 I don't know if you ever listen to the lyrics of this song, Mercy by Peter Gabriel. He sings about everything you see around you, whether they're cars or buildings, companies. They were once someone's dream. And those dreams made real. And then he goes on to sing, I'm looking for Mercy Street and dreaming for mercy. I want to thank you all for coming here. I want to welcome you here. I want to thank you for coming here with all your heart to save lives of people we don't even know because you've been touched by the lives you've seen lost. Yes, we can do it. Before I start to tell you the things that are in my mind today, I want to take time to appreciate the work of so many people around this movement. I want to first thank Ariana and her army of incredible, passionate people who get so much done with so few resources. I want to name a few. I want to thank Shanta Fisher, Kimberly Coppins, Roger Wu, Rachel Reigns, and the numerous volunteers for your tireless efforts to make this possible and bring this event together today. I want to acknowledge and give my debt of gratitude to the regional network chairs who work so hard to get the message around the globe within the US one state at a time, one hospital at a time. I want to thank our regional and national steering committees and the work group members who have put the energy to create these actionable patient safety solutions to start with so much data, so much information, and to bring it down to the essence of what needs to get done. It's what is allowing people to go from hoping for zero to planning for zero. I want to thank our board of directors who are dedicating so much of their time to our movement. And I want to thank President Clinton for inspiring us and joining us for the seventh year. This is his movement as much as it's mine and as much as it's yours. I want to thank the American Society of Anesthesiologists and the European Society of Anesthesiology for co-convening the summit with us. It's a great honor to have you involved in what we're doing. Anesthesiologists were the first to show what's possible when people don't want to put up with a status quo. I think you know the numbers of people that would get harmed under anesthesia and how it's fallen orders of magnitude. I also want to thank the amazing panel members and moderators and those announcing their commitments at this summit. Their commitment announcements inspires us all to push this movement forward. And it's the commitments that make publicly that allows us to have this incredible success we've had to date. And I'm proud to recognize some of our past humanitarian award winners who are with us here today. Alicia Cole, Robin Betz, Tom Calstrom, Dave Mayer, Mike Ramsey, Edmund Lofton, and Kai Zakharowski. Let's give them a round of applause. And last but not least, I want to thank the families who are here sharing their very personal tragic stories. I'm sure the last thing they want to do is to be recounting those stories. But they're doing it for us. They're doing it for you because they know those stories and not the statistics is what drives our passion to eliminate preventable deaths. As we approach 2020, I've been thinking long about the last seven years and the time that we have left. First and foremost, a deep feeling of gratitude overcame me because of you and the many people around the world who've joined the patient safety movement without hesitation. And I worked so hard, this dream is feeling like it's real. Then frustration hit me. I began thinking of the many people who haven't joined despite numerous attempts. I'm so frustrated by the prevalence of apathy, pettiness, and minimalistic effort when people's lives are at stake. Are we not going to put these mortal plights aside and do it for the sake of our sisters and brothers? At our last year, mid-year meeting, which wasn't so mid-year as in September, Senator Young was there speaking to us through videoconference and his passion to create transparency laws and align incentive laws to get the rest of the hospitals and people to do what you're all doing. One of the attendees challenged them for wanting to do that. And soon after the meeting, the protectors of the status quo paid a visit to Senator Young to scare him from doing what he was determined to do. Look, maybe legislation is not the answer, but how are we going to get everybody else involved? One life is one too many that we lose, and we're losing millions a year. A recent study showed that in developing countries, more people die from poor care, medical errors, than those who don't even go and reach out for the care. But think about that. How can anyone not be willing to try anything and everything to stop reckless care? It's 30 years after Walt Bogdanic's book, The Great White Lie. 20 years after the IOM report to Eris Human. Look, we've tried everything. We've tried the volunteer work. I've said it before. I'll say it again. We need to do anything and everything to get to zero. We owe it to ourselves. We owe it to our patients. How do we know legislation won't work if we're not even given the opportunity to try it? Don't we owe it to ourselves, if not our patients? Don't we owe it to them to try everything? I want to tell you a couple of stories. I want to tell you a story about Chivins Hospital of Orange County. Their CEO, who I admire greatly, Kim Kreut, reached out to me asking me if I joined their board. And I said it would be a huge honor, and I'd love to. But if I join your board, I'm going to be pressing for zero preventable debts. And I may annoy people. I may bother people. And I said, no, we're focused on patient safety. That's one reason we'd like you to join. I joined them, and I joined their quality committee. And I remember going to the first quality committee meeting, and they have an amazing group of talented caring clinicians. And they were reporting on the medical harms that they were tracking. And they were discussing their results compared to other hospitals, other children's hospitals. And they were better. And I asked them, why isn't zero or goal? Why are we looking at other statistics and wanting to be below them? Why isn't it zero? And they looked at me and said, you're right. You're right. It should be zero. And then to my amazement, they decided to make zero preventable debts. One of the three criterias for the faculties and the executives bonuses and the full board when it was recommended by the medical staff, of course, agreed. And I have to tell you, the next time I went to the quality committee meeting, I saw something that made me think about this idea of stop hoping for zero and plan for zero. What they had done, we've learned from. In fact, you'll see our apps. We no longer have bullet points. We have a box to fill in. But what they had done, Chuck had gone to all of our apps and looked at the executive summary checklist. The ones they were doing in each of the apps, they marked green. The ones that they weren't doing, they marked yellow or red. And then the next page for each one of these apps, they had a mitigation plan to bridge the yellows and reds to make them green. That moment, Chuck went from hoping for zero to planning for zero. So I know it can be done and knock on wood anywhere. They've had incredible results. I'm so, so amazed and honored that they've done that. And they've showed me what's possible. They are now the first children's hospital, as I know, in the planet to have implemented every apps. I want to also tell you about the candor program. When I was first asked to testify at the Senate hearing on patient safety by Senator Tom Harkin, who is the chair of the help committee, there was a few things that I thought about. And I don't believe I was the original thinkers of these. But these were common sense ideas of transparency, of aligning incentives, of root cause analysis. Well guess what? I learned that my dear friend, Dr. Dave Mayer, for 15 years had been working on a program that they called candor. And you're gonna hear more about it. We've talked about it before. And what did they do? They did the common sense thing. And what's great, they've got data to show, big data to show that it really works. First of all, when someone gets harmed, immediately apologize to their family. Even if you don't have all the facts yet. That apology means so much to people. I know firsthand of parents who've lost children that got the apology and parents who lost children that didn't get the apology. Guess who moved on? Who became more productive. The ones who got the apology. Number two, they said, you know what? Whatever you came in here for, you don't pay for it. And if the patient survived, gave him a credit card and said, whatever care you need related to this care, wherever you get it, we're gonna pay for it. And most importantly, they had made the plan that within 30 days they would have root cause analysis to know what caused it, how to fix it, and disseminate it to their entire medical staff and to the community that they served. They also decided that, you know what? We know when we kill someone what the damages are. So they went to their lawyers and they said, whether you spend half an hour settling this case or you spend five years settling it, we're gonna give you a fixed fee. And guess what happened? I know one year of 73 incidents, there's only one went to trial. And not only they dropped mortality by over 50%, the hospital saved tens of millions of dollars. So we know these simple ideas work. But you and I are here because we care and we're willing to do what's necessary to get to zero. But how can we inspire others to do the same? How can we inspire everyone to join our effort? The effort to get to zero. How do we get everyone who's not here to do it? Or, I'm sorry to say it, get out of the profession if they've stopped caring. Or they've gotten used to all this dying and they think it's just part of the system. How do we get them to think about the next child? They have to explain that their mother, brother, or siblings are not coming home. Don't get me wrong, I am grateful to you for what we've accomplished. We've accomplished so much. I remember after the first summit, fearing that no one would show up to the second summit because we made the commitment to zero per requisite for invitation to the second summit. Those of you who are here know you don't get to come twice unless you made a commitment. You made the commitments. You showed up and you saved not just one life which would have been enough for all of us for what we're doing, but you saved 273,077 lives today. Last year, you saved one plus 90,145 lives. Please give yourself another hand. Please get up and give yourself a standing ovation. Stretch out a bit. Stand up, I thank you. And for my friends in the med tech industry, thank you. You signed the open data pledges. Most recently, Baxter signed. We now have a major infusion pump company and much more with us. This is gonna get us just that one step closer to the patient data superhighway that can be used to create predictive algorithms and decision support so that clinicians can identify patients' distress before they become fatal. So that clinicians can make acts of commission instead of acts of omission. Look, losing a loved one to a medical error is a great tragedy. The good news is we're making progress together. And here are some of the highlights. 50 countries, strong movement. 89 open data pledges, 4,710 hospitals. And four hospitals now. Parish, Children's Hospital of Orange County, University of California, Irvine, and Hospital of Spaniol have implemented all of the apps. Ask them, you're gonna meet them, ask them. It can be done, it's not that difficult. But we're not done. To a great extent, we've accomplished a lot with this movement. We have unified much of the healthcare ecosystem. We're not siloed anymore. It's no longer just nurses and doctors and patient advocates who are pushing for zero. Today we have ministers of health, high level people in governments, medical associations, universities, medical technology companies, and a lot more all pulling together. We've created 17 actionable patient safety solutions available to anyone who can use them. And this year at our meeting, we're gonna focus on the top six that we believe hurt the most people. And we're gonna introduce last but not least, number 17, which I'm really excited about. As we all know, love and dignity for the patient is paramount. And thankfully, this attitude is becoming more prevalent and more expected. Family and patient engagement are working and keeping patients safer. We have a terrific panel here today to discuss how to best do this. Transparency barriers are falling. Last year, you heard Secretary Jeremy Hunt about what he had done with transparency in the NHS system and the amazing results that we're seeing. At this summit, you'll hear of another major development on the transparency front, this one in the United States. I'm excited that the summit we're delivering on the seventh and final objective, which is patient safety hardwired in the curriculum of medical schools, nursing schools, pharmacy schools, respiratory therapists, so that hopefully it's not something they hear about at a summit like this. It's something they come and teach us. And it becomes a way of life. Dr. Scheinman, representing a group of amazing education leaders from around the United States, worked very hard to come up with this curriculum. And I'm really excited to have him come up and tell us all about it. It's going live in our website and anyone can have access to it for free. This was not an easy one. This was one of the hardest ones to put together. And I'm grateful for the day Dr. Scheinman and I met and the journey began. We had people that were ready to do it, but there's a lot of heavy lifting and we needed him to do it. And you'll hear more about it. I'm really excited. Look, we must care for our brothers and sisters. We have to care about the children of refugees. We have to care about the children of immigrants at our borders. We have to care about the children whose childhoods have been ended by military forces and occupied territories and war zones. We have to care about the millions of newborns dying before they turn one month old in developing countries. We have to care about the children who have died due to medical errors. Who are left fatherless or motherless because of why? Because of medical error. Not some grand event with medical errors. And we have to act. Look, in some cases, it's a tweet. It's a march. Something you write to your legislator. But when it comes to something we are so close to and we can act upon so well, the call to action is even greater. We have to be the best amongst us. The best. Isn't that what Thomas Bolstrom from Northern California said to us a few years ago? He said it so well. He said it so casually. And I'm sorry about the weight it puts on our shoulders, your shoulders, the clinicians. But Tom and Claire lost their daughter to CLABSI. Her name was Nora. And they said, I'm sorry, but the profession you chose, you gotta be mindful all the time. Because you've gotta be the ones that make it happen. You gotta lead us to zero. Next year, we wanna have every hospital, if not in the world, at least in the US, implement every apps. If you ask the four hospitals who've done it, they'll tell you it can be done. There's no reason not to do it. As we draw closer to 2020, our goal of zero by 2020 is gonna feel even more daunting. I know it does to me, but we're not gonna give up. I'm not gonna change the goalpost. I'm gonna own it for what it is. But you know, if we had to go to the hospital today, I'm lucky I've got chalk and UC Irvine in my backyard. Some of you have parish in yours. Well, where are you gonna go? Well, I have to say, I don't want it to be me, you, our children, our grandchildren. And if I'm standing here in 2020 and we've not gotten to zero, at least we should have given it our all. I'm gonna give it my all. We have to. But we have to do much more. We have to take risk. Aligned incentives and transparency is not so risky. What do we have to lose? We can fix the unintended consequences of well-intended laws. So please reach out to your legislators, your ministers of health, ask them, ask them to do a secretary-hunted, create transparency. Ask them to let's have aligned incentives. Please reach out to your associations. Reach out to the hospital associations. Tell them you're not afraid of legislation. You know that if we can get to zero preventable deaths, hospitals will be more efficient as well. You're here to share, you're here to learn, you're here to inspire, so we can continue to renew this passion. We have so much work to do. And I ask you to please help us get to zero. I know I'm preaching to the choir. I have to tell you, my son read my speech with me and said, Dad, don't say these things. These people like you. I love you guys and I'm not telling you this. I'm asking those who are watching and I'm asking you to please get others around us to commit to zero. What gets measured improves. What gets measured publicly improves faster. That's why it's important to make a public commitment. I stand humbly in front of you doctors and nurses who do this amazing healing. It's a miracle what can be done today. But don't let your miracle of healing get hijacked by some medical error that causes your patient's death. We've got to reject the tyranny of apathy and embrace the brilliance of action out of kindness to areas human but to not put in place processes that can avoid human errors from becoming fatal. That's inhumane. We need your help. Please don't hope for zero. Plan for zero.