 Thank you, Mike, and also thank you, Dave, as well. So thank you. We now move on to the first of a number of really serious pieces, which we want you to take away with. We want you to consider. We want you to learn and reflect on as important parts of our journey to improve the safety of others, as well as the safety of our health care staff. I first met James Titcom nearly 10 years ago when he came to see me in London to talk about what had happened to his son. And he wanted to talk it through on the basis that he had some knowledge of safety systems. And the surprise that he had that he came up against numerous obstacles in trying to find out what had happened to his son. Now, you'll see his James, and you'll learn of Joshua's experience and the family's experience in the video. And this was going to happen very soon in this session. After the session, the video, you'll hear from Jeremy Hunt. Jeremy Hunt is well-known to many of us in the safety world. And I've had the pleasure and privilege of knowing him for many years now. Really, first of all, in his role as the Secretary of State for Health and Social Care for the UK. But also, I think, as a pioneer and champion of a different nature, a political champion for patient safety. That's a rare commodity these days. And it's a commodity that we need. We want to change systems. And we want to change and support change across whole citizenships. We need politicians on board. Jeremy has this in space. And he really worked very hard. Not only in his role now as chair of a really powerful select committee for parliament in the UK for health and social care, but also in his role to support WHO and the work that many of us are doing through the Patient Safety Movement Foundation, but also through the Patient Safety Collaboratives that we've set up across the world to try and help all nations, not just the high-income nations, but low-middle-income countries, to really help them embed systems and practices and leadership cultures for safety and safety of patients and safety of workforce. So I now pass over to Josh's video. My wife was pregnant with our second child. We knew it was going to be a boy. Drove my wife to the hospital. I think I got there about six o'clock, which was just in time, because Josh was born exactly 738 on that Monday morning. And when he was born, my reaction was, thank goodness, he was just a perfect, healthy, beautiful little baby boy. It was about 30 minutes later that things started to go wrong. He had a low temperature. He wasn't breathing properly. He was reluctant to feed. But at the time, we were just reassured. He's a little bit premature. All these things are normal. The next day, it was obvious he was a very poorly baby at that point. He was transferred to Manchester by ambulance. The team in Manchester told us, actually, the only thing wrong with Joshua is he's had an overwhelming infection and he's suffering from sepsis. We kept thinking, Josh is here for that basic care that he could have had in the first hour of his life and he wouldn't be here at all. He was actually flown by helicopter from Manchester to the Freeman Hospital in Newcastle. And that's when we were advised about this treatment called ECMO, basically a heart and lung machine for babies. Unknown at the time, his left lung began to bleed because it was more damaged than anyone realized. And the consultant had a conversation with my wife and I and said, look, if we tried this operation, it'll be futile. And we just worried it will make himself more. So on the 5th of November, yeah, we... The consultant said he's going to turn the ECMO machine off. And he went away. 20 minutes later, it came back and we said he's gone, hasn't he? And the consultant nodded in his head. And, yeah, Joshua had died. I think the first time, actually, that point, we'd seen him without all the tubes and all the equipment and he just looked like the perfect baby boy. And we said goodbye to him and, yeah, the hardest moment of my life, without a doubt. The hardest moment. What I remember thinking was if Joshua's care was this bad, if he had so many obvious signs that he was poorly and he was just left until he collapsed, is it just him or could this have happened to other babies? What we know is that there were huge discrepancies between what the midwives had reported and what my wife and I remember happening. I'd actually met a number of other families. These are families that had lost babies. It seemed that the pattern of what happened was very, very familiar, so doctors not being called. Investigations that covered up what happened. In early 2013, I met the health secretary at the time. Jeremy Hunt, he agreed to hold an independent investigation and it found a lethal mix of failures and the words in the report were that we have no doubts led to the preventable death of mothers and babies and they found that 16 babies and three mothers had died following poor care and of those, 11 would have almost certainly survived with the right care. And the tragedy really for me is six of those baby deaths happened after Joshua died. The whole management of the trust for years and years, denying that there were any problems using statistics to paint a picture of a very safe maternity unit, they described that as an ongoing cover-up and this became the headlines in England for over a week. There's no doubt to my mind that those records didn't vanish by accident. Somebody took those medical records and made a decision that it was better to get rid of them than to present the evidence. My reflection very much was, why didn't they learn from this? And you realise that we've got the culture wrong in healthcare. We just make it too hard for people to admit to ordinary human error, whereas things like the airline industry, the oil industry, the nuclear industry, they have all learned that they need to make it easy for people to admit when they made a mistake so that they can then develop the systems that prevent those mistakes being repeated. And there's a real danger, I think, of people using high-level data to misrepresent and using data for assurance rather than actually what can we learn from this. Because if you don't quantify the problem, we won't get action to change it. And we've got to have that honesty and that candour to address problems. I wish I could turn back the clock. I can't do that. I can't change things for him, but I do think his life hasn't been in vain. And I think there is a legacy for him and hopefully that legacy is safe for maternity care. I think he's played a small part in helping that happen. It's a privilege to speak to your conference today. I'm sorry I can't be with you in person, but it's a double privilege to come after the video you've just seen of James Titcombe because when I became Health Secretary in 2012 in the UK, I really have very little idea about health. I was right at the top of this huge pyramid, the fifth largest organisation in the world, which is what the NHS is. And I had no idea what it was like for people at the bottom of that pyramid, people like James, who had to write more than 400 emails before the NHS would admit what went wrong in Joshua's care. And there was I sat right at the top of the pyramid and it wasn't until I met James and a number of other families that I began to realise that things had gone radically wrong. And that really started me on my patient safety journey, which has taken me a long way. But in the process, my thinking has evolved and developed. I started off thinking that the biggest challenge with patient safety is transparency. And the tendency that we have in modern healthcare systems to cover things up when things go wrong. Often for very understandable reasons, it's incredibly difficult psychologically to deal with the fact that you may have been responsible for someone else's death. No one goes into healthcare intending that to happen. And so very often there's a kind of pressure not to confront something that might have happened. Sometimes that can be caused by lawyers. Sometimes it's just how it is. And so I felt transparency was the first thing I spearheaded a number of initiatives to bring transparency to patient safety issues, including independent rating of all hospitals in the UK for their safety and quality, including introducing a legal duty of candour on all hospitals when a patient is being harmed to be honest about it with them and their families. We introduced a huge maternity safety programme aiming to halve the number of neonatal deaths, maternity deaths, neonatal injuries, and stillbirths over a period of 10 years. We set up a new body that did airline style no-blame investigations. And all these initiatives helped make important progress. By the time I finished, after six years as Health Secretary, three million more patients were being looked after in hospitals that were independently rated as good or outstanding. We had, over the course of the last decade, we have reduced the number of neonatal deaths by 30%, the number of stillbirths by 25%. So there have been some very important improvements. But the more I reflected on the challenge, the more I realised that the real change can't be top down. It can't be because a Secretary of State or a leader decides to impose change on a large organisation. There has to be cultural change that comes from inside. And at the heart of this is the fundamental problem in modern healthcare systems that we're not very good at learning from mistakes. You compare that to other industries like the airline industry, the oil industry, the nuclear industry that have all developed systems to make sure they really do learn from mistakes and openly aim for zero accidents, zero mistakes, zero harm. We have a long, long way to go in healthcare. We know that in the NHS in England, hello, we have 150 avoidable deaths every week. And that is pre-pandemic, normal times number, but that is the equivalent of one aeroplane falling out of the sky every single week just in the NHS in England. We know that the rates are similar in countries like Holland and Canada and indeed throughout the world. And really what this is about is understanding that doctors and nurses are human beings who make mistakes too. They are particularly brave because they go into a profession where the price of those ordinary human errors can sometimes be a tragedy, a fatality, but we need to find a way to differentiate between the ordinary human mistakes that we all make that we need to be open about and learn from and gross negligence, the egregious errors that should never be tolerated. And that's what's happened in the airline industry. If you turn up to fly a plane drunk, you'll lose your license and you'll never get it back and you'll be drummed out of your job. But if on the other hand you forget to do check number 48 of 71 checks, then people look at the system-wide reason why that mistake was made and they try to rebuild systems so that that mistake is not made again. And we haven't yet learned to do that in healthcare. So this is really about cultural change. It's not gonna happen overnight, but I was also UK foreign secretary and I always remember one of the most respected diplomats in the world, Dr. Henry Kissinger, what he said about diplomacy. He said, diplomacy is the patient accumulation of partial successes. Well, it's the same in patient safety. We should not be disappointed that the success is partial and nor should we underestimate the amount of success we can achieve if we're patient. And someone who knows about this far more than me is your next speaker, Professor Albert Wu from Johns Hopkins University. Someone who I am a huge admirer of. He is the person who coined the phrase second victim to describe the fact that clinicians too are victims when there is a tragedy and we need to remember that and support them to be transparent and to learn from those tragedies just as we need to support families who experience them. He's also editor of the Journal of Patient Safety and Risk Management. So it gives me great pleasure to introduce him and to thank you all for the incredibly important work you are doing in patient safety. Thank you very much, Jeremy. Well, I'd like to begin by introducing today's panelists. Diane Perez, could you introduce yourself briefly? Sure, Albert. Hello, hello everyone. I'm Diane Perez. I'm a physician and journalist. I'm a news anchor and medical correspondent for Televisa. And Arianne Marie Mitchell, also can you introduce yourself? Sure, I am a faculty member in the preventive medicine and pediatrics department at Loma Linda University. I am also the medical director for health equity for the children's hospital. Thank you. And Raj Ratwani. Thank you, Albert. Nice to be here. I'm Raj Ratwani. I serve as the director for the MedStar Health National Center for Human Factors in Healthcare and also the vice president of scientific affairs for the MedStar Health Research Institute. Thank you all. I'm looking forward to a really great discussion. So James' tragic story highlights the need for greater openness about the inevitability of error and the ever-present potential for harm in healthcare. Greater awareness and acceptance of human fallibility is really needed for the entire system to be able to improve and become safer. As humans, when something goes wrong, our first instinct is to blame. But we have learned since then that it's the system that really causes hazards and creates safety. I guess one could ask, what do we mean when we say the system? And what are system factors? Who are all the players who shape how care unfolds? Raj, can you enlighten us? Yeah, happy to. Albert, I think as you described, when we think about the care process, I think the first thing that often comes to mind is the patient, the doctor, the nurse. We probably think about the family. We probably think about the caregiver. But we know it's much more complex than that. And so we often describe the healthcare landscape as a system. And when we say system, what we mean are all the different components that impact the care process. Some of those are very obvious, like people, the people we just talked about. And then there are some not so obvious ones. There's things like the technology, medical devices, the electronic health record, there's equipment, the beds, there's other supplies. There's the processes that are happening between people and the technology. And then of course, there's things like culture and policies. So these are all different components of what we call that system. And each of those components interact. And each of those components can contribute to the types of horrific errors that we just saw. And so for us to really tackle safety, we need to consider all these different system factors. We need to consider how they interact. And we need to look at how those system factors contribute to errors so that we can actually mitigate risk and make improvements. Thanks very much. That was very clear. And we have learned, of course, that there are factors that can contribute to errors and harm at every level of the system. Indeed, we've learned that safety is consistently improved when patients and families are actively included as members of the team. But this doesn't always happen. Arianne, can you tell us what do you see as the biggest barrier to this actually happening, to patients and families being included as members of the team? I think there are several barriers that come to mind. One is just often our visits with patients are very time pressured. And often our staff are stressed for a variety of reasons, including that time pressure. And often we're not well trained in how to communicate in a way that fosters listening. So I think all of those things contribute. But if I thought a little bit more about the biggest barrier, I would have to say it's how we think about healthcare services. So right now our healthcare systems are designed around the idea that healthcare is something that we do to someone. We need to redesign our systems around the idea that healthcare is something we do with someone. If that perspective shift were made at every level of the system, from the front desk to the most senior executive and all the processes in between, then inclusion would be recognized as integral to patient safety and would naturally lead to elevating the importance of reducing time pressure, reducing staff stress and prioritizing communication. Well, even though there's a lot of talk about being patient centered, I guess our system is still pretty clinician centered. So how did that happen? What role has the health industry played in preventing patients and families from becoming meaningful partners? Diane, can you shed some light on this? Sure. I mean, I believe this is a shared responsibility, Albert. Patient safety is not about finding who is guilty or blaming health professionals for malpractice, but to understand that the issue might have happened because the health system, very well described by Raj, has failed. We need transparency from health professionals and institutions to be able to find and correct possible implementation errors that could lead to tragic situations. Including the patient and his family is also a key element to reach the best results with the treatment. And this could also involve cultural aspects. For example, in Latin American countries like Mexico, it is very common to see family members going to the doctor with the patient, although this does not necessarily mean that the family member will be actively involved in the patient's treatment. I think there are three main points that need to be emphasized. Transparency, inclusion of patient and family, and also technology, automation of processes in order to reduce human error. Well, I think all of those three points are important. I'd like to focus for a second on transparency or as they say in the United Kingdom, being open. So there are a lot of barriers, it seems to help workers being open about all the things that might and sometimes do go wrong. How do we start to remove those barriers to being open? Raj, can you help us with this? You know, I'm happy to chime in first on this, but I wouldn't mess up to several of the panel members here because I don't know that we have the exact right answer. And certainly if we did, I would hope that we would have implemented it by now. So I think there's probably gonna be a lot of strong thoughts by panelists here. So let me start. You know, I think there's a couple of elements that come to mind right away. The first is culture change. And this has to be both a top-down and bottom-up process. So we've heard time and time again how culture can be shaped by leadership, leadership style that's absolutely true. And we need key leaders to understand the importance of openness and the implications that that's gonna have for safety. But this is also a bottom-up process or can be a grassroots process where frontline nurses, clinicians, patients, family members can keep pushing and championing for this so that it influences the rest of the organization. So I think that's a critical process here. The other important thing that I would highlight is alignment of incentives. And we see this so often in healthcare where incentives are just misaligned and it leads to this kind of, you know, secrecy or closed environments, the opposite of what we're trying to go for with openness. And I'll give you a concrete example of this. If you look at many of, at least in the United States, if you look at many of the contracts between EHR vendor companies or other technology developers and healthcare facilities, there's often what's called a hold harmless clause. And this clause essentially shields some of those companies from any ramifications of malfunctioning technology and harm that may then occur. So you can see how that's a really big misaligned incentive in terms of delivering safe care to patients. If there was to be a tragic event related to that technology, there's not necessarily a strong incentive for that technology developer to now make improvements because they're shielded from so much that happens with the technology. And so that's just one example. There's many, many examples like this. And until we get that alignment of incentives, it's gonna be really difficult to have these open conversations that we wanna have. So, Raj, I think you covered it. Oh, Diane, please go ahead. Oh, thank you. Thank you, Albert. Here, I think that the regulations in each country are fundamental. In some countries, doctors who make a mistake are punished, although they did not cause intentional harm. And I believe that must be changed from a legal perspective. Oh, great point. And Arianna, I wanna give you a chance now since our other two panelists have weighed in. Oh, I think I concur with all that they said and would go back to some of the things I said at the beginning about really just needing to change the system to focus on working with people. And if we put that emphasis on what matters to patients and families, it's drives those kind of policy changes and culture changes that we need. Great answers, thank you. So even in the best healthcare systems in the world, there are still inequities in the quality and safety of healthcare, even within single institutions. This is obviously not right, but what can we do to eliminate them? Arianna, can we get you again? Yes, absolutely. It's a topic I care a lot about. And I would give sort of two general answers. I would describe that the changes that are needed on an individual level and on an organizational level. So on an individual level, staff education about societal oppressions and how they lead to inequities is key to increasing understanding, generating dialogue and initiate the kind of changes that we need to improve our outcomes. So that education should focus on raising awareness. How is my lived experience different than the lived experience of someone else? And it also includes being aware of how implicit or unconscious bias may influence all of us in our interactions and decisions. So that would be staff education on an individual level as part of the answer. And second component is that organizational level change. So healthcare systems need to examine potential disparities in outcomes they are producing. As I've gotten involved in this work, I've just been surprised that that just hasn't been the standard to date. We've looked at our outcomes, but we've not necessarily looked at our outcomes by different demographics. And if we don't look, we're not, we don't know if there are disparities. So disparities would be population level differences and outcomes that are related to a history of disadvantage that is based on societal constructs. In other words, based on something that's not inevitable. So therefore it's something that we can potentially prevent. And when we identify those disparities, which we surely will, because we know that that's part of the society that we live in, when we identify then engaging a wide range of stakeholders is really key to designing effective solutions. And of course that's got to include members of the community that are being served. So for example, on our work at Loma Linda to promote health equity, key components of that includes staff education. We have a task force that's focused on measuring our health outcomes and looking at potential differences by demographics. And we are soliciting community feedback from our patients and families. Albert, if I just may quickly add two points to those really important points that we just brought up. I think one thing that is critical here and is missing is the feedback loop. So if you think about implicit bias and some of the subconscious processes that are happening there's no doubt that what was just highlighted in terms of education knowledge is critically important. But what we also know about performance improvement is that you need immediate feedback and it's got to be just in time. It has to be within a short window of the occurrence of the event. And so until we're able to create the methods and processes to quickly identify these point-by-point health equity issues and these biases and give that feedback directly to those that are committing them it's going to be difficult to make the widespread improvements that I think we're all hoping for. So interestingly this is a problem of transparency too but it's transparency or communication within the healthcare team perhaps at different levels. And if you see something as the expression goes you should say something whether it has to do with a medical error or perhaps some other error in the communication process. Now that said, we all patients and families included we all have great expectations for healthcare particularly our own personal healthcare. We all hope for the best even to the extent of ignoring the fact that things can go wrong. Now on the other hand we read maybe not every day but every week or every month in the newspapers and we hear in the media about terrible things that went wrong. There seems to be a little disconnect. Diane can you help us understand what role does the media play in this problem and maybe a harder question. How can the media help to improve the situation? Thank you Albert I love this question I love this topic and well it's a fact that when you go to the doctor you expect to be cured and you rarely think that something might go wrong. So the media generally publish either great advances related to science and technology or as you said huge tragedies when something goes wrong especially when it relates to a public figure. Although this is necessary from an informative point of view the media also needs to share educational information related to patient safety. It is okay to tell stories about success and failure but always we have to give a choice to all the parties involved and try it at the end to send a positive message. The media definitely plays a huge role in changing behaviors in society we have seen that many times and could be used to include patient safety issues in soap operas for example in TV series sharing information about what can be done to obtain the best results in health care. Of course we also must consider social media but it could result in a double edged sword due to poor self-regulation now in the case of social media. But undoubtedly social media is also a very powerful tool to contribute to patient safety. I'm glad you brought up the last points and in fact the people who are using who are exercising social media are humans too. A human thing I mentioned earlier a human behavior is we tend to blame or look for someone to blame when something goes wrong. So a really difficult question I think is how can we change that culture of blame? If you are a worker and feel like that you'll be blamed and shamed and punished for talking about things that have gone wrong or could go wrong then you're not gonna talk very much. So Arianne can you help us? What can we do to make people feel safer to reduce that fear of being open and to reduce the cover-ups that result as a result as they did in James's story? So a couple of thoughts come to mind. This first is sort of acknowledge what Raj said earlier about the importance of culture change involving the whole system. And often the emphasis is on leadership but we need all individuals in the system involved. So I absolutely agree with that having said that I'm gonna focus my statements on leadership because they really, really are central. So perhaps the most important thing in my opinion that leadership can do is model the change they want to see in their organization. So if they want their staff to show empathy with their patients then they need to show empathy with their staff. If they want their staff to listen to their patients then they need to listen to their staff and perhaps one of the most challenging for many of us but if we want our staff to prioritize self-care so that they can show up at work being the best possible people that they can be to do that work then leadership needs to model self-care. The second aspect that I would say that is important for leadership to do is to drive the focus on patient-centered outcomes. And this might be the researcher and me talking but I just think what we measure matters and leadership drives that. So don't just talk about the value of patient experience but measure patient experience and focus on improving patient experience. And that's gonna require talking with patients from different demographic groups and especially talk to patients who have a social disadvantage from one reason or another listening to and incorporating feedback from the most disadvantaged patients will improve care for all of our patients. I think that what you say is very true. Raj, can you talk for a second about how we can suppress our instinct to look for blame and to make it safer to be open? I think Albert, you sort of called us out. I think it's so innate for us to think about an individual to blame. We're generally linear thinkers. It's very difficult for us to think about system factors and all those contributions and how those might interact. It gets really complex. And one thing leads to another thing and that causes this error. One thing that I've seen work is to really come up with good use cases or illustrations of how these things unfold. So if we can show how the poor design of a piece of technology is what actually contributed to the error rather than looking at the individual blaming that person for using the technology wrong. I think it's those kinds of examples that help shift the culture. It helps us think about what are the other system factors in the environment that might be contributing to these issues. So I think I like these comments around leadership and highlighting those pieces. This is another one where I think leadership can start to highlight some of the contributing system factors and start thinking about all of the other players and stakeholders in the environment that we need to work with. And I think Diane early on called out shared responsibility. I think that's critical to this. So I think use cases would be the punchline for me is clear illustrations of system contributions. And a very practical punchline I think. So Diane, the media has an instinct to find a good story. How can we get to the leadership of media institutions to perhaps get them just to press that instinct long enough to provide a more balanced picture perhaps? How do we train that? Yeah, it's hard because of course media is looking for rating and the rating is given by big things. And unfortunately bad things attract more attention than the good news. So that's also one point that we need to fight in the media. And but we definitely need to have a focus on education and empowering the patients and show people that they have a responsibility when it comes to healthcare. They have to be involved and the family members need to be involved with what's happening with their loved ones. So I think their media can do a lot and not necessary only in the news shows which is my expertise. But also as I said in soap operas or TV series we need to include these topics of patient safety in those that attract people in a very light way and that they can pay attention to it and realize that they as patients can have an important role in their healthcare. So we need more telenovelas that you can tell the story also. Exactly, exactly, exactly. Well, this has been a great discussion. I feel like we could talk about this, go on talking about this for hours and with experts like the three of you, I suspect you'd be very happy to join up. But in summary, I see that we really do have a problem. And the problem is perhaps the biggest problem perhaps is with changing our culture and being truthful with ourselves. I think that we need to think more about how we can face the truth about patient safety and the fact that the truth is that care is not always safe. How can we get people to acknowledge that truth? Arianne, how can we persuade people to acknowledge this without scaring them off so that they run away from healthcare? And in fact, we wind up decreasing access instead of, and perhaps reduce equity, create inequities. How do we... Yeah, I mean, it's a difficult problem. I think as you're talking, I think there is not exactly the same thing, but a parallel to talking, for example, about the topic of racism, where it's a difficult topic. But part of what I have found helpful to acknowledge the influence of race and culture on our society is to recognize that we're not trying to identify the baddies, the racists, so to speak, right? We're trying to recognize that, for example, that we all have biases that we have grown up with, that from the day we were born, we are being taught about these biases and that these influence us and that these are part of our system. And so it's about recognizing that we all want to be treated with love and respect and receive good medical care, and how do we get to that common goal, right? So I guess the parallel to me with patient safety and errors is again, we're not trying to identify the baddies, right? We're trying to recognize that there are aspects of literally how we are designed as human beings that contribute to the potential error. There are aspects of our systems that we have built that can contribute to patient error. And so how do we all rally around what we all want, a just and fair in society, a safe and equitable healthcare system? How do we rally around that? Partly by recognizing the role that we can all potentially play in improving it. Well, that's great, thank you. I think that we really are not interested anymore in finding the bad apples and throwing them out. But in the circling back to the video that featured James Titcom, we learned that workers at many levels at Morecam Bay felt inhibited and really had information but didn't speak up, didn't come forward. And as a result, this perpetuated this pattern of substandard care and in fact, the tragic deaths of many children. Raj, how do we convince clinicians, doctors, nurses and others that we're not interested in blaming them, that it's safe and in fact, even desirable for them to talk about things that go wrong? Yeah, it's a great question. I think first is asking the question, why? So as we watch that video, why is there this move to cover things up? What's the incentive to do that? And I generally don't believe that they're malicious actors. I believe that there's in their minds, there's some reason why they can't talk about this openly. It could be repercussions from leadership. It could be financial penalties. It's a whole host of factors. So I think we have to first understand the why. And we can make some good guesses as to what those are. But in every situation, I think we have to think about that individual or that group and think about the why. And then I think it's important to come back to culture and to help people realize that the only way to improve and we should all be incentivized to improve, the only way to make improvements is by these open discussions, is by identifying the system factors and coming back to those system factors to make improvements. And it comes back to the top of this conversation at the very beginning. We talked about being patient-centered and always striving to do what's best for the patient. And we have to make sure that again, all those incentives are aligned so that we're there to deliver the best care possible and everybody's moving towards that goal. I'm sure Diane may have some other comments here and thoughts on that. So I turn it to you. Yes, Raj, I agree with you. I think culturally competent care is something very important. I see people who go to the doctor, how they react in Mexico versus how people go to the doctor and react here. I mean, I think we need to empower the patients to not be ashamed when they are with their healthcare provider and feel free to ask questions. I have seen a horrible stories in Mexico of people who do not understand what the doctor is saying and do not understand, for example, the prescription. And well, in some countries, like Mexico, for example, where prescriptions are not optimized as here. Unfortunately, you go to the doctor sometimes and the doctor writes it and we are famous for not having a very nice writing way. And sometimes the pharmacist does not understand and the drug delivery is something different and has also secondary reactions that are not the expected. So I think it's very important to empower patients to not feel ashamed to ask questions when they do not understand something and also to try to educate healthcare providers to make sure that the patient really understood what they need to do and really understand what kind of medication they are receiving. So again, I think this has to be very different and very customized in every country. So it can be really, really effective. If I could just make a quick comment on that. So I was listening to a community health worker sharing a story about a Spanish speaking patient. She also spoke some English, but she asked the nurse if she could have a translator because she wanted to really make sure that she understood what was being communicated and the nurse responded with like an eye roll and like kind of, right. So this is a microscopic little interaction, a little story that I heard about. And so it's easy to be outside and say, gosh, what's wrong with that nurse? Why didn't she respond with more compassion? And I'll bet you if I were to pull that nurse's side outside of that situation and talk about culturally competent care, she'd say, of course, everybody should have a translate, right? But the thing is we get into the situations because very often, she was stressed, she was tired. I'm just thinking about things from the nurse's perspective. And that's where I think the full answer to design a safe healthcare system really is recognizing all those players in there. And it is about, to get to patient safety, it's about creating staff wellness as well, creating that's getting at that culture. So. If I just may add to that, I think that's an incredible story and such a great example. And I started by saying, let's look at the why. So if we dug into that further, just as you were, we could all come up with some hypotheses as to why the nurse may be reacting that way. From what I've seen in certain care environments, it could be that there are very few translators and the wait time increase by asking for a translator is significant and you had talked about the time pressures here. So this is adding to the time pressures. We've seen that some of the translation technology is not always fully functional and has all kinds of issues that arise. And so you can imagine the stress that comes on to not only to the nurse, but the care team if you dig into that system factor of technology. And so I think it's such a wonderful story because it highlights how we turn to thinking about that nurse as probably being not a very nice individual, not caring about equitable care, but a layer underneath are all of these system factors around technology, workflow processes, et cetera, that contribute to this. And I would wager that probably most of us in that nurse's shoes would probably act the same way given all of those constraints. And so we really need to think about how do we alleviate those system factors? I think such a great story that you brought up. So, Diane, you sort of sit in between in some ways, all of the worlds. But I think that we've heard about sort of the importance of the perspective from perhaps the bottom of the system or the base of the system, patients and families, and providers, how do we educate leaders to encourage everyone to be more open, to speak up when they see something or think something is happening all the way down to patients who shouldn't just ask questions about their own care, but should be volunteering their perspective about the quality of care that they're getting. What do we, how can we convince those people at the top? Well, I think education, education, education and of course, media's responsibility is not to educate, but we still have the duty of providing that information. So I think media can help very much in this sense. And also all these truthful sources of information like the patient safety movement, for example, it's great to have these tools where people can consult and have access to all that information. And this patient aider, for example, app for patient safety, that people can read and can really get confident with all what's going to happen if they go to the hospital and know what to expect. Because unfortunately, when patients go to the hospital most of the time, they just don't know what to expect and they try to believe the people that they understand the more, which probably are not the healthcare providers, but maybe an assistant that is filling all the forms or a receptionist and they get close to that person because they feel that person equal to them. So what we need is first to try to lower the healthcare providers, nurses, doctors, technicians to the patient's vocabulary and then also give tools to that patient to be able to understand what the healthcare provider is telling them. So to have this communication among patient and healthcare provider that flows easily in order to get the best results. I'm really glad that you got us around to tools because many people up and down the system have good intentions but don't know how to do, don't know how to take action to do the things that they understand they need to do. There are many free healthcare safety resources that are available for clinicians, for administrators and leaders and for patients and families. Many of them in fact are on the Patient Safety Movement Foundation's website. And anyone viewing this panel can, I hope will go sometime after and just look around a little bit and see what is available there. I'm going to ask for one line piece of advice or action from each of you. Raj, if you had a one-liner, what advice would you give? My one-liner would be to make sure that as a patient you have a champion on your side. A family member, a loved one, a caregiver, got to have a champion on your side. There's strength in numbers. Yeah. Ariane, what would you say? Albert, this is really unfair of you to take a very complex topic and make us reduce it to one line at the very end. I will simply say, I'll say one word, which is listen or learn how to listen. It's not easy, but it's important. Ooh, you've done really well though. So despite the unfairness of my question and Diane. I believe Ariane says, listen to the health care provider and I would tell the patient and the patient's family to be curious and to reach out to truthful sources in order to find the information that can help them lead with the disease. Well, thank you for your one-liners of wisdom but also for all of your thoughts and comments over the last hour. I've learned a lot. I feel smarter now than I did an hour ago. Thank you very much to all of our panelists and thank you to our audience for your attention. Thank you all for joining.