 Who wants their loved one to be the one, the statistic? I want to make preventable deaths history in our hospitals. I am passionate about zero. I am loving zero. I commit to zero. I'm imagining zero preventable maternal deaths. I am zeroing in on zero. I'm facilitating zero. Yo trabajo para cero. I'm dreaming of zero. I'm building it to zero. Zero is an imperative. I'm praying for zero. I'm celebrating zero. I'm sprinting toward zero. I'm supporting zero. I am championing zero. I'm advocating for zero. And I'm legislating zero. I'm planning for zero. And I am pushing zero. Zero. Zero. Zero. Zero. J'aime zero. Zero. We can do it. Zero. Zero. Welcome. Today is World Patient Safety Day. And for those of you who are not aware that we have a World Patient Safety Day, this is the second one, an annual event, which was the initial idea of Mr. Jeremy Hunt, the previous British health minister who's done so much for patient safety and has now been taken up by the World Health Organization and they're supporting it every year. I am Mike Ramsey, chairman of the board of the Patient Safety Movement Foundation and I'll be one of your hosts to kick off our Unite for Safe Care virtual event. I'm also chairman of the anesthesia department of Bailey University Medical Center and a practicing anesthesiologist. The videos you just saw is a collection of interviews from our previous meeting last year in January from the many members of our organization whose families or friends had had patient safety issues and some of these videos are really very telling. As you get to know us, the Patient Safety Movement Foundation, the organizers of Unite for Safe Care campaign has been running for the last 10 days. You'll learn that we're a global nonprofit that is tired of inaction and believes that gathering like-minded people, passionate people will help us reach our goal of zero preventable deaths even faster. Though we couldn't gather in person today, we have a phenomenal program for you. You'll hear from leaders who have been passionate about patient safety and healthcare worker safety for decades and others who are thrown into caring about this issue because of tragedy affected them or their families or their loved ones. To open our show here to join us is Dr. Tedros Adhanon-Gabrielsis, the director general of the World Health Organization to welcome us all to the second annual World Patient Safety Day. Dr. Tedros. Dear colleagues and friends, on behalf of WHO, I would like to extend our greetings to all the people joining the Unite for Safe Care campaign in honor of World Patient Safety Day. This year's focus is dedicated to the team of health worker safety which is a priority for patient safety. The COVID-19 pandemic highlights the serious difficulties health workers face around the world as they respond to this unprecedented public health challenge. Keeping our health workers safe makes us all safer. I would especially like to thank my friend, Joe Keani for his leadership at the founding chairman of the Patient Safety Movement Foundation. We're grateful to you, Joe, for your collaboration and partnership with WHO and for the generous donation by the Massimo Corporation to the COVID-19 Solidarity Response Fund and the WHO Foundation. In May 2019, the World Health Assembly adapted a resolution calling for global action on patient safety and established World Patient Safety Day to be observed every year on the 17th of September. World Patient Safety Day calls for global solidarity and concerted action by all countries and international partners to improve patient safety. Patient safety is at the heart of universal health coverage and the color orange is one of the signature colors of the Health for All logo. The COVID-19 pandemic has unveiled the huge challenges and risks health workers face as they do their work around the world. This includes healthcare-associated infections, burnout and stress, violence and stigma. Some of these risks may lead to illness and even death, as you know. Working in such difficult conditions can have negative consequences for patients too as health workers are more prone to making errors. The slogan for the World Patient Safety Day 2020 is clear, safe health workers, safe patients. Health workers' safety and patient safety are two sides of the same coin. As you know, every year millions of patients die or are injured due to adverse events at the result of unsafe healthcare. Most of these deaths and injuries are preventable. To ensure no one is left behind, it's vital that we work together in solidarity. And WHO is working to bring together policy makers, health workers, patients and the public and private sectors to improve patient safety. When errors do occur, it's important that we learn from them so that we can prevent them from happening again. By following best practices, we can avoid harm to patients and health workers alike. Patient safety and health workers' safety is everybody's business. Thank you, Dr. Tedrus, for joining us today for the Unite for Safe Care virtual event. This is the first program of its kind and we hope that you'll be inspired, laugh, be entertained and perhaps even move to tears and that you will become more educated about what you can do to improve patient safety and healthcare and ensure safer care for your family. This event would not have been possible without the generous support of our co-conveners, the American Society of Anesthesiologists, International Society of Quality and Healthcare and the LeapFrog Group who helped spread awareness of this program to their networks and encouraged many of you to be here today. And thank you for the long-standing support of our founding organization, the Massimo Foundation for Ethics, Innovation and Competition in Healthcare and our benefactor, Medtronic, for your continued support. And a huge thank you to our sponsors that are listed below. We want you also to help us remember those who have lost during these past months and celebrate those who have survived through the most incredible circumstances. For all of us, the pandemic has brought forth an important issue to the forefront of every media outlet in the planet. The healthcare system was broken before COVID-19 and became a household word, but now it's been stretched beyond relief. It's estimated that more than 200,000 people die of preventable errors in the U.S. alone, hospitals every year, and many more suffer from harm from these errors. Now healthcare workers are getting sick and dying as well since we got hit with the pandemic. Healthcare worker safety is patient safety because without them we cannot keep our patients safe. The good news is the system can be fixed if we all work together. Now COVID-19 is also getting close to that number of 200,000 preventable deaths. And this is really very concerning, but together we can beat it, we are beating it and we'll put this behind us and we'll learn a lot about it so that future pandemics will be much better prepared for. We conducted a poll in the midst of the pandemic at the end of April, and we discovered that most of you have never heard of the term medical error. In fact, 79% of Americans don't know that the safety of patients is compromised every day in healthcare. So it's important that we begin our programming today with some history to give you some context into why this matters to you, to your family, to your friends. If you're shocked, you're not alone. Let's watch a video about Lewis Blackman that we recorded several years ago, but it's still as relevant today. Lewis was our oldest child. We have two children. He was really a live wire. He was a very lively boy. He was also quite brilliant. He was one of the most highly intelligent people I've ever known, and he learned a lot. He knew a lot of things, far more than most adults. So he had this sort of wide and varied knowledge, and he also had a wicked sense of humor. So he was... Other children really enjoyed him. He was just a fun kid. He had a condition called Pectosexcovatum, which is a condition in which the breastbone doesn't really grow straight. It's a cosmetic condition. We saw an article in our local newspaper talking about this safe, minimally invasive new surgery. And we ended up taking our son for Pectosexcovatum. And Lewis came out of surgery, and we thought, phew, we've made it through that. About three days after surgery, he suddenly had this excruciating pain and his upper abdomen. He was prescribed a drug called Catorlactortol, which is an insane pain reliever like aspirin. He developed a perforated ulcer because he wasn't properly hydrated at the same time. And no one noticed. He declined for 30 hours, and they dismissed it as constipation. By the next morning, he had no blood pressure. He had sky-high pulse rate. He lost 2.8 liters of blood for a child's size. I think he had about four liters altogether. You know, I watched the color drain out of his lips. It was just like water going down in a glass, and they turned the same color as his skin. Just all the pink left his lips. It's really hard to even imagine seeing something like that. And then he said to me, it's going black, and he went to cardiac arrest. I ran out of the room. I thought he was having a seizure. I ran out of the room looking for help. These young residents and nurses were just astonished, and they worked on him for about an hour and a half before they gave up. But they never could bring him around. Losing Lewis has been devastating. I started in mothers against medical error, and we came back from the hospital. The first thing we did was the legislation. The Lewis Blackman Act. So one of the things that we have tried to work on is full disclosure. Informed consent, transparency, badges, labeling of people because we had been misled about who was a resident and who was a doctor. And rapid response, having an emergency number for people to call, and allowing people to call their doctors as well. So those were four things that had come directly from our case that we had seen that we thought we could fix with legislation. Lewis was monitored, but it kept alarming, and they would keep setting it lower and lower. And finally, they had it down at 85, and it still kept alarming. So they turned it off. Every patient deserves continuous monitoring. You never know what's going to happen, particularly with post-operative patients. Lewis is a prime example. He was a perfectly healthy child, which is why no one believed that he could possibly have anything wrong with him. So you need an objective observer like a monitor. My name is Jake Lyon, and I'll be one of your co-hosts for today's Unite for Safe Care virtual event. Hearing Lewis Blackman's story really highlights to me the life or death stakes of the patient safety movement. Lewis would have been 29 this year, and frankly, I can only imagine the burden that his family carries while working to spare others from that same tragic fate. My own father, who is the filmmaker who helped share this story with the world, has been diagnosed with Parkinson's disease for almost a decade. Right now, I just feel lucky that he was spared a disastrous medical error. Ultimately, though, this ought not be a matter of luck. This is a public and human rights issue. We want a future in which a medical emergency or a need for long-term care does not bankrupt us. We want healthcare that we can trust to be safe and that puts patients first over financial profits. In this opening segment on the history of medical error, you'll hear from health workers, administrators, public figures, and family members who have lived through preventable medical errors. This first segment is to help you understand why we're all uniting for safe care today. I was blown away by what Mike Ramsey said. Nearly 79% of Americans don't know that the safety of patients is compromised every day in healthcare. Now, let's hear from Danielle Ofri. So many of us are familiar with Peter Kronervos' very famous intervention on catheter-related infections when it came up with the five-item checklist. Very simple. Make sure the areas sterile use sterile gowns, use sterile dressings, not rocket science, and yet the infection rate plummeted almost to zero. But 135 years earlier, Florence Nightingale did almost the same thing with almost the same steps. She'd used the words clean where he used sterile, but in fact her rules for making medical care safer were the same. Make sure the patient is wearing clean clothing. Make sure the nurse or the doctor is wearing clean clothing. Clean the wound, wash your hands, put a clean dressing on. And when she showed up in the 1850s to the Skatari British Army Hospital in the Ottoman Empire, four times as many patients, four times as many people were dying of... When she came to the military hospital in the Skatari region of the Ottoman Empire, four times as many people were dying of infection and disease and then were dying on the battlefield. And so she began... And the first thing she did was to rigorously collect data. Where were the deaths happening? Where was food being prepared? Where was waste being removed? Who was taking care of the patients? What were they wearing? What were they doing? Now, of course, she drove for supervisors crazy because she took all this time to get all this meticulous data. But in fact, she showed, as did Peter Pronavost a century plus later, that if you don't measure where the problems are, you'll never figure out what's going on and how to fix it. Now, within a year, her mortality rate at her hospital plummeted from something like 33% down to 4%. Just by measuring where the problems are, making intervention, making simple rules, and then measuring the outcome. And I look at Florence Nightingale as really the patron saint of the patient safety movement. We think of her mainly as a nurse and the beginning of professional nursing. And in fact, this year, 2020, is the 100th anniversary of her birth. And so the WHO has made 2020 the year of the nurse and rightly so. But we should also think of Florence Nightingale as our first patient safety expert, our first biostatistician who recognized that in order to make healthcare, to make medical care safer, we need to measure what's going on.