 Thank you Joe. Good afternoon everybody. I was terrified watching Secretary Hunt that he was going to fall off the steps so I'm going to stay right back in case I worry about myself. I'm going to be talking a little bit about the WHO's Medication Safety Challenge. You've already heard about the scale of the problem of medication safety worldwide, medication error both in human terms and in economic terms, but really as we've all found when we're relating to this subject and trying to find ways of inspiring people and galvanising action is when we look at the granularity that we start to see how this is affecting real people and why it's such an urgent need to address it. This little baby was born in a hospital in the UK in the mid-2000s and she had a congenital heart abnormality that needed major heart surgery but it was something that was treatable and for all children and indeed adults in these situations when you have heart surgery you usually need an anticoagulant at some point in your care and she was prescribed 1500 units of heparin that was what she needed. That was the way the prescription was written. That was the way the prescription was given. An error which killed her, 15,000 of units of heparin given because the abbreviation you for units was used. An error that's happened not just in the UK but in other parts of the world as well. This lady's face and name will be well known to many of you especially those of you from the United States. Betsy Lehmann, the award-winning health economist of the Boston Globe. She was treated in her local hospital in Boston, a major teaching centre. She had breast cancer. She was put on an experimental cancer drug. There was a clear protocol for it and the calculation of the dose was by the patient's body surface area and the calculation was performed and she received four times the proper dose over four consecutive days and she died. 12 different people, a mixture of pharmacists, doctors and nurses, counter-signed these dosage calculations. Another woman on the same experimental drug therapy for cancer had the same treatment and she also got four times the intended dose over a four-day period and she was severely harmed. She didn't die but both patients were given another drug to counteract the side effects of the cancer chemotherapy and they each received four times the dose of that as well. There was a major media furor against the hospital you can imagine. The reporter of the local newspaper, one of their own, had been killed by the local hospital that she'd written about in positive terms many times and Arnafaba was subject to all sorts of regulatory action and fines but it is one of the hospitals in the world, for those of you who know it, that used the occurrence of Betsy Lehmann's death to transform their approach to patient-centred care and to genuinely transform it and I'd like to step aside just a second from the medication safety story there just to make two general points about patient safety and there are all sorts of things and I've been involved in this for a long long time now both in the UK when I was chief medical officer before that when I was a regional director in the NHS and then subsequently in the WHO program since 2006 there are many many unanswered questions some of them very very profound and one of them is when a tragic event like this happens why is it that some hospitals dedicate themselves to transform permanently and some regard it as a sad moment that they have an inquiry report they try and learn but really their practice their culture their ways of doing things doesn't change at all why why such a difference and why is it that other industries when an aeroplane comes down or a nuclear plant that there is a major often industry-wide transformation but what you see in relation to patient safety is that not only do you not get an industry-wide transformation you don't even get an institution-wide transformation and it's the minority that those occur so that's one of the if you like there are many unanswered problems and questions in patient safety that I've encountered and that's one of them the other thing is to say about this particular incident with with Betsy layman I mean it was a terrible tragedy our husband worked in the same hospital as a as a research technician that she didn't die from an simple error coming out of the blue when the authorities look back at the hospital they found some very very adverse features of the culture going back a long way and so her death if you like was a tragic marker of an organization that did just did not have the right culture a degree of arrogance and all sorts of things which were pointed out by authorities and investigators so those are two to I picked those two examples even though you might be quite familiar with them because if you like they're right at the simple end of of medication error an abbreviation and a calculation error both of which could be I think you could get pretty close to zero if you banned abbreviations and I think on the calculation front there are ways also of dealing with that when I was helping with the design of the WHO's medication safety challenge I read back on the literature and I came to an article by I'll come to who it was by in a minute but the nobody had ever referred to before in the medication safety or medication error literature and it was written by a man called Alphonse shapanis I don't know whether any of you have heard of him or know of him but he was one of of a group of people in the golden era of ergonomics immediately post-war we now tend to use the term human factors rather than ergonomics but there was a group of people non-medical people often engineering scientists who really unpacked and understood safety almost exclusively working in industries outside health care and when you read their stuff it's unbelievably turgid and difficult to follow very very very technical I don't think many of them were inspiring speakers but their names should be up in lights because in fact in the sky they transformed airline safety with this science of ergonomics but shapanis was one of them and he took a sidestep only once early on in his career and he did a study of medication error in a large American hospital and he has all good patient safe or safety research as he wasn't a patient safety researcher he distilled the all the individual errors into a number of key themes and you can see them there there are seven of them 1961 Alphonse shapanis did this work every one of those is still alive and kicking around the world today causing harm to patients so the huge tragedy and irony in the fact that between the work of the ergonomics experts in the 1960s and even before that 50s and 60s all the other industries that they'd observed and worked in were transformed to have been transformed in safety terms over that time health they weren't particularly interested in but when they did look they found the same sorts of things but that transformation wasn't picked up by the industry and carried forward one final story and I'm doing these stories with a purpose you will have heard me maybe on previous occasions talk about this young man Wayne Jowett when I was chief medical officer I produced a report called an organization with a memory which started the patient safety program in the NHS and the intrathecal administration era was one of the case studies that I put in the report for the non-medical people young people receiving treatment usually for leukemia as part of their therapy get two injections one into a vein intravenously and one into the spine intrathecally and Wayne like a lot of the people around the world who've been subjected to this treatment ended up it was very I met his parents five years later and they were deeply traumatized by everything that had happened no one had spoken to them when they when the accident happened then they went to the clinical area they were told three different things he'll survive he'll survive and be disabled he'll be he'll be dead within 12 hours those were the three things by different clinical teams that they were told and they were so bitter and angry that nobody had spoken to them and the trauma they experienced was terrible anyway Wayne went into hospital out of turn out of sequence because he was a typical rebellious teenager and he hadn't taken his gone for his therapy and the hospital moved to try and fit him in and the process of fitting him in went terribly wrong and he received these two injections look at them they're in similar syringes the one containing vincristine which is meant to go in a vein has a warning not for intrathecal use but the two young doctors who were stepping in trying to help injected him in the wrong way and he was paralyzed and died and his mother told me that when she went to see him in the intensive care unit he asked her mom am I going to die and she told me that she had to tell her own son that he was going to die and it was the most terrible moment she could ever have imagined in her life so one of the things we did and I used to hate people that play videos in presentation I didn't ever think I'd be one of them but I've got a very short snippet from an educational video and I'm showing you because it's been so powerful in educational terms around the world and it's a it's the story not of Wayne exactly but of the many cases like is which where something goes wrong where good people are trying to do the right thing and inadvertently they do the wrong thing so I've been out of clinical practice for many many years in public health and management but I I can feel myself in that moment and I know a lot of young doctors and medical students and nursing students who have seen the video have found the same thing they feel what's going on and that's I think a really good example of the sort of educational material that we need to produce it's the granularity and the and the human nature of it that draws people in and they never forget so my mother was a great Agatha Christie fan and she always saying to me Liam you want to read this and I was always too busy she's she's long passed away now but she'd often say to me but you've got to read this one Liam because it's got a twist in the tail you remember that expression for the little bit on the plot that adds in well the Vincristian story has a twist in the tail just to recap it's a rare catastrophic event it's a very good one to study because it is a classic accident with multiple factors interacting there was something like 70 cases worldwide when we first started to study it and since new guidance was put out new measures to try and resolve it there were other cases in Southern California in Hong Kong and in South Korea and probably elsewhere but those were the ones that were reported so there was no international learning at all from this sort of effort that was put into it but the twist in the tail is this suddenly I woke up one morning when I was chief medical officer and somebody rang me from the Department of Health and said there have been a hundred cases of Vincristian paralysis and I couldn't believe it I thought my my job is on the line here we said we'd eliminate it so a hundred cases where are they and he said in China and what had happened after a long investigation is that a drug manufacturing plant that was manufacturing two drugs Vincristian and the one that's genuinely intended for intrathecal use safely that traces of the Vincristian had contaminated the other drug so that when it was legitimately used for intrathecal use it paralyzed patients and most of them died right across China now who would have thought it we'd studied and studied and studied how this Vincristian error could occur but we never thought of going upstream to that extent so the general point there I think the general patient safety point is we have to scope the whole all the possible elements of a chain of harm in order to be sure and just for good measure and this is particularly shocking this was Agatha Christie with two twists in the tail so here's another one this was a publication in a medical journal about a rare complication of my multiple myeloma where the authors recommended the use of intrathecal Vincristian for treating this condition can you imagine it recommended its use it was an online journal so it was quickly redacted when the experts got on to the editor but how many people had read it fortunately it's a rare condition but a total unawareness of this problem so that's the story of Vincristian a many many many lessons there to be unpacked but but basically a story of slow slow slow learning and what we did in the UK is we pursued the creation because we immediately Wayne Jowett died I got a torrent of letters from doctors saying to me you idiot all you have to do is to commission a device that connect you can't connect to that sort of syringe but then we looked into it and it affected the whole of the lure and non-lure connection system plus the devices industry weren't interested because they didn't think it was a big enough market so it took 10 years until we eventually managed to get a shamefully long time a device which was a fail safe so all of these influences on medication safety you've heard about them look alike sound like medicines handwriting violation of procedures ignorance with what I've talked about today numeracy all of these things and many more contribute to why things go wrong in medication safety in 2006 the WHO's program was founded I was the first chair of the World Alliance for Patient Safety and early on we as part of a range of programs we decided to have the first global patient safety challenge we wanted something that united the world and we thought nothing would unite it more than health care infection so we set up the first challenge clean care is safer care the flagship element of that was the hand hygiene program until then alcohol robbs were hardly ever used in hospitals around the world and then secondly with the help of Dr. Attall-Gwandi we we introduced the state the safe surgery checklist the first challenge we did by getting ministers around the world to sign a pledge to commit to a program of action on reducing health care infection and over time the program covered something like it now covers 90% of the world now this is soft it's not easily measurable we can't demonstrate big outcomes but what we did learn from it is that these challenges can galvanize action but they have to be something that inspires people they have to be simple ideally they have to have what Malcolm Gladwell calls a sticky element the the alcohol gels were people immediately understood the clean hands message and the surgical checklist and the parallel with the airline industry people immediately understood that so in designing the next challenge we're seeking to create the same sort of excitement and action and engagement particularly at the political level which is terribly important in this sort of change so the third challenge has been launched you've heard a little bit about its target we agonized about a target but everybody advised that in global health unless you have something clear cut there are too many competing priorities and you'll never get on the political agenda you might get on the professional agenda but to get on the political agenda you've got to be bold and ambitious we're doing it by I think quite a clever technique of devolving responsibility for working out the detailed programs to the countries themselves so we have four domains health professionals what they can do and what what causes medication harm in their area medicines as products processes and procedures including regulation and then patients and the public and so the idea is that each country would set up its own national group in these four areas and I think the clever part of it compared to the previous challenges is that the it would be likely that you would then get a community of experts and patients and others who would grow up to form these groups and ultimately be part of the program of change process of change but in addition to that we've picked three flagship elements after careful consultation one is high-risk medicines and we'd be asking the country themselves to pick for their country which is the best high-risk medicine to will it be anti-coagulants what will it be will it be non-sterolec anti-inflammatory what will it be but something measurable and where rapid progress on the source of harm can be made polypharmacy we were talking about this I visited some hospitals there's one hospital I visited in in the UK which I talked to the pharmacist who was doing the discharges of the elderly patients at the weekend who got better and were leaving and he said he'd given he'd filled prescriptions for five patients who'd gone out with 12 drugs each and this is not uncommon when I talked to colleagues around the country so polypharmacy and then the other one the transitions of care the errors that occur when people move from primary to secondary from hospital to hospital from nursing home to hospital so the medication safety challenge is up and running a secretary Hunt is one of the first health ministers to sign up and we're delighted about that that the UK is showing a lead the Middle Eastern region particularly with countries like Oman I've also signed up so we'll be working very very hard but the key to it is to grow that community of experts and and enthusiasts in the country's concern because with the other challenges we had infectious control experts we had surgeons so we you know the infrastructure was there but here we need to bring people together and it's best done at local level where they can determine their own priorities and then hopefully the thing will be sustained and grow and will become Joe a movement just like yours where you've shown such expertise in how to establish a movement so I'm gonna finish Joe was asking me about Churchill and his associations here did have you seen the film the recent film about Churchill have any of you seen that I went to see it there's one lovely point where he's he's under the cosh with his political opponents in Parliament including his own party and he wins the day with a great speech as usual and one of the characters in the who were plotting against him and have had to throw in the towel said to his colleague this this was in the film he's mobilized the English language and sent it into battle and I think so I was thinking when I thought about that we we've heard some great inspiring words today and so I thought well what now would we mobilize the English language and to tackle this problem and I remember all the all the polls about people's favorite song in the UK it always comes out with imagine by John Lennon and I've always thought imagine is one of the most powerful words in the English language and in the field of safety and reducing harm I think zero is the most powerful word that you could have so I end by saying to you let's mobilize imagine zero and go into battle against avoidable harm thank you