sarah Miller. I'm our director of partnerships here at the patient safety movement foundation and we're very excited again to welcome to you to this month's webinar and in a few slides we will introduce our panelists, but I will start off by jumping into the objectives. So the first objective for today is defining the term medical air and discuss the most frequent types of patient harm. The second is understanding the difference between negligence and human error. The third describing the typical process for reporting unsafe care. The fourth is discussing how to escalate concerns that are not adequately addressed even after they have been reported. And then finally, the last one is examining ways that patients and families can get involved in driving organizational improvement. Next slide please. So just a quick housekeeping items for those of you that are on the live webinar today, we will be providing one approved credit for BCPA. It will take about five to seven days to process. So if you have any questions at all, please feel free to email clinical at patient safety movement.org with any questions regarding your CE. So with that said, we will jump into introducing our panelists so I will be facilitating today's webinar, but it's my great pleasure to introduce our moderator Marcy Romero. So Marcy would you like to introduce yourself. Yes, thank you so much, Sarah. It is a pleasure to be here today with all of you, and especially with this esteemed panel. My name is Marcy Romero. I'm a registered nurse. I am a nurse at the University of New Mexico Hospital in Albuquerque, New Mexico, and I am the manager for the patient family advisory committee. I've been in this role for about a year and I am passionate about including the patient voice and the delivery of healthcare. The patient perspective is so important to everything that we do and in fact we cannot move forward without it. So with that, I am going to introduce our panelists here. I am going to begin with yourself. Peter Capitain and Peter, I'm sorry if I said your last name wrong, comes to us from the Netherlands and as a patient advocate as well as a CEO and inspired to live. An organization with an international reach that connects patients, researchers and clinicians in the fight against cancer. Currently, program manager and advisor for complex and politically difficult problems where he organizes, congresses and lobbies the matrix of public authorities that's difficult work Peter. Healthcare organizations, insurance companies and health research institutes. Peter's sole aspiration. I love this is to create awareness and hope through showing people to live their lives happy and healthy in harmony with cancer. Peter, thank you for all that you do. Carol, Carol, you have an impressive bio Carol graduated from Colorado State University go Rams with a degree and speech communication. She received a master's degree in patient safety leadership from the University of Illinois, Chicago, and a second master's degree in healthcare ethics from Creighton University. Carol has worked in healthcare for 30 years. She was an adjunct professor at the University of Illinois in Chicago for 10 years, teaching and their master's program for patient safety. Currently, Carol is the senior director of education for MedStar Institute for quality and safety, and she is also the director of education at the executive master's program for clinical quality safety leadership at Georgetown University. Pamela Garn is involved in patient safety work across the country. She sits on the leapfrog patient and family caregiver expert panel for quality safety and experience at Children's Hospital Colorado, pediatric substance outcomes collaborative at Children's Hospital of Colorado, clinical excellence council for Colorado Hospital Association, and the board of directors for the collaborative for accountability and improvement. That is a mouthful Carol, her passion resides in transparency and communication after medical health care communication, and the power of storytelling that after the aftermath injured by providers patients and families when medical her transpires. And last but not least, I introduced Robin Betts who is an R and like myself, and a leader and clinical assistant and the implementation of safety improvement. She has dedicated her professional life to patient safety quality and high reliability systems to elevate patient safety and quality and health care. She has a distinguished 38 year health care career as a pediatric and NICU nurse nursing informaticists and executive leader of quality risk management and patient safety. As vice president for quality clinical effectiveness and regulatory services for Kaiser Permanente, Northern California, Robin helps further advance Kaiser Permanente's nation leading excellence in quality and patient safety, mental health services, and overseas health plans and hospital regulatory functions, including compliance licensing and member grievances. She sets the vision for patient safety and quality in pursuit of clinical quality excellence. So with that, let's begin. I'd like to begin by asking our audience to go ahead and use the chat box and define the term medical error for me please. And while you're doing that, again, use the chat box to find the term medical error. I'm going to give you a definition from the Institute of Medicine of Medicine and as well to our panel so Institute of Medicine defines medical error as the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. There are two types of errors, right. We have errors of omission and errors of commission errors of omission occur as a result of an action not taken. For example, not leaving the bedrolls up for a patient that is at risk for falling, or let's say not using the proper safety protocols when transferring a patient using a prance transfer device, maybe a lift errors of commission occurs the result of the wrong action taken. So an example would be providing medication to a patient where it was documented that the patient had an allergy to that medication, or operating on the wrong body part. I think it's important with that being said that we know that not all medical errors result in harm, right. And likewise, when harm does occur it's not always the result of the medical error. Often the medical error is a preventable adverse event, and they can occur in a number of settings. So Peter, from your perspective, I'm curious as a patient advocate, do you believe the majority of patients have a clear understanding of the definition of medical error. The answer is, it depends, of course, always be aware that I look at the world from the cancer patients perspective. So, coming to the moment that you have your diagnosis, I think most patients do not have an understanding of medical errors, which is quite logical because the day before you were not a patient yet. Looking at the two definitions omission and commission. I think even cancer patients who are shortly ago diagnosed have a feeling what a wrong action taken might be, because they feel it quite in quite short term. They do not know omission errors, which is quite normal in cancer patients life that they have that the result of actions not taken because quite a lot of treatments are not available for patients within a country, or external of the country. Well, it depends. Most patients when they are only in a short, short term, a patient do not know anything, but become aware of the situation and cancer patients live. And that's of course, a good thing, longer and longer and longer and then they become aware of what is possible what is what is an error and what is not an error, which is a failure which is not a failure. So do you think in order to make an impact globally that that patients should be more well equipped with knowledge so have that knowledge beforehand. Do you think that would help aid in the reduction of medical errors. Definitely. Yeah, but but but again, when you become a patient on day one you do not know anything so you need help. And for that, I mean, I always make a difference. My definition between a patient and a patient advocate the patient is, well, does not know any anything from the start patient advocate should know they, and they should assist patients in the way they should in well preventing them from having not the right treatment and make them aware that there are medical errors that should be prevented that if they happen they can assist in, well, do the things that are necessary to prevent them in the future. Absolutely, you know, it makes me think of what you said, like for example, if I were to go to a car mechanic. I don't know a whole lot about cars, and I certainly wouldn't know what to ask for and diagnostic terms, right. And so but the certainly once your car breaks down and you have to, let's say replace the transmission, you might do a little bit of education, and if I could remind everyone to please go on mute. That would be helpful. Thank you. All right. And so I recently, as you know I'm the manager for PFAC, and I recently had an advisor have the privilege of presenting with our residents of the Department of Internal Medicine. And one thing that she brought up was the mental and emotional impact that sometimes medical errors have on patients that really providers don't think about. Carol, 87.3% of patients and the recent patient safety movement foundation poll reported that they knew nothing, or had heard nothing about medical errors within their local community within the last year. How important is it for clinicians and patients to speak a common language in an effort to reduce medical errors. So Marcy, it's really important because as we know in healthcare, healthcare has its own language, big words, acronyms, and there's a real push out there with organizations, not just across the healthcare, but across other industries, and it's called plain language. So in other words, in healthcare, we tend to use words like expire, when what does that mean to different cultures to different people, someone died. The other thing is, is in using plain language, then patients and families can understand more about what is going on in their care. And they can speak and articulate back to the provider so that it's a bidirectional communication. So it's really important that, you know, we're talking and communicating where everyone is on what they say the same sheet of music. Exactly, we're singing from the same hymnal. And what you said about, you know, bidirectional, they agree and it makes me think of teach back and how important that relationship is between the provider and the patient. And I'll be honest, as an RN, providing patient care, there have been times when I had thought that I explained something very clearly, when in fact, I had not. Carol, you know, I completely agree with what you said and with that being said, I will change the focus to patient education. 2019 report published by the Betsy Lehman Center for Patient Safety estimates the annual cost of medical errors in the state of Massachusetts alone. I thought this was fascinating to be $617 million. The state of Massachusetts alone. Again, this member does not reflect the emotional and mental impact that's placed on patients and providers so Robin. I'd love to hear from you from your perspective, what's the biggest barrier to providing comprehensive person centered education on quality improvement so the patients can understand this whole process or at least the tip of the iceberg. Yeah, I think that's such a great question. Health cares has a long standing history of designing for the patient instead of with the patient. And so in general, we are more comfortable directing care, instead of partnering in that care. The concept of patient and family centered care emerging two decades ago when the Institute of Medicine published crossing the quality cast. However, there is a lot of great maturity patient family advisory councils have been formed, but they largely remain existential to the safety and quality organization structures where we kind of reach into them when we want their input. Instead of embed them and having them be representative on our quality and safety committees to both hold us accountable for quality and safety and to provide insights into solutioning for safety. So there is a maturity and many organizations are somewhere along the spectrum, but we still have a long way to go. And I agree. I think it's exciting to see organizations not only form P fax, which we know have been around since the 1970s, but also to inform P fax with QS so patient family advisory quality and safety councils, and including patients in the beginning of a process rather than creating a process, and then going to them and saying hey what do you think of this. In fact, it saves a lot of time when you include them at the beginning because they will notice things and they will have input which as a healthcare professional. We want that. I think about transparency, and it can be scary, right, especially when we're being transparent about flaws, or something that we're normally not transparent about what you just shared, you know about the collaboration, I think is spot on. So Peter, again, and I know everyone on this panel has a lot of experience so please feel free to chime in but Peter, I can tell that you're extremely passionate about improving health outcomes for patients and families. And I want to play the doubles advocate for a second. I've been told by patients at times, and that they want to put all of their trust in the doctor, right. So why, why should I be involved, the doctors the expert. You know, I, he, this person here she has all the education, they're the ones that went to school. I'm just going to trust the doctor. What's wrong with that scenario. If you have a broken leg I think you should rely on the expert to repair that broken leg. But in many diseases there are choices to be made. And it's not always the right thing to treat until the end. Sometimes patients do not want to be treated at all they choose for a good quality of life for the rest of that life that might be three months, six months a year, two years. That means that, yes, the doctor might be the expert on that disease, but the choice is a personal perspective. And then the quality of life is determined by the patient. So the ends, the outs, the pros, the cons of different scenarios in treatments should be decided by the patient based on good information. And yes, the professional can give that information, the patient herself can also find a lot of information about it. And in the end, in a good discussion is the decision of the patient, what the right treatment is so yes, the expert is necessary, but it's not the only one who determines what the right treatment is. Robin, do you have anything you want to add? Robin, I see your hand. Yeah, I, any high, there's a concept about higher liability signs. So these are a highly reliable organization is an organization that consistently delivers on quality they have very, very deep effects. And one of the principles of high reliability is deference expertise. These organizations defer to the experts no matter where they reside in the hierarchy. In healthcare that may mean a patient or family member who is a content expert regarding some of the normal baseline. And they often are the first signals that our patients or their family member is getting into trouble and so listening to them is imperative. Absolutely Carol. Oh, Marcie is I think we have to also think about this from a cultural and generational. I agree. You know, my mom's 85 that generation you listen to what the physician said. They're very technical savvy new younger generation that are doing a lot of homework they go away and they ask questions. But there's also cultural issues where certain cultures would never question someone they feel is at a higher level or higher authority. You know, we can teach and we need to teach and we need to make people speak up. But we also have to be aware of where people are in their lifespan and how they've been brought up. All of those other things play a factor into why some some patients and families do not speak up. Absolutely. Absolutely. Thank you for bringing that up. I am glad someone brought that up and I also saw a comment in the chat that stated that the patient is the expert on themselves and absolutely. And I believe it's probably it's not probably it is the role of the health care provider to empower the patients to to empower the patient to take control of their health care, because it isn't always natural. It doesn't always come natural, especially when it's foreign. Right. And so, and I think about access to access to information. Not everyone has equal access to information. So, thank you. The one other thing I'll add because this goes a lot with Robin's expert in different expertise. We can often see when our loved ones are decompensating way before a lab test, because we know them we know those behaviors, and we know ourselves. So understanding again to listen to the patient and family because we might not be able to say oh we think they're septic, but we can see the changes and say something's wrong something's not right. You know, listen to me I don't know the medical term I don't know the technical term, but I know this child, and this is not their normal behavior. I think I'm sorry I'm sorry. I just, I just love that but what what makes deference text is so important to a highly reliable organization is because they, they are able to intervene early before things exacerbate. Accepting the information from the patient or family member, that's giving you that early signal allows us to intervene early instead of react in a situation where there's a complete decompensation. So it's just such a beautiful concept I love Carol's comments to about high distance power that can be cultural it can be age and and upbringing as well and so it's such an important factor to consider as we in healthcare need to have sensitivity to that. Oftentimes those social determinants of health have a have a definite play in this. I'd like to play a rather provide some troubling statistics, which I'm sure many of you know. It's estimated that between 210,000 and 440,000 individuals died from medical error yearly, which makes medical error the third leading cause of death in the United States behind heart disease and cancer. Now globally, there are an estimated 3 million people that died each year, and to put those numbers in perspective, that is more an HIV tuberculosis and malaria combined. It is the equivalent of three jumbo jet crashes every two days. Could you imagine. So Peter. In your opinion. How have we gotten to this point. And what have been major milestones that we have. And what have we learned from other industries. Well, to start with the last one I think to prevent medical and medical errors. We learned a lot from from the, from the aircraft industry, and, and a very, a very big tragedy happened in 1977 when it was the biggest incident in, in, in, in aircraft was was on the island of Tenerife, where over 500 people died. And that was kind of an impulse in, in, in making good controls and checklists, which were also used, of course, not from the technical perspective from a different technical perspective, which were also used in healthcare. And one of the biggest thing that was introduced was, you could say a kind of a second opinion that if someone says this is it, someone else has to say, yes, you're right. Doing surgery, the surgery has to say, this is the way we have to do it. And another one says, yes, you're right. And if of course the other one says, no, you're not. There's a discussion which cannot be taken too very long during surgery. So we learn from, from different industries. But by the way, I also think that other industries will learn from healthcare. Absolutely. I agree. And the double check, right. So I'm thinking about, and healthcare is a nurse, you know, having having another nurse double check and medication administration let's say of insulin. And so those would be things that we have learned from, from that industry. Another, another comment that I just saw come through that I, that I absolutely agree with, we have to consider where patients are in, in their journey. And so many of our patients come into the setting. And I think of, I think of patients just being diagnosed with cancer scared, right? Nervous, anxious. Right now, I think of the COVID pandemic. A lot of times they're not able to bring in visitors with them. So they're alone. And, and how, how do we empower patients that are in that, in that mode. Patients again, another chat, communication disabilities. I mean, we're thinking our difficulties, we're thinking about all of these factors and, and we can't forget them when we think about patient safety and getting this message across. I'd like to talk about the reporting of medical errors because I think this is really, really important. Robin. Can you tell us about the normal process for reporting medical errors, and who's the most likely person to report a medical error. Typically, medical error is reported through what we call event management systems or event reporting systems and they're really a requirement of hospitals and care delivery systems in America and in other national health systems. And now, and it's the responsibility of everyone, anyone who sees something or, or is actually an actor, and it could even be a near miss. The idea is that you as leaders create a culture where we want to hear from you. Please tell us even when you almost made a mistake so we can learn early and mitigate before harm occurs. So a great safe culture would see lots of near miss reporting and see their serious safety events go down at the same time so they have increased detection. But there are other ways to increase detection. You can do proactive monitoring of potential care gaps. You can also use codified triggers based on things like medical billing or other codes in the medical records such as a code that says return to or the patient return to the or that could generate a trigger that populates a work list of an identified resource who would then evaluate and make recommendations to do a deeper dive and say is there's something we could learn here and share with the rest of the organization about why this person had to go back to the or. And then not waiting till something happens in your own institution, but learning from literature and the industry because many of us are publishing our findings and our improvement methodologies to mitigate and eliminate harm. Right. And how do we share all this information. How do we, how do you know if there's so much so much information out there sometimes it's overwhelming. Yeah, there's wonderful organizations that we that are involved in the safety and quality science. For instance, there's a huge database where we submit a bunch of data about surgeries, all of our surgeries, and we share that and all that data is aggregated with thousands of other hospitals that are doing surgery. And we look at our performance trend and benchmark against each other. And so we know who the best performers are we can reach into them and talk to them and get advice. We do a lot of publication. So, whenever my team is engaging on an improvement project, I always ask them to let it to review scan the environment. What's been going on who's been doing what and then reach into those that have published, but we don't reinvent the wheel but we actually take that learning and laterally deploy it across our own organization. Absolutely. Harold, do you have anything to add I. Yeah, so Marcy it's interesting right now because you know we've had these PSOs these patient safety organizations out there for years, based on art, and a lot of them have not been successful. And I can tell you right now patient safety movement foundation Jewish healthcare are really trying to establish like the NTSB the national trans transportation safety board a healthcare patient safety board that for finally all the data will come in that we're looking at everyone's data hopefully at some point, then we can see those smaller nuances, but the patients and families also have access to this and are part of this. We need the same side as type of regulatory body for healthcare, like we have for transportation, if we're going to ever really make healthcare safer. I agree. And that's why I think it is so important that that patients are become educated that they that they start to learn some of the ins and the outs of quality and safety so that when this does happen to them, or, you know, God forbid that they know the actions to take right. And so I hear you talking about throughout this conversation human factors, and I think that that is important to consider as well. And, and, and reporting, right so when a provider experiences an error miss reporting that so that we can learn from it and not make those same mistakes again. So let's talk about the BIPOC or BIPOC and LGBTQ plus communities. We know that medical errors disproportionately affect these communities we've talked about this a little bit, and it negatively breaks down communication between the provider and the patients. We know that from our the number one reason for medical errors is a breakdown in communication. We haven't taken oath to treat all patients equally. Yet we know this isn't always the case. How, how do we ensure how how do we ensure that the impact on patients isn't greater than it already is how do we come together to help solve this problem because it is, it is growing quickly. And I think about the IT right and access and, and how an even reporting mechanisms for patients. Are we leaving people behind right now. So I'll take us first step at this Marci and I think there's several things is one. We're seeing more organizations doing training on cultural diversity language pronouns. She all of these things to not to further harm patients, you know, if you're transitioning and someone is calling you by the wrong name or the wrong, wrong pronoun. Those are small micro aggressions to those individuals. So, you know, we know that on the human factor scale education is one of those lower level things, but we have to start somewhere. So it used to be multi prong. So for instance, research used to be in white men, and then women were allowed to be part of research and now we realize that we have to look at age we have to look at different ethnicities. You know, that's one part how we address people. And then the other thing is, is that, you know, we have harmed certain groups. If you go back to the Tuskegee airmen and the way we did research with them and syphilis and Henrietta locks. There's a trust issue out there with certain different cultures and populations, and rightfully so. So how do we break down those barriers and I think where it's really showing right now is vaccines. You know, we need to get everyone vaccinated, but we have to have that trust again. I'm curious, who do, who do patients normally report to. Do we know that the number one person that a patient when they experience a medical error, who is the who's the first person they're going to share it with family. Right. And then what happens, and then and then what do they do. They're afraid to say anything if they're still in the hospital. They're afraid that they won't get the kind of care that they should. There's not a great mechanism for patients and families to report how it often comes out is when they get their prescani survey or something else where they feel that they can really put everything out there. But they, it's very difficult in the hospital, because you're already in a vulnerable state. Now you've been harmed and you feel even more vulnerable. Right. I think, I think about going to a restaurant and you get bad service, and you don't want to complain, because you don't want your food to come back, you know, with something in it. And so my husband always say mercy, don't don't complain. Medical medical error that's way worse, you know, you have the sphere of complaining because what if, what if then they don't treat me well which of course that never happens. And that never intentionally happens a provider always wants to provide exceptional care for their patients. And I think that we are scared as patients sometimes to ask those important questions. I've been a patient myself numerous times admitted to the hospital and I am, I am a healthcare professional. I know the questions to ask and I was scared to speak up for myself. So I can't imagine how our patients feel, who should they go to I saw when I saw a comment that they would report a medical error to PCP primary care provider. And I think that's, that's excellent and I would hope that the primary care provider would then file something saying that this happened and we now need to learn from this. Who do you recommend that patients report to most hospitals hopefully have a patient advocate. Yeah, and that would be a great individual to work with. They generally have a risk and quality department and there's always the administration that you can go to. If argumentation is responsive, which that would be unfortunate because I think we know enough about safety science that there should be some systems in place to support members through the patients through that process. But there are other escalations through regulatory agencies and, and unfortunately with hate for them to have to take legal action. That would be a disappointment I would call that a failure. So, there are a lot of opportunities I think there's opportunity to level flat early, and really in that case, so that they feel comfortable speaking up. You know, some of the things that have emerged in healthcare in my organization is we actually do. Shift handoff reports at the bedside and include the patient and appropriate and allowed by the patient family members in the discussion and we clean again a lot of information from those content experts. There's even more multidisciplinary rounds are conducted in patient wars and if appropriate, they'll bring the families into those discussions as well during the admission process. There's a lot of opportunity for the patient and family to be oriented to how they can escalate their concerns and participate in those daily roundings when they are so that they are there and ready to participate. There's also clinical handoff routines. As you know, during COVID we created virtual opportunities for families to participate in those discussions. And I think, you know, and another emerging thing are the visual boards in the room that include information for the patient, but also some of the patients that are helpful, such as including the patients individual goals, they're short and long term goals. Including the patient and family members in event investigations when safety events happen so that we understand from their perspective, the sequence of events and get their insights as to what they think. It's different or enhanced to prevent the event we've instituted that an organization and we've made system changes based on input from the lens of the patient and their experience in a harm event. Inclusion. I like that word. I'd like to take it even further Robin is the patients and families need to share their narrative. I've heard of one thing you should do. So that's, that's part of when it comes for the event review. Now, I know a lot of organizations are not doing that they're not getting the patient, you know, their perspective, and why it's such a big miss is the patient and family are the ones that are 24 seven. Everybody else is like a revolving door they see snippets of the movie, they never see the whole picture. They aren't getting it. We're not learning, but then it's closing the loop. So not only do we have it here and I understand that very few organizations literally have the patient and family in the full organization conversation because there's still fear the providers won't feel comfortable whatever, but we're not closing the loop at the end. We're not going back to those patients and families and saying, Here's what we talked about. Here's what we came up with. Do you agree with that? Or what do you think or what did we miss. And if we don't close the loop at the end. We're still missing things because again they think about a different you filled in certain pieces, they may be like, Oh, no, no, that didn't happen or that did. And here's what we could have done better. So it's not just the upfront. What are we doing here. And then how do you let them that they want to be part of the process improvement. Be part of that because for many people that's a healing opportunity. It's also an opportunity where they know something's been done. They're doing it in honor of a loved one that may have lost their life so there's there's multiple reasons to let them be involved in that work. It's very humbling for the for the healthcare provider as well I can speak to the institution that I work at and I'm proud to say that we recruit our advisors that sit on our patient family advisory committee from grievances and and from result grievances and that's not always an easy conversation to go into, however, that is the only way we're going to learn, and even more so, including them in the root cause analysis like you said of what what exactly went wrong and I think patients need to know that they can ask to be included, you know that they can they can speak up and like you said Robin speak out to re judge when advocate or an administrator, and really say that that I want to be involved in this process, and you may get to know, and then you take, you take the next steps right because I saw a comment about ambulatory care and I'm going to shift the conversation, because I think this is important we've been talking a lot about inpatient, and we know that the majority of medical errors actually occur in the outpatient setting. Again, often related to diagnostic errors and miscommunication. Why is that that is that that's where we need that that's the first stop, right. And so if we can stop medical errors, hopefully from occurring here, then the patient, hopefully never ends up in the hospital. And the ambulatory setting and specifically the primary care setting. I'm thinking Robin about education. I'm thinking, I'm thinking like you said those whiteboards and I think that's great. I think that's fantastic I think about transferring that from inpatient to the outpatient side I speak about this a lot a dream of mine would be to go to any ambulatory clinic and see clinical measures posted for patients and staff to see, right, but it's only useful if we talk about it with our patients, those whiteboards are only useful if we include our patients in them, I can't tell you how many times I see, I say a patient rights and responsibilities hanging up, and it's not visible. It's not somewhere where the page it's visible to the patient but are they really going to be looking there. Maybe not. How important isn't to include things like that in the ambulatory setting that the one of the nice things like for me I work in an integrated care delivery system where we were a health plan so we provide the insurance and we have the help and care delivery as part of our company and then we have hospitals and yes, that's a care. So we're able to use our systems and shared learning and adapt them to the ambulatory space and so you're exactly right it needs equal attention our event management system includes the ambulatory space and engagement and we have the adapting for that space because the types of injuries or events that happen in the ambulatory space are sometimes the same but need modification based on the types of risk. And so just being cognizant of how do you adapt it, but it's very feasible to translate all of this and it is done. But I don't, but but I think in the standalone ambulatory space is probably not done with the rigor that we would like. There's a big Marcy there's a big time pressure. You know, physicians have to see so many people are, let's face it our payment system drives a lot of this and we have a perverse payment system. So we have to sort of fix the payment system and this is more relative to the United States. Other countries don't have this because they have a single payer system. Another thing is, is, you know, we've really just started talking a lot more in the last several years about diagnostic error, you know the work that hard to sing and Traver and others are doing in this space is really calling out. What are all those biases that play into it where's the communication breakdown. I think it's probably one of the fastest growing areas that we need to invest money into and keep researching. Because we do know, you know, we know technology has not solved all these problems we thought, having electronic medical records and triggers and you know all of this. We know it because we see it over and over again misdiagnosis diagnosis no call back whatever. So, you know, I know a lot of people are looking into it. I know we don't have a perfect solution yet. But I think that's the next for a first patient safety. I think I don't know Peter can speak to be it because it Scandinavia as some of the most advanced safety systems and, and the way they're legal, their med legal is designed as well, facilitates a more open and comfortable dialogue for the providers. I don't know if Peter has any insights into that. There's not much in Scandinavia, we are close to Scandinavia, but I do not know much about Scandinavia. But I think yes there is a difference between the United States situation and your situation and within Europe there are different between the Eastern and Western part of Europe as well I think Scandinavia and the Netherlands are more or less the same. There is a lot of overtreatment because of the payment system in healthcare in the Netherlands as well. And I'm pretty sure that is also the case in Sweden or Denmark. There is a perfect situation in that. Yeah. I'm listening to this conversation as there is a kind of a big elephant in the room about medical errors and there was the not diagnosis because of COVID. I may not know the data from from the Nettles but I do know the data from the United Kingdom, where in 2020, 2 million diagnosis have been postponed, which it's, which will cause thousands probably more than 10,000 people dying because of a too late hospital death is kind of a medical error as well. Absolutely and the strain placed on on hospitals and healthcare professionals is not helping the situation either. I think it's, you know, I think it's important we have about 15 minutes left and I want to make sure that we have time for for Q&A with our audience. Let's talk about diagnostic errors. What are some other common types of medical errors that patients can experience or should be aware of? Well, that is what what what I call we do not execute what we already know. I mean, if there are several ways of treating patients with, for example, lung cancer. In the Nettles, we have a little less than 100 hospitals and it really makes a difference in what hospital you are diagnosed because the hospital that diagnosis determines the treatment and not all the treatments are of the same quality. But they are given because that treatment is available and that treatment is being reimbursed in that hospital. So, and I consider that as one of the biggest medical errors that that that exists, we do not execute what we already know. I agree. And that speaks to what Carol said, you know, with diagnostic error. Absolutely. Absolutely. I think about medication errors. I think about wrong site surgeries. There's quite a few, you know, that we could go on and on and it's so important I think for patients to be aware of that. And to give one example of that, I know we were quite a lot with a company called IQFIA, one of the biggest clinical research organization, and they have data with for lung cancer. I know it. Let's say there are two ways of treating three ways of treating people with lung cancer, medication A, B and C. Well, they can see that the result of A is lousy B. Well, it does something and C is the best, but they see in that data that A and B are still given to patients. And this is the data that that that can be analyzed and can be published, but who is the one who dares to publish this data. And then of course, if it's published, who is the one who dares to take up a stand and say, hey, this is not something that we like to continue. Right. I think it's, you know, I think it's up to each and every one of us. And so, so with that, I am going to turn this over to our audience members and see if we have any questions. Let me. And I can move this. Okay, fantastic. I'm going to open the chat box. Okay. Generally, what is the first step that large integrated health systems take to begin including patients on the care team and taking the time to listen to their voice. I would like to answer this question. I think we talked about it earlier. I think, you know, the first is probably to establish your service culture and your values, and really, you know, establish that and have that burning platform. In my organization, we create caring moments because every moment matters. And some of the values include respect and compassion safety is first. And so, we can link everything to that and then begin to think about how do we integrate the patient into the patient voice into our work so like my organization and many others we have that side shift handoff and I talked about multi disciplinary rounding. During the admission process really orienting to patients to where they can elevate their voice including signage that gives them the information so they don't have to remember to how they can elevate or escalate or have the discussion. I think sometimes it helps even to have some scripting for writers that helps them get out of their kind of checklist mode and then give them that that scripted guidance so that they remember to ask the questions or ask that patient's opinion. And then, you know, just in every way we try to look where we can include including what we call human standard design. When we start an improvement process we get when we're designing, we include all the stakeholders, whether it be a clinic doctor or the hospital and the nurses and then the patients and then when we look at equity, did we design for those disparities and that's the maturity we're getting to now do, did we look for disparities in our baseline data that said hey we've got a problem here and as we're designing, we're actually designing to bridge the gap between where we have equitable disparity and so those are some thoughts I don't know Carol has anything to add. Well, I think you have to have leadership first that's going to support it. Leadership risk management legal because I can tell you the battles, you know you can have people at the front lines I want to do it, but if you're still betting heads because it's a denying defend or they don't want the patient voice. There needs to be a culture that says we want to engage our patients we want to learn with them from them, all of those different things. I think the other thing is, is that you're seeing more and more patient advocates that we feel like we've softened our voices, because it was our way to get in the door, you know, and I think there's enough patients out through P facts and things that really now, we don't have to soften our voices anymore. We really there's enough of us now that we can speak up, and I can see. I'm going to let you say something Stephen because I can see you believe in that like I feel like we've got that tipping point. Absolutely. I saw in the chat, there is a remark about the patient bill of rights should be posted as well. Our organization inspired to live in 2014 2015 we built together with a dozen of other organization patient advocacy organization, the cancer patients bill of rights and we handed it over to the European Parliament. And well that was really a statement that we could make. And of course that's a long term trajectory to bring it into practice, but shortly after that we together with the organization that I mentioned before. We made a statement that that how to implement the cancer patient bill of right what to do and every time knock on that door of your own Parliament European Parliament, whatever you are. And what Carol says I think really a good example of how patient advocacy can be very effective is the act up movement for the HIV AIDS patients in the 90s of the former century. They were very successful. They knew what they were talking about that's very important that you know what you're talking about. So you have to know things about. My expertise here have to know about molecular biology have to know about healthcare you have to know about treatments, how to design drugs etc etc. And if you know what you're talking about you have to be very active because otherwise they won't listen to me. And I think that the way you said about, there was a comment about P fax and, you know, I think that most organizations are starting to come along with P fax right and the really meaningful work that our advisors can do. And I would even take it a step further with the patient bill of rights or patient rights and responsibilities and say something that you want to match did was our patients actually wrote the patient rights and responsibilities are P fax. And so there's some ownership in that it's not. It's, it's nothing about me right without me, and that is really, really defining that so. Absolutely. Let me see if there's any further questions and I am actually going to try to stop sharing my screen here from a minute. Oh, absolutely. Okay, it looks like no problem. I got the message. Okay, so here's another question. Let's see how do we stay away from always being concerned with the revenue and healthcare great question and going back to caring for human life. Great question. Great question, but a great question. Yeah, I don't. Please, please go on. Yeah, you know it's a difficult question it assumes that everyone is still looking at dollars I actually get people kind of look every day to do the right thing they went into healthcare for a reason, and it's rare. So that is solely in it for some sort of revenue producing. You know there is a need to be solvent right so we can keep our care delivery system open in our community so we have to be excellent stewards of the finances that we that will manage. I think that there's probably some models that are better than others. You know, for me coming to Kaiser was unique because our, our system is designed that we carry the risk, and we actually don't make money when our people are sick so, or when they have surgery and so we are whole world is focused on optimizing health. And there's no pressure for our institutions to try to have more market share of the total hips and knees and those kinds of things so this is a new culture for me, however, more and more for instance the American College of surgeons in fact one of my hospitals was for one of the first hospitals validated for their geriatric care program, and they provide criteria and guidance to partner with the patient in decision making through really clear transparency around all the risk and options for surgery. We opted this in our organization, because we found that we are really transparent with our patients that in some cases 60% opt not to go to surgery and try other therapeutic so there's not a rush to that that that surgical experience so I think that there's, you know, growing awareness and I think that Peter spoke to what is the patient want and how much care do they want and how willing are we to hear their voice and partner with them in those hard decisions so they get the amount of care, and the level of care and intervention that they want based on their personal goals and needs. So it's evolving but I think the heart during the right place. I can't say it's perfect. I also think about nursing care models that that organizations can adopt, such as like compassionate connected care, or even candor right using candor when communicating with patients or encouraging patients to share their lived experience has a document where patients you know are prepared to answer these five questions prior to going to their appointments and so I think those are all useful tools as well to think about the human side of of medical error. So fantastic. I'm going to see if we have time and also you know aligning incentives, right, we have to encourage health organizations to start aligning their incentive incentives it has to happen. I agree Carol. Now we have a voice and, and I think p backs have a stronger voice to, and we'll have a much stronger voice when we all come together providers and patients and cultivate collaboration so this was very enjoyable I think you all for a robust conversation and I think the audience for being so engaged, and thank you patient safety movement foundation for this opportunity. I'm going to turn it over to Sarah. I see you're back on and you need me to end this let me know and I can do so. Perfect well I just wanted to close this out and say thank you again Marcy for moderating thank you to all of our panelists for such a great conversation. Thank you that joined a little bit late I just wanted to provide a few more housekeeping items just a simple reminder that if you are joining the live webinar we do have one C e credit for DCPA credit so again it will take about five to seven days to process if you have any questions at all. Feel free to email clinical at patient safety movement dot org. And then finally, if you enjoy this webinar and you want to continue hearing all of the great webinars and educational content that we have to offer just keep in mind that we do provide this free of charge. So obviously as a nonprofit we do rely heavily on donations from individuals like yourself so we really want to just ask you to consider helping us continue to keep these going and donate on our website at donate at patient safety movement dot org. But again thank you so much thank you to all of our panelists if you guys have any questions at all feel free to email us but we encourage you to just continue doing all the great work that you're doing and keep up the great work. Thank you.