 All righty, good morning everybody. See our attendees are trickling in here. Good morning, good morning. And I see some names I recognize from all around the world. So it's good to see some folks here from everywhere. All righty, wonderful. Well, we're gonna give it just a few more seconds for people to trickle in here before we get started. But thank you so much for joining us here today. My name is Olivia Lowensbury. I'm the Quality and Safety Program Manager for the Patient Safety Movement Foundation. So I'm really excited to see all these names on the screen and get to learn from some of our panelists today. So let's go ahead and get started. We are focusing on we can't do this alone. So the role that patients, family members and the general public play in advancing patient safety. So our objectives here today are to understand the current policy work happening around the world, to recognize the importance of regulation and legislation and advancing patient safety, to discuss the importance of regulatory oversight and to examine actionable recommendations for patients, family members and members of the general public in policy work. So we've got quite a lot in store for you here today and definitely a few actionable recommendations you can take home with you towards the end. I do wanna emphasize that we are offering BCPA CE credit. So these are for our board certified patient advocates. We're offering one BCPA CE credit and participants will receive a certificate from the Patient Safety Movement Foundation within about five to seven days of this webinar. So I do just wanna do a few housekeeping reminders here. You have both a chat and a Q&A function. Go ahead and use the chat to reflect on any of the insights from panelists to add any of your remarks in there. And if you want your question to be answered live during the last 15 minutes of this webinar, go ahead and put it in the Q&A and somebody from our team will be monitoring that so that we get hopefully to all of the great questions that are in the Q&A. Alrighty, and I'm very excited to introduce our moderator, Yvonne Gardner. Yvonne has been very involved in patient safety efforts at the Patient Safety Movement Foundation, particularly from a patient advocate and a family member perspective here. So Yvonne, I'm gonna pass it over to you to just introduce a little bit more about your background and what brought you into this work. Well, thank you very much, Olivia. I lost my son after a tonsillectomy and we found out the cause of death was respiratory depression brought on by the opioid that he was prescribed. And we were able to take, we found a lot of information about others in our area that had died in the same manner and compiled that information was able to take it to the legislature and pass a bill that brought on more education for the doctors in our area and the hospitals for this problem. And we've been able to raise some awareness that this is a big problem. And the best part of it, I've been able to hear of a lot of people that have been saved because of some of the information that they have received through this legislation. And Olivia, I don't know if you want me to go ahead and I'll introduce our panelists today. We've got Dr. Aether Tajik joining us from Norway. And if you'd like to go ahead and introduce yourself, you're in a minute. And then we've got Beth Bailey Olem and Mr. Tai Moss, who's the CEO and co-founder of Niles Project. Thanks for the introduction, Yvonne. Just very briefly about myself. My name is Aether Tajik. By training, I'm a cardiologist and specialist in both internal medicine and cardiology. I have worked in setting up the Norwegian Health Care Investigation Board for the last three years. And formally, I was the medical director in that organization, a national oversight organization that investigates serious adverse events with the aim to improve patient safety and quality of healthcare. Currently, I'm working as associate director in MSD, pharmaceutical company, working in vaccines and infectious diseases. I have many years of interest in and working in various projects and in quality and safety improvement and have also worked in health technology and innovation for delight previously. Thank you so much. Beth, would you like to go ahead and give us some information about your background? Sure. Hi, everyone. Great to be with you today. My name's Beth, and like Yvonne, I lost my son to medical error and kind of brought me in this journey into healthcare that I never thought I would be in. I was formerly in business, worked at McKinsey and in banking, and I pivoted to try to create some of the change to prevent future harm that happened to my son. That sort of led me down a path of really thinking about which are the areas that I felt I could have the most impact and needed to be changed. And I've worked really extensively on engaging governance in oversight of quality and safety, wrote the seminal white paper for IHI with the governance role, board role is in governing health systems on quality and safety. And I'm super proud to be involved with a fabulous group of patient advocates trying to change the US direction of patient safety by forming a WHO chapter in the US called Patients for Patient Safety US and really trying to elevate the drift that's happened in patient safety in the US and reprioritize and create greater accountability around that. I've also been deeply involved in the candor work and advocating and advancing the apology and disclosure and transparency efforts in the US. So great to be with all of you, thanks. Thank you very much, Beth. And it's kind of as Beth points out, one person can make a huge difference. And thank you so much, Beth, for all that you've been doing. Hi, would you go ahead and introduce yourself and let us know the things that you've been working on? Sure, thank you for having me on the panel today. I really appreciate that. I'm the CEO and co-founder of Niles Project. And our Niles Project Foundation is a Public Health Patient Safety and Nonprofit Awareness Foundation we started in 2007, my wife and I. And it's basically to provide education and bring awareness to eliminate the preventable harm that we've all experienced. We lost our 15-year-old son Nile in 2006 to MRSA, Hospital Acquired Infection. And we've been on a journey since then to bring education and awareness. We're not doctors, but on the scale of learning things, we feel like we're almost a PhD in some of the things that we've been able to do. So we continue to work with other advocates and organizations to bring awareness. We've had some success here in California with some legislation. And we want to share that information with you today as we go through this. Great, thank you so much, Ty. And something that I'm aware of is just as a patient advocate, I see that in Ty and Beth. We want to share the love that we had for our children with everyone else and help them prevent this happening in their families. All right, we're going to move on to Beth. What is the Global Patient Safety Act plan and how does legislation align here? That is a big question of on. So I think the question is for each of us, the Global Patient Safety Action Plan is something that was adopted by the World Health Organization in May of 2021 and really is a framework for looking at patient safety within your country through a lens that allows you to identify deficits or opportunities to improve patient safety. And also to be able to have a global network to talk with other countries about some of the innovation ideas that you might adopt in your country or might advocate in your country to improve patient safety and sharing of those ideas across borders because there's some really good things happening in other places like Norway or England. And we can bring those to the US and the US might have a nugget that we could share with somewhere else in the world. And so it's really this framework to really commit and advance patient safety and look at your own country's progress or in the case of the US, I would say lack of progress towards patient safety on many fronts. So it's just a great tool. For us as patient advocates in the US, we use this as a lens to look at the state of patient safety and where we wanted to prioritize some of our advocacy efforts. And so what we've really observed even though many of us have spent 15, 20 years working in patient safety and we've had some nuggets of great success, the overall drift and leadership commitment and the drift in progress in patient safety is frankly palpable and painful in the US. And so this was just a good framework for us to try to identify how do we move forward from here in patient safety. All right, how does legislation influence the quality and safety efforts? Sure, I can start on that and then I would love to have others jump in because certainly legislation is different based on how your country's rules are structured and your health system is structured. If you have a universal health system, your centralized approach to feedback on safety issues is gonna be coordinated very differently than if you have a pretty disaggregated and fragmented system like in the US. So in the US, our system is incredibly fragmented. The payers are fragmented, the tracking of errors and harm is fragmented and frankly, the incentives to be transparent do not supersede the incentives to be non-transparent in the US. The penalties are not great enough and the incentives aren't good enough. So that fragmentation is one of our big barriers to progress. So one of the things that we're using that WHO Global Patient Safety Action Plan is to come together as a group of patient advocates to create greater legislative and government accountability pressure because unlike other big patient movements, whether it's an issue related like heart disease or cancer or Crohn's and colitis, those are not seen as I think culturally as threatening to the healthcare system, whereas I think patient safety kind of gets at the everybody's deep vulnerability in healthcare. And so in a way, I think culturally, there's just a bigger resistance to seeing the problem, owning the problem similar in a way that racial bias in healthcare is avoided. It's a very vulnerable and painful topic. So one of the things that our group is doing is trying to overcome the fragmentation of the patient advocate world because so many people advocate for their particular niche issues, but we at some point all have to come together to put greater legislative pressure. There's just not enough commitment at least in the US to the accountability that needs to happen for both for the budget and for governmental oversight of payments related to safety as well as oversight for reporting and things that are structured to happen that don't actually happen. So the WHO gives us a platform to come together and have those conversations and frankly a little bit of authority to come together to get meetings that we maybe one off couldn't as easily congregate but together as a WHO group, we have been much more able to pull that together. Kind of that. Yes, thank you very much Beth. And Arthur on the international scene, what do you see as far as legislation and how that is helping? Sure, I'll pick up on that. And I just want to pick up on some of the points that Beth made first addressing a little bit about the issue of fragmentation. And of course we have to understand it's a really, we have to understand the scope and the size of the issue. And patient safety is really a large question. We see consistently one in 10 hospitalizations across high income countries leading in serious adverse events leading to huge costs and huge scale of suffering in human terms. And we see that when we're talking about patient safety we're talking about the broad issue, broad set of issues. We're talking about cultures. We're talking about processes. We're talking about procedures, behavior, use of technology, use of innovation. And when addressing the barriers to actually introducing legislation it is actually because this is such a big topic. It is such a big issue. It touches upon every aspect of medicine. And from a clinician's perspective it touches upon the daily clinical day to day how do you actually improve on the processes you are doing? How do you actually learn from adverse events? How do you actually learn from serious unexpected events? And we see that serious adverse events there is a culture of shame among clinicians. We see that there is a lot of resistance against talking openly and addressing these serious adverse events from a systemic perspective. So we see that there is a limit limitations regarding the understanding of the scope and the fragmentation of the issue. So that's one important barrier. Secondly, of course, every country is unique. As Beth pointed out, the US has a larger part of its more private healthcare from our experiences here in Europe. We have a more of, let's say, single-payer system in many of the countries from experience in Norway. But interestingly, you might expect that there is much less fragmentation in, let's say, a single-payer system. And of course, there is probably a little less than in, let's say, in a system where you have a large private sector. But still you see also in countries like Norway and the UK and Europe, you see that there is a lot of fragmentation. There you have clinician professional bodies, you have patient interest groups, you have government agencies, you have NGOs, you have healthcare providers and everybody's speaking different from a different perspective. And finally, I would also add the point that I think there is also a lack of understanding, perhaps on the political side, because you do have patient safety efforts that are local, but you also need something on a national level. Because of course you have, let's say, you see that there are serious adverse events in, for example, one hospital, some patient is administrated, given the wrong medication. And then you see the same kind of error happening again in just the hospital across the street. And again, sometimes even in the same hospital in just the department across the ward, something like that. So there is this lack of coordination, there's this lack of a national oversight. And there's that understanding is necessary. So those are some important barriers as I see it. Thank you for sharing that with us. Ty, do you have any insights that you'd like to share with the panel and our guests as well? Sure, I'm happy to jump in. I agree with Arthur and Beth as well. Legislation drives regulation that requires a certain action. And in patient safety, it moves the process from being an option to a requirement. So that's very important, trying to get things in place that people will have to adhere to. So I think that's key. And also it provides clarity for those that are writing regulation and for those that provide services. So we are very strong advocates in terms of getting regulation in place. Yes, Ty, were you able to see with your work through Niles project that some of the procedures were able to be changed in your local hospitals there? Yes, we have noticed a lot of changes to be honest, especially here in California. For example, one of the things that we worked on in 2008 was our SB 1058, which was Niles law but in place where hospitals must provide their infection rates and to the public annually. And that's a very important point. Very hard to get through a lot of the pushback that we got from hospitals and things like that. But overall, we as advocates continue to work on these, it seemed like it's never ending, but we continue to work hard at what we care about. And hopefully through that effort, we find we do get things done. So it just takes a lot of push. We need a lot more people doing what we're doing. Yvonne, one thought I had, like Niles, the law that you guys created took a long time and it's so much work to push these laws through. And it's always a trade-off of do you introduce new legislation where you have to introduce new legislation versus is there existing legislation and government oversight that just isn't being implemented or executed? So just an example would be one of the things that our group did is we literally mapped the patient safety ecosystem on a national government oversight level in the US. So from the CDC to the Centers for Disease Control to the Center for Medicare and Medicaid Services to the FDA to, so all the different organizations that have their hand in the pot of managing patient safety. And then we went down in each of those organizations and we mapped out what are their specific levers, what actually do they oversee? And then we actually said, okay, how do we actually get them to turn up that lever? What could we change? Could we add questions to the hospital surveys around safety? Could we ask them to produce a congressional report on accountability of the budget towards safety? So there's always this trade-off of do we, where is new legislation needed and where is there existing oversight that's just gotten lax and any more need to turn up the pressure? Yeah, so Beth on that, how are we able to track the legislation and keep that in front of our hospitals and administrators, those that are making the policies? Is there a way to do that? Yeah, so there's, I mean, there's state legislation and then there's national legislation, right? And one of the challenges as patient advocates, most of us are people in our own homes, just doing this out of passion. We don't have a giant lobbying firm that tracks legislation. We don't have the dollars of big pharma and medical device and so on and so forth that can track legislation that relates to them or in the case of the US, the big lobbying of the American hospital. So it's really hard, you know, one to track legislation and to propose legislation. So we've kind of taken, and so I think if you have a very targeted issue, like you did for Niles's law, I think it's really effective to do legislation. If you're trying to, I think move a lot of different pieces, we've worked more through the relationships that we've built, like really getting to know the people at these different organizations and work with them to know what the oversight is and trying to ideate or innovate with them on how to elevate the pressure. And, you know, it's our fault also as advocates in the US not having aggregated to create greater pressure. You know, one person calling a big healthcare organization like, you know, that does oversight like the Joint Commission usually doesn't get heard. But if we had thousands of people calling or thousands of people writing, we would get heard. So as patient advocates, we have not done what other patient movements have done, which is aggregate our voice to create deeper, you know, noticeable pressure. And I do think that's a fault for us, at least in the US. I don't know how it is elsewhere in the world, but I think that, you know, really being strategic about what you wanna change and aggregating the voice to elevate that change is effective. And as opposed to just going in and generically, I've seen so many patient talks where people are like, we need better safety. But like, we have to actually, you know, roll up our sleeves and say, what does that mean? Okay, does that mean we need, you know, different questions on the hospital questionnaires? Does that mean we need different penalties for safety events? Does that mean we need different incentives for hospitals doing high reliability? You know, I think too often it's just patient advocates have not taken the time to, you know, to really figure out what that means when we say we want better safety. I would like to pick up on some of those ideas. And of course, coming from Norway and from a European context, it's not easy to fully understand the US context, but I think it's worth making some reflections on the differences. For one thing, as I, of course, the US is a very large country. It's geographically diverse, it's huge area and a huge population and very, very diverse, both state and federal kind of legislation. So I can imagine that it's a much bigger challenge to, as you say, have a unified voice in the US for patient advocacy groups. But what I can say is that what has been successful in European countries is the alliance or the trifecta, you might say, of the patient advocacy combined with clinicians, clinicians strong support from clinicians. And this has been kind of a recent development because if you go back just a few decades, clinicians, they didn't really understand patient safety because they said, okay, but we are just trying to do our clinical work according to the best medical practice that is patient safety. So they had a very simplistic understanding. They didn't understand the systems level. They didn't understand that there's a culture, their mechanisms, there's all these things around it. So this change in mentality among a larger and larger portion among the clinicians. So you have the alliance between the patient advocacy groups and the clinicians. And in addition, you have the politicians on the side, on the same side. So you need some champions in the political sphere that really understand the systemic approach. And the systemic approach, it means of course you can't summarize it in one sentence, but it's not about somebody gives the wrong medication or some serious mis-procedure, some procedures performed in the wrong way and just focusing on that narrow issue. It's looking at what caused that, going a step back, looking at education, looking at financial incentives, looking at evaluation, looking at all these things that are surrounding it and having politicians that understand that. So kind of having that alliance is absolutely necessary to kind of push legislation. But again, I can imagine in a country as large as the US that has compounded these challenges. But I think in Europe, you've done a better job of institutionalizing the patient role in the feedback and oversight process that we have in the US. In the US, there are some hospitals that have really integrated the patient role. And then I work with a lot of hospital boards. There are other hospitals whose board would never talk to a patient and who don't have patient and family engagement processes and panels. So it's just hugely variant in the US, whereas I think in Europe it's institutionalized and a deeper cultural commitment to it. So for us, we really do need the government push in a way to say no, everybody has to do this. And then the accreditation process for hospitals will look at that, or the condition of participation process for government payments will consider that. So you're ahead of us. Okay. But yeah. I would agree as well. Patient efforts is fragmented here in the United States for sure. And there's no true collective voice in it. It's very complex. Patient safety efforts are very complex. And as you mentioned, things that happen federally and things that happens in the States are going to be totally different. There's different efforts underway. So the thing that we found at work or helped us initially was reaching out to other organizations and found out what they're doing and how we could join and be a part of what they were all about as well and support those efforts. As long as we were all finding our passion and working together. So I think that's important. It's a life long effort to be honest for us, something that you continue to do when you take those little wins as you go. But bottom line is you have to have a passion for this type of work that we do. And it's not easy for everybody. So we've had success, but we again would like to see a lot more federally. We'd like to see a lot more people involved. And that's why I think we're talking about this where we can't do this alone. We have to work together. And we're happy to do whatever we can do, share our stories and provide any kind of background that we've had success at. So really it's an ongoing process. So I'm really glad to be a part of the conversation here. Hi, did you see that a lot of your success came with educating the people when you're working on your project? Absolutely. It was a matter of educating your family, friends. That's where we started. And also joining other organizations to find out what they were doing and seeing how we can support each other. That's really the key. It's a grassroots kind of a thing for us anyway. And then as Beth mentioned, there's a lot of other work going on domestically and internationally as well. Like what Arthur's doing is sharing stores, sharing information. And over time, you see progress. We've all seen progress and that's why we do what we do. So that's really the key to it all. And we've had our challenges, but we feel it's worth every effort, every time we get a chance to talk to people, to be a part of these types of programs, panels, whatever it might be. We jump at that. Yvonne, I would love to add, like I think my patient advocacy journey really changed. Like, first after I lost my son, it was much like my ecosystem was small. It was about preventing that harm in that hospital where that harm happened, right? And making sure that there was learning and in a way that his death wasn't in vain, right? And then it kind of evolved to, I had this greater understanding of the barriers to learning after harm. So my passion really became, how do I help other hospital systems have shared learning systems? And I think there's somewhat of an organic evolution because as I then started to understand the quality infrastructure, the risk management infrastructure, which was also often separate from quality. And then the state and governmental oversight, my vision of what I wanted to change went from changing within one hospital system to changing within many hospital systems to what's the role of legislation and governmental oversight. And independent body oversight to create incentives for that kind of learning and improvement. So wherever you are in your advocate journey, you might be at the point where you just want your hospital to make change, to learn from that event. And that's a really good place to honor and try to make that change on a one hospital level. And that change can help tons of people. And you might be at the point where you say, my hospital's not interested in learning, but I wanna work with other health systems or my hospital already made changes. And I wanna make sure other hospitals make these kind of changes or everyone in my state makes that kind of change. So I think it's important to kind of think about your own journey and really reflect what's important to me, what change is important to me to make. And then as you understand that ecosystem better, figuring out what you wanna change might evolve. And that's okay. And I do wanna emphasize one thing that's helped in my patient advocate journey has been the power of really rolling up my sleeves and getting in the weeds of how payment works, how legislation works, how accountability in all these different ways works. And then the power of conversation and collaboration with other advocates, with other quality leaders, people who care about safety want to help other people who care about safety make change. So really committing to some of that collaboration and conversation. So roll up your sleeves and get in the weeds so that when you come to those conversations, you understand the payments, you understand the ecosystem, you understand that quality is often separate from risk in the US and what that means that you're game on. And be willing to learn and collaborate and join panels or join working groups to learn more. Yeah, I agree. And the other thing I would mention too is important change happens when there's true transparency. And that's really something that we have worked on. Just trying to make sure that we all are understanding what Beth just mentioned, that we're all doing what we can do to make sure that organizations are providing, especially government agencies are providing true transparency so people can share and understand better. I would like to also address the importance of advocacy, both patient and family advocacy. And from experiences in many European countries, many of the most important legislative efforts have been championed by patients and their families and actually led to real change. So that's one important lesson to bring with us that this is actually an important tool because the power of the individual story has the effect of kind of lifting these, can have the effect of lifting these things up to a national level. And both in those cases that I'm most familiar with in Norway and in the UK, for example, the Norwegian Healthcare Investigation Board was set up shortly after the health minister had direct conversations with the individual patients that had been advocating for such a national oversight organization for many years. Another thing I want to point out to the importance of advocacy is what we have seen is within the medical field, perhaps over years, you have let's say a narrow way of thinking and a limited set of tools that you're using. And what we have seen is that some of the families and the patients that are advocating for change, they're bringing in completely new tools. Some of them they are engineers, they're worked in quality control, let's say in the airline industry, maybe they have worked in the military, maybe they have some experience from the global telecom industry, something completely different. And they're bringing ideas and tools that kind of address systemic improvement, data-driven improvement, monitoring that's completely different from what we have seen previously from people working in quality improvement in healthcare. And also we have seen, which I think is very, very important because we see now that tech and innovation is becoming more and more important. It's actually a tool of empowerment for patients. It gives them the ability to both to monitor their own data, but there also gives them a tool to control their own kind of, their own medical history and so on. And we see that there is inpatient advocacy and patients that push that aspect as well has been very important in the patient's safety aspect. So it's an absolutely important, it's important to get involved and it's important to kind of get your sleeves rolled up and get involved if you are interested in bringing your competence and your viewpoints to the table. Matthew, you made such a good point. In my situation with my son, the ENT that operated on him and did his tonsillectomy was our biggest advocate as far as pushing through the legislation. Once we gathered data, we lived in a small town about 20 to 30,000 people and we were able to go back a few years and find five different cases of patients that had died the same way as my son. And a few of those were his patients if you weren't, but with some other information that we had gathered, he could see the need for more tools, just like you said, that would help the healthcare system do a better job and make it easier on them. So he did go to some engineers, to some large companies and say this is exactly what we need and that company was able to work on that for a few years and engineer products that would keep patients from dying. In my case, my son's case from respiratory depression at home once they were sent home. So I appreciate you bringing that point out that there are tools out there. There's people, ones listening that work in the medical profession and others that maybe have seen a need and work in different fields that could help solve some of the issues that we face every day in the medical communities. All right, we've got just a few more minutes. Ty or Beth or Arthur, is there something else you'd like to add? You know, I would just add that if you're not at the point where you are ready to do state or national legislative change, you can do change within your health system of just making sure that the patient committee reports to the board and asking what percentage of your, this is more in the US for boards of health systems, what percentage of their board time is spent on quality and safety because frankly, if it's not a priority in the boardroom it's just not a priority for the leadership team. So that is something that we encourage all patient advocates to push. Just on a very local level is our leadership team spending time on this. And does the board walk around, do a safety round, look at the safety dashboard, look at the total dollars spent on medical malpractice and the total number of claims. There's a lot of basic safety metrics that the board should be looking at, never events and your infection rates and all that sort of stuff that we all know about. And if they're not looking at it, the patients within a small ecosystem of a hospital or a health system can create pressure, aggregate pressure to at a minimum get that board to look at it and have that be part of the CEO and leadership team compensation. Just another idea like if, for some people legislative change feels like huge but there's different ways to create change and create pressure. And everybody has to kind of figure out what's right for them at their point in their advocacy journey. One of the things that we've been working on with the safety movement is the National Patient Safety Board. We think that's, as you mentioned Beth, very, very important that we have something like that and implemented. It's just like the NTSB, it's important. It's can help implement and regulate health care policy and to make for better patient outcomes. So I think that's something we all need support on and we surely want to promote that to the folks that are listening. And it's gonna help us all domestically. Just a brief point on, just a very brief point on that and I really do agree with what Ty is saying and what Sarah pointed out. We need efforts on all levels. So quality improvement happens on the local level but at the same time you need that national oversight and that is because of the large volume of reports of adverse events, the large volume of underreporting there are large areas we don't know anything about. You need somebody thinking about it strategically. Where should we put our efforts in to get the most, to get the most improvement for most people. All right, we're gonna be moving on to some Q&A and so feel free, anyone on the panel here that would like to answer these questions. The first question is, what are the examples of levers in organizations? Some like to comment on that. Sure, I think in different countries your structures are gonna be different. You have, I think of levers as carrots and sticks, right? Some of the levers are things like accreditation. Like are you allowed to be open as a hospital? Some of the levers are payment. Like how much you get paid or how much you don't get paid if an event, a harm event happens. Some of the levers can be reputational like the star system in the US or leap frog recognition. So you have levers that are dollars, you have levers that are reputation and you have levers that can deeply affect your ability to exist, right? And all of those are levers that patient safety leaders and advocates should be looking at of, you can't push for all of those levers to change at one time. So which of those levers is gonna be most important or most effective at changing the particular issue that you're working to change? So that's one of the things that we went through with our group, our WHO group is looking and really mapping out each organization and the levers within that organization that they control whether it's reporting or payment or incentives like reputational incentives. So I'm happy to share that in the US with anyone. Join us and I'll put in my thing in the chat if you wanna join us and we'll share that all with you. I would like to jump in on the first two questions as well, the question on the levers and what's in it for them, for the clinicians. So absolutely I agree, carrots and sticks both are important but I do believe that the carrots are more important than the sticks, of course we do need sanctions. Of course there is gross malpractice, there are doctors who completely kind of their conduct is completely not acceptable and that those are some cases but that's really not what we are talking about. Those doctors, they should be sanctioned and so on, they should perhaps even have their license revoked but for the majority of clinicians, doctors, nurses, healthcare personnel, they go to work and they really, really want to do a good job. They want to help people, they are completely running themselves to exhaustion to use their best efforts to help people but still these same doctors and these same nurses, they still they are involved in serious adverse events and they are related to human factors, they're related to how their shifts are set up, how the payment and structures are set up, how they are incentivized perhaps to do unnecessary procedures or unnecessary diagnostics where there is no need for that and so on. So the most powerful levers are those that facilitate because really what we want to do is that we want the majority, this is the majority, the majority want to do a good job and they know how to do a good job but they need the help and the most powerful lever is to facilitate and go into conversation with them and ask, how can we use our story, how can we use our voices to together kind of help you address these issues that you need to do to address to do a good job and that has to do with all kinds of things that's on the systemic level. And so we need both but the carrot part is more powerful. And I think the other thing encouraging shared learning, collaboration between shared learning organizations like I'm involved with Solutions for Patient Safety which is a pediatric shared learning organization committed to advancing safety that's had a huge success in the US and we have about 140 pediatric hospitals where there's shared, all teach, all learn committed advancement of everybody has to identify their issues and then come up with collective solutions and then whoever's doing really well on certain of the metrics has a responsibility to teach everybody else. So as patient advocates, you can push to say are you involved in a shared learning network and how can you help your organizations be involved in one of those shared learning efforts? And like you guys said, my experience with legislation was a lot easier and to answer the third question we had on here about how people can use social media to be heard for legislation, when my son passed away, of course it got out on Facebook, what had happened and everything and instantly, I mean, I didn't see those responses for a few weeks later but instantly I got lots of replies of this same thing happening to this person's child or niece or nephew or brother and sister and how and so I was able to gather a lot of information that way and then after my son's autopsy came back, I reached out to those parents or those people that had contacted me through Facebook to gather some more information. And like when Ty was talking about earlier, mostly when we went to the legislature, it was just presenting the information and educating them. We didn't get one negative vote and they were so shocked that this was happening to people that were just taking their prescription as they were prescribed and that it could kill them and that they didn't know that that was such a deadly alternative to reducing their pain. So for us, as far as we just wanted to get the information out there, so no one else had to die like this for no reason when it's totally preventable. And as far as using social media, I think it's a good thing just to let people know what is happening because sometimes a lot of these incidences get swept under the rug and that's what had happened in our community. And so when people had contacted me and said, well, did you know, this happened to a little three-year-old just a year ago, when I was told that this was just kind of a freak storm of events that my healthy 21-year-old son, the dying is asleep, and then that was just a freak storm of events, I knew that that was not right, especially when I started getting other people that would collaborate and say, no, my three-year-old died the same way. My 32-year-old child died the same way. So I think like Arthur says, it's getting information out there and trying to collaborate and correct these issues. Anyone like to? Yeah, I would add to that. And when Nile passed away in 2006, there was not much for us to gather information from. It was Google, that type of thing, but today we have so many other tools that provide a lot of transparency and a lot of input. So I think it's helped us a lot. It's a good way for people to get involved, to learn initially, especially if they don't have any background in healthcare and they want to help to do some investigating and through social media. And I think it's such a great tool, so many different organizations out there today that can provide information. And we even had a time where we were doing a lot of drive-time radio on particular subjects with organizations and radio stations around the nation wanted to have us on to talk about our story and our journey. And we found that to be very, very helpful, very enlightening, a lot of good questions came to us from that. I also mentioned that I'm a musician, so it's been a lot of time with other musicians and people that provide music. And we've used music as a tool for our advocacy, that's helped us get the word out about what happened in our particular situation. And it's allowed us to learn from others, their stories as well. And that's really the key, it's just the grassroots piece of it, it's getting out, talking to other people, providing any way that you can get the word out to bring people in that wanna help. There's a lot of people that wanna help, but they just don't know how. And these are some things that we are able to share, happy to share. But I would just add that, I think the biggest benefit that social media and has provided to me was a community because I think losing a child from medical error or losing anyone is a very isolating thing. It's not the same, it's a bizarre injustice. And so I think that, I remember finding like Carol Hemmelgarten and Sue Sheridan and it was like this bond that like, oh, we see each other's pain and that was very consoling to me, but also this empowerment that like being with other people who kind of understood this crazy stuff that we were trying to do and helping each other figure that out. And the collaboration that it connects you to people that are hard to connect with without that. So it helps break through those barriers and helps you get mentored because I think a lot of the knowledge that I've developed since 2003 has just, it's hard to gather that structural knowledge, the legislation of knowledge. And I'm the first to say there's so much that I just don't know. So I'm just grateful for that I have now this community of people that I can call to say, help me understand, how do HCAPs actually work? Or help me understand, how does the joint commission process actually work? I mean, now I know those things, but I didn't before and to have the mentors through social media to ask the questions of how do I make the change that I'm trying to make? Or someone to guide you to help you figure out what change you might wanna make? I just want to also very briefly address a little bit the question of transparency and the importance of transparency. Of course, when you're hit by such a tragic incident, somebody has this kind of incident in their family or it hits them, it's an isolating experience. So just having the option, the possibility to connect with others and share your information that's from a human perspective from an emotional perspective, it's absolutely important, but also from just from an information sharing because it's really, it's interesting, the story we have mentioned here, many of these stories, similar stories with opioid overdosing in hospital has happened many times also in Norway and also in the UK. So it's interesting that something can feel so isolating and that this just happened with me, but in reality, it turns out that this is something that happens over and over again, both in the US, even in the same department as you mentioned, and in other countries. So that points to underlying issues and that again points to having access to systemized data. So health registries, transparency of registries, transparency of hospital data, transparency of operational data, clinical data, of course taking personal data safety into consideration is also an important area of advocacy. Yeah, I would say one other thing too. Over the years working on patient safety issues, we felt kind of isolated in a way because it was kind of our focus, Merza, CEDA for those types of things, Sepsis, but now that we've had this pandemic hit, it really is, I think, open opportunities for especially advocates because this affects everybody. The pandemic has created the awareness of people having family problems and issues that they have to deal with. And I think it's opened a lot of people's eyes that may not have paid it much attention to what we've been working on for lots of years. Alrighty, everybody. Well, it's very hard to follow a discussion with the expertise, the emotion, the engagement and the historical experience that our panelists have had. And I do wanna thank each and every one of you. Yvonne for being our wonderful moderator, Beth, Ty and Ather for teaching me things that in a lifetime, I never would have been able to acquire myself. So I really, really appreciate your time today. I do just wanna kind of close out here with a few housekeeping items. There were some wonderful questions that we didn't get to answer today live. You can expect us to develop an FAQ informed by our panelists and our moderator. And that'll be posted on YouTube with this recording in about three days or so. So you can see that FAQ on YouTube if we didn't get around to answering your Q and A. And I'll also look at the folks who we didn't get to answer. I'll send that FAQ to you directly. Some other things here is that, again, we are offering board certified patient advocate credit. You're gonna get one hour of CE if you registered as such. You can expect to receive a certificate from the Patient Safety Movement Foundation in about five to seven days here. And of course, if you have any questions about that, please go ahead and reach out to us. The last thing here is we are doing our best to keep these efforts free and to provide free CE for our patient advocates and for some of our webinars, our physicians, our nurses, our pharmacists, et cetera. If you are able to donate, please do. You can go to patientsafetymovement.org and you'll see a donate button right at the top of the screen there. Again, I do wanna thank all of our panelists for your wonderful expertise and the time that you put into developing this content here today. And to our panelists, please don't hesitate to reach out with any questions or ideas for us. And again, until next time, we'll see you soon.