 and welcome everybody to the Patient Engagement Panel. You've really been hearing a lot about patient engagement all day. I think that's sort of indicative of the role that patient engagement plays. It's part of everything. It's multifactorial, I would even say, multi-tentacled. And we're here to explore that a little bit. We've got people from five different perspectives, five different areas of interest in patient engagement. Henrietta is gonna tell us about the government role of a government representative, assigned to protect the patient interest. Meropy, who will talk in her role as a family member and tell us about some of the solutions that she's thinking of. Angie, with the professional point of view, Sue on global engagement issues and Vanda, last but not least on the family and patient perspective on bedside practices and what we can do about that. So I'm not gonna take too much time talking, I'm just gonna turn it over to Henrietta to kick us off. Well, thank you so much for inviting me to speak today. And I found this morning and this afternoon so motivating hearing the experiences but also the real passion of everyone here and it's wonderful to have so many allies. So a patient safety commissioner role, why do we have this in England? And it's come about because patients were harmed and families were harmed and they weren't heard. And groups of patients taking sodium valproate during pregnancy and their children were harmed as a result, women who'd had pelvic mesh surgery for incontinence and organ prolapse and also women who were given hormone pregnancy tests and their children harmed as a consequence. And these patients and their families found each other very much like we were hearing earlier through social media, through being on television and in the press. And their voices together hadn't been listened to individually but when they raised their concerns through their politicians, through the members of parliament, a report was done commissioned in fact by Jeremy Hunt who will be speaking tomorrow. And Baroness Cumberlatch who wrote the review also called First Do No Harm, so there was a great synergy there, made a recommendation that there should be a patient safety commissioner to act as a golden thread in the siloed and disjointed slow and system which really lacked compassion. And that's my role and I started in September last year and I've been listening hard to the views and voices of patients and families about their experiences, about the wide range of different issues around medicines and medical devices. And I've had over 250 different correspondents contacting me on a wide range of issues much wider than the report. And my role is appointed by the government although it's an independent role and I'm accountable to the parliament. And my role is to value and promote the voices of patients and families to ensure that patient safety is promoted and to help the government and the system to listen. And that's no small task, we had over 127 million medication errors in England in a year. But there were also a whole range of other issues to do with understanding who's had which treatment, what medical devices patients have got and there are a whole host of actions that are being taken as a result. But what I've found is that when we work together with the many different patient safety departments and organisations that we can actually start to speak with one voice that we can put patient and family engagement at every stage in the design and delivery of healthcare. That I can work with the commissioners, with the regulators and also with the providers of healthcare to understand how together we can do better. Because I think that if we don't, there's a risk that harm will persist, that the situations that we've heard about today will continue, that the statistics that we had similarly in the USA as in other countries will look back and say why didn't we act? And the people here in the room are the people to act. So I want to say again thank you so much for having me and really keen to continue these conversations for the rest of the conference. Great. Thank you, Henry. May I have a seat? Yes, thank you. Thanks for having me in for listening to Martha's story. It's not the story I wanted for her, that's for sure. I will try not to repeat too much of what you heard this morning, but in case people didn't hear it. You know, my daughter, Martha, she was healthy. She had a bike injury, handlebars went into her stomach. She suffered pancreatic trauma, and at first the NHS worked how you would want it to work. She was helicoptered to a specialized hospital that dealt with pancreatic trauma and we were told many, many times she was gonna be absolutely fine. It was just a question of time. She'd be back at school soon. One doctor, I remember saying, I'm going on holiday because she looked like she was improving. I hope not to see you when I come back. But after four weeks of being in hospital, she got an infection. And at first we weren't worried about that because she'd had an infection before and the antibiotics were given to her and it went away. But with this one, that didn't happen and days passed and she didn't seem to be improving. She had an extremely high temperature and then she started bleeding out of a pick line and tube in her abdomen. And I was quite worried about this, I think. She was as well, my husband was. But we were just told that her clotting abilities were slightly off and it was a normal side of infection and any doctor I've spoken to since then or has read Martha's medical note says that's absolutely not the case that DIC is a really serious sign of sepsis. But we were just told this was normal, a normal infection and the word sepsis was never used with us. Martha seemed to get worse, she was deteriorating. Back holiday weekend was approaching and at that point my husband and I started to worry and put two and two together and actually talked about sepsis ourselves with the doctors who just reassured us that that wasn't the case, that this was normal, infections come and go with this injury. New consultant would come in again and say this is normal. By the Sunday of the bank holiday she couldn't stand, she was dizzy and she got a rash. And a rash really set me on red alert because I'm not a doctor but even I know that a rash with an infection is a really worrying thing. So I stood over her and said I'm worried this is a sepsis rash and the doctor insisted it was a delayed allergic reaction to antibiotic which sounded to me odd and improbable and I kind of questioned it but I also thought well you're the doctor you know what do I know? I talked to a nurse about it, I said I'm worried he's got this wrong. I'm worried it's a sepsis rash, I've been looking out because I started to look it up on the internet and she just said trust the doctors they know what they're doing. So I decided to follow that advice which turned out to be the worst advice I have ever received in my entire life. And overnight she just drank crazy amounts of water, the nurse came in, took her OBS which I know were bad and she collapsed at five in the morning. She was finally taken to ICU probably six days I think after. She should have been and we were quite quickly told that she was at risk of death and shortly after that she died. From our perspective, I think the most shocking thing for us is that the whole time we were by her side we asked questions, we felt we were articulate, we were grateful, we were trusting, you know so grateful. We heard other people shouting at doctors and being rude and we would never have done that. You know we felt that in some way that would give probably Martha the best care and it didn't turn out that way. In actual fact we felt we were sort of managed and controlled by not using the word sepsis or not telling us how serious some of these things were because they might have thought that we would have looked up and known that she should have been in ICU and insisted that she get better care. So we were told almost nothing and just repeatedly told this is normal, this is fine until we were told that she was going to die. And just reflecting on some of the things that have been said this morning where people talk about protocols and practices and standards, the key thing I would like to say is that those things were in place at King's College Hospital in London where Martha was being treated. There were at least six opportunities when she should have been transferred to ICU. According to their own guidelines, she was, you know, there was a BPUS chart, BPUS 5, she was meant to be transferred to ICU or a conversation was supposed to, she was at BPUS 8 on Sunday. The nurses had put her at risk, that's another sign that you should be transferred to ICU and the parents were worried. And in actual fact, the parental concern, which is meant to be a trigger to move a child to ICU, the opposite happened. The consultant who wasn't in because it was a holiday weekend and I would like to say holidays, weekends, such an issue, sometimes people try and say it is a huge issue. It was a completely different atmosphere at the weekend and as I say, the consultant was at home and he told the duty doctor not to get a critical care review for Martha because it would only increase my anxiety. So that's the opposite of the hospital's own guidelines. So I think there's an issue when we talk about human factors is what happens when humans override the protocols and guidelines that are in place which happened several times in Martha's case. Yeah. Yes, you're talking about humility and hubris. Angie, go ahead. So thank you, Helen. From the clinician's perspective is I've been a registered nurse for 30 years, over 30 years. 25 of those I've spent as a certified registered nurse and as the test. And I know like many of you, we've been talking about air and patient safety my whole career. And I even look back as when I graduated from Anastasia School was the same year that the Institute of Medicine released to air as human which really did establish the what for us. We know there's a problem, but the part I wanna emphasize is I'm not sure if we would have had that without the advocacy or activism. I'm gonna start using that word now is the activism of patients and families who have been harmed contacting their elected officials and really saying you must do something about this. What came out of that clearly was the Institute of Medicine and National Academies of Medicine. I think AHRQ, IHI, we have patient safety foundations. So we've got the what and we've got the people who are interested. Now the next step is really what do we do with it? And Helen and I have had this conversation is when I moved to South Carolina in 2010 one of the things that we had during my hospital orientation was talking about patient safety. And the thing that they mentioned was the Lewis Blackman Act from 2005. And they talked a lot about how providers need to identify themselves to patients and families. And patient and families rights to just like Maripi was saying to a different level of care or a different provider. So I was indoctrinated in Lewis Blackman my whole career so far down in Charleston. And it wasn't until I was making sure I had my facts together for today that I was going back and looking at the Lewis Blackman Act and what it meant and how it came about and the years of it and realized that I was gonna be sitting here with Lewis's mom. Which I think is amazing. So I contacted her and I said, can I talk about Lewis? So when we teach our students, our nurse anesthesia students about patient safety one of the things we talk about really is that. So I wanna make sure that advocacy and activism are so incredibly important. And I think that is something as healthcare providers that we can influence. I was lucky that I worked in an ICU in Minnesota where the nurses were incredibly empowered. The hierarchy was very small. And what that did is not only was at a level playing field from the least credentialed person to the highest but what it did is it created an ICU environment where nurses empowered patients and families. Patients, I know visiting hours are mentioned. I was an ICU nurse back in the early 90s. We didn't have visiting hours. It was open hours and families were there all the time. And this was in an ICU and we made sure that all patients and families felt empowered and engaged. So the next thing I wanna mention is a few things that I see are barriers from the what to the doing. One of them is and we've heard it a lot so I won't go on it too much is implementation of evidence-based practice. I think nursing has come a long way in their doctoral programs very clearly and that is spelled out is we practice evidence-based and the next thing that they do is gonna lead into my next barrier. I think that we often are working in healthcare systems and quite frankly in regulatory and legislative bodies where we don't have leaders who are prepared to step up and make that change and engage people who work there to implement evidence-based practice and to put patient safety at the top and to break down barriers and limit hierarchy. And then I'm gonna say the third thing that I wanna say and that's gonna lead into everything else is communication. When I take a look at all on the Patient Safety Movement website and from listening to the ladies here who have lost loved ones, communication, gaps and misunderstandings, I think one of the number one things to lead to these egregious errors. So about effective communication is the first thing I'm gonna mention, it's about listening not hearing. Listening involves an active intent, not standing there hearing, but truly listening what that patient and family member are saying. I think that that is something we have got to really help our healthcare providers to do better at. I mentioned a little bit of my ICU about the experience that we were very engaged with families and at that time we were starting to talk about multi-disciplinary rounds and how important it was for every healthcare provider to be on the same page. What I have seen is an incredible change in the last 10 years, not fully implemented. We do it where I work, is the family is involved in the rounding. So we have a multi-disciplinary round where a family member is there and they are hearing what every consultant is saying at the same time and the plan is developed and families are empowered to ask questions. I think that is something that is important. The final thing that I want to mention with communication is living in the anesthesia world, is most of my communication with patients and families is doing pre-op assessment and making sure that my conversation with them and the communication and the listening is non-biased and open and transparent so that patients can share those difficult conversations with me, whether it is their drug use or transgender or non-binary, all those things that are really difficult to talk about, but they know that as an anesthesia provider, I'm there to take the best anesthesia care for them and I need that information in order to do my very best for patients. And then I want to talk a little bit to the AANA, the Association of Operating Room Nurses and the American Society of Perioperative Nurses recently put out a statement on workplace civility. One of the reasons, and I see this in the operating room, I've worked a lot of places, so it isn't just one place, is we see the hierarchy sometimes and the in civility in the operating room has led to errors in the operating room, things that never should happen, wrong site surgery, that if somebody was empowered to stand up and say to the surgeon or to the anesthesiologist or the CRNA or to the nurse, this is the wrong thing to do. We've got to work on that and that is something as healthcare providers, anybody with an interest in patient safety, that's important. What in civility also leads to is problems with provider mental health and that impacts patient safety also. Two things that I think we need to work on a lot and we're working on it with AANA is dealing with patient safety in our rural areas, especially obstetric underrepresented minorities, that's got to be a priority for us in patient safety and our rural communities that don't have access at all to patient care, much less patient care that is not safe. And finally, and I'll put on my anesthesia hat again, and for anybody who's a patient in a room or family, I want to empower you for this, is in anesthesia we are under incredible production pressures, spend less time with patients, get the patient in the operating room, get the surgery started, that what has happened is we've lost that ability of that listening and listening and making sure that patients are truly heard. So for everybody out there who's a patient is if we are moving too fast for you, tell us to stop. That's your right as a patient. It's important for us to know exactly what you need and what we can do for you. You are empowered to tell us that. And finally, the last thing that I want to say is, you made me think about it when you were talking about connectorous and you said he was the only person who'd had it. I'm sitting here going, I saw it myself, is some of the near misses that once we start talking about things, that we really do realize how many of us could have been in your boat is, and I get a little emotional when I think about it too, is I had a near miss with a three month old. I was told my daughter was dehydrated. I knew it, I was a nurse. I was told to put her to bed by the on-call pediatrician. I refused to listen to that. Took her to an ER. We ended up being gone by ambulance to a pediatric hospital that she spent a night in the ICU. If I would not have stood up, the ending would have been different. And what I would say is I am so grateful that I was a healthcare provider and I think about those of you that are not and I knew the right things to say in due because I'd been there and not everybody has those abilities. So it's important that we educate patients and families of that also. So thanks, Helen. Thank you. And Sue. Thank you, Helen. Gosh, so much to say about this topic of patient-family engagement. I mean, I think all, Helen, Rhonda, Merope, and I, I think there were a common thread amongst all of us that we were, our cries for help were ignored and we were not listened to. And I've thought a lot about this. I've had 28 years to think about this and there's just so much we can do about having healthcare workers to listen to us. We can't write a federal policy that you have to listen to your patient. And so that kind of took me and others who have experienced harm, like Helen and others to the next level up where we got involved in policy. We know that there's gonna be this vulnerable moment with patients where they're not listened to. So we have to ramp it up and get more into policy to prevent the harm, getting in triggers and getting in forcing functions and other policies. And that's what we did for Connectorys is we changed the standard of care so all babies are tested because the moms were not listened to and so we ramped it up. And so policy is really important for us all to be involved in. And so that leads me to wanting to talk about what's going on globally with patient-family engagement. And Sir Lam Donaldson, I think in earlier this morning, the WHO's Global Patient Safety Action Plan has been touched on. I believe Nilem Dinger is going to go through that action plan. And it's a remarkable plan that many of us patients read and feel like finally. There is this comprehensive, multi-dimensional, all-stakeholder plan for us to engage as partners to drive change. And Nilem will talk about this, but there are seven different strategic objectives in the WHO's plan. And one of those strategic objectives is patient-family engagement. Now, this is not your traditional, have your patients ask questions, although that's part of it. What they've really done is they've elevated patient-family engagement into the government level, into the healthcare system level, into capacity building. And so they have five strategies that I think we can all learn from and all implement. The first strategy is engage patients, families, and civil society in co-development of policies, programs, strategies, and guidelines. Without our input into these policies, we will not have a patient-centered, safe, equitable healthcare system. We need to be at the table. The second strategy is learn from the experiences of patients and families exposed to unsafe care. I think we have an epidemic of not learning from us. And imagine what our healthcare system would look like if we had multiple mechanisms in place that we could report to that there's surveys that are asking us questions about safety. I know we have our HCAPs, but what if HCAPs had questions about our experience in safety? So we're calling for these kinds of changes. Number three is to build the capacity of patients, families, and leaders in patient groups. And this has been talked about for years, but we simply haven't done it. What if we invested in developing leadership with patients and families and patient groups that we are at all the tables, that we are part of the healthcare sector, there's some papers that refer to us as like the lost continent and the subcontinent that were kind of lost world that were rarely invited to the decision-making table. And so building the capacity of us and others and civil society I think is just, I really admire WHO for highlighting that. The fourth strategy is to establish the principle of practice of openness and transparency. I mean, you've heard this all day today. We've talked about it for 30 years. We haven't accomplished an open honest healthcare system here or probably around the world. And I say we have to absolutely commit to that. And what I mentioned earlier this morning that we have all learned that truth telling is optional and that's unacceptable. And the last strategy of WHO's Global Patient Safety Action Plan for Patient Family Engagement is to empower us with the right kind of information, with reliable information, with action, with information that activates us. With jaundice and with conectoris, we recently went through a revision with the American Academy of Pediatrics and originally the doctors wrote it and I'm all four doctors. I'm married to a doctor so I'm not dissing any doctors. But it was all clinical, talked about the liver and the sluggish uptake of the hepatic uptake and the red blood cells break and the mom said, we don't care about that. We wanna know what do we need to do to take action to prevent harm. So I think we can do a much better job of getting patients and families at the table recreating patient information that speaks to us that motivates us. And finally, I wanna say that Sir Liam and Neil and I think we're bringing up Sir Liam already did patients for patient safety, a global network of patients of which I'm on to you part of and Helen and Melissa who spoke. I think we have several champions in the room but champions are advocates. And there are over 400 champions globally of networks in several countries and I wanna read something that is our North Star and I think it's a message to all of us and it hasn't changed. This was crafted in 2005 by patients from 21 countries all who'd experienced harm from unsafe care and this was under Sir Liam's leadership that we got together in 2005 and it's called the London Declaration because we all met in London. And we really hadn't planned on creating a declaration. Matter of fact, we didn't even know what declarations were at the time but this is our North Star. This is our vision and our promise. And this is patients and we have several in the room. Just for the end of it Sue, I think we wanna have time for Vonda. What's that? I said can you just read part of it? So we will. Part of it. Well why don't we just leave it in the, yeah. Okay. I'll speak fast. So I was gonna read. We patients for patient safety envision a different world in which healthcare errors are not harming people. We are partners in the effort to prevent all avoidable harm in healthcare. Risk and uncertainty are constant companions. So we come together in dialogue participating in care with providers. We unite our strength as advocates for care without harm in the developing as well as the developed world. We are committed to spread the word from person to person, town to town, country to country. There is a right to safe healthcare and we will not let the current culture of air and denial continue. We call for honesty, openness and transparency. We'll make the reduction of healthcare errors a basic human right that preserves life around the world. We patients for patient safety will be the voice for all people but especially those who are now unheard. Together as partners we will collaborate in devising and promoting programs for patient safety and patient empowerment. Developing and driving constructive dialogue with all partners concerned with patient safety. Establishing systems, reporting and dealing with healthcare harm on a worldwide basis and defining best practices and dealing with healthcare harm of all kinds and promoting these practices throughout the world. So in honor of those who have died, those left disabled, our loved ones today and our children yet to be born, we will strive for excellence so that all involved in healthcare are as safe as possible as soon as possible. This is our pledge of partnership. So I hope we can all take that pledge. Thank you, Sue. That went faster than I thought. Okay, Vanda, take us home. Well, I'll say that I was here for not the first year but I think the second year my husband died in 2012 in just 18 days. It will be his the 11th year anniversary. And over these 11 years, I have noticed the narratives change in part because of summits such as this. And there are a few noticings that I think stand out for me that I think would be very helpful for all of us to consider. One is that there is a distinction. I make a strong distinction between implementation and integration. I leave implementation to the systems, the relationship between what we know and the processes and policies that we know need to be put in place and actually implementing those so that they happen. For me, a lot of the work is on the integration. That's the human and culture side of the equation. That is the capacity that we have as human beings in the relationship with each other and those processes and policies and systems that help us give input into the system, that help us receive that input in an active ongoing way. And then most importantly, help us integrate that feedback, that input. And one of the things that I think stands out for me most over these last 11 years, but I will say 10 years just in terms of, it took us a while to even recognize that there was errors as common as they are then is that there's been a strong leaning and bias. And by bias I really mean like, it aligns for me around the purpose, around the motivation. What are we motivated here to do? And the origin stories of healthcare medicine are, the strongest motivations are around that human relationship to our health and our wellbeing. And there has been a shift in awareness. And I have certainly hoped to have been a part of this and I know that my loved ones here in the family of patient safety have helped shift the awareness that the business of healthcare is interrupting and has been a centralized component of the delivery and the motivation of that intention to give wellbeing forward. And I think we need to be honest about that and to unpack it and to not be shy or concerned about raising the hard questions around the ways in which monetarily we also have to be attentive but not in replacement for that human relationship. So I would just leave us with that need and I think call for action as activists, thank you, to really make the discernment between the implementation of AI and technology and all those things that are so critically important and so important policy process and also that need for our human cultural integration to learn how to be with these mistakes because they're going to continue to happen. And our psyches, our egos, our relational aspects with each other really need to know how to integrate this learning because it's really not enough to just simply learn along the way. As Maropi, you pointed out so poignantly and I think was certainly the case with us is that it had been 40 years that there was knowledge around hospital associated venous thromboembolism when my husband died. We knew what to do. We hadn't integrated it at an individual level and so I hope I will leave you with that and thank you for allowing Yogi Raj's experience to continue to inform, to help with the learning but also help with the integration. So we do have time for a few questions. I have one for you, Henrietta from Joe Chiani who says, when you hear about Martha, what do you think should be done to keep this from happening again? So the first thing I was going to say is that there's no doubt that everyone here on the panel and everyone else who's been speaking at the conference today, it's not because of lack of being articulate or asking the right questions, it's not, I agree about patient and family empowerment but I think about it much more from the perspective of those who are delivering care, that leaders need to create the intent to listen and to understand the societal and cultural biases that we have speaking as a doctor but I've also been a patient and I will be a patient in the future. That the words that are used by patients and families do not have the same power and value in the healthcare settings as those used by professionals and there's an undoubted injustice in that. There's an injustice in knowledge, there's an injustice in the patients and families narrative and there's also an injustice in the language because doctors are more likely to believe and understand each other. And we have to take this on board and use this as a reality to then act on that and when I see descriptions of healthcare systems they normally start with governments and with regulators and providers up at the top and patients down at the bottom but we need to change that entirely so that patients and citizens and families are at the top because that's who the governments are accountable to in the first place. I mean, I would say that the most important thing in this is that we are always putting that listening with intent and with a real curiosity to every single word that patients and families are saying and I'm very lucky in my own clinical practice that I had additional training for a year of listening to the patients and families narrative and maintaining that intense curiosity to every single word that is being told to me but even then I'm sure I have my own biases. We jump to try and understand the pattern and the diagnosis and stopping and pausing and listening but then also what is it that's stopping other members of staff from speaking up if they're not content with what they're seeing and my previous role was setting up the speak up process for the healthcare system in England and I know that fear and futility are bound so the more that we're able to have a just culture a learning culture and one that the resources follow the recommendations I think is absolutely key. I'm absolutely appalled from the things that I've heard today and the examples that I've heard and I know that these are just some of many, many tens and hundreds of thousands of examples and what we have to do is take that on board and build it into the way that we educate the way that we commission and train and work as members of teams and I'm sure that the pandemic as much as any other problem that we have with workforce, et cetera is going to act as a barrier so what we have to do is take all of that learning and then dismantle those barriers one by one. Yeah, one of the things that we always say is that it's not patient engagement that's the problem it's provider engagement, the patients are engaged but they're not received. Merripy, we've got about a minute left. I wonder if you could just very high level talk about some of the solutions you're seeing. So after I wrote about what happened to Martha in The Guardian, I was contacted by a lot of people a lot of doctors, a lot of patients who'd had similar experiences. I think that's how you messaged me originally but the, I was contacted by some people in Australia where they have something called Ryan's Rule it's just, it's only in Queensland, Australia, I think where patients can request a clinical review for themselves or for a family member in hospital and they said, you know, if you'd had something like this this could have helped Martha and we have been talking about trying to help Martha and trying to create a similar Martha's Rule in the UK. I would say that the main thing I felt when I was in hospital is totally powerless, had no power, I was not part of the team of people looking after Martha. I think back to that last day when she got the rash and I could, the consultants in the morning were talking to each other and they were whispering outside, outside the room and I remember craning to try and hear what they were saying and I know now that what I should have been doing is saying, sorry, can you tell me what's going on because I need to know as much as you because I'm right here all day and you're gonna be doing other things but at the time it didn't occur to me, I didn't know that that was my right. You know, it's hard to explain if you've never been in hospital before and I should say we'd never been in hospital ever, none, no one in our family, we had no experience of this, we weren't medical families, we didn't know how the system worked, we didn't know that errors like this happen all the time and well, not all the time but you know, enough to worry and so I wish we'd had more power and the numbers of people that saw Martha as she was deteriorating over the course of the week, nobody spoke up, any number of them could, some of the nurses did document they were worried but they didn't speak up, they were all doing what the most senior person was doing which was nothing and I wish that I could have created a critical care review and insisted on it and what I said to Helen was that the idea was this is a metaphorical red button where you could insist that a critical care review happened if you were worried that you or your family member was deteriorating. The argument against it, people say is that patients will overuse it which to me is just another way of patronizing patients and saying they're idiots who don't know what's going on in their body, they do, they won't overuse it, they're not gonna press it for a cold, I know I wouldn't have done it but I would have done it if I'd known about it at that time, Helen said why does it have to be a metaphorical red button, why can't it be an actual red button but the point is that, you know, patients aren't idiots and parents aren't idiots who overreact about things, you know, you know when something's wrong, you make that judgment and I'd like there to be more power in the hands of the patients. Yeah, thank you. Thank you all, I think that's it for our panel. I just, I can't resist a couple of last words which is, you know, this is not just one of the pillars of patient safety, it really is the foundation of patient safety, we're all people and we need to relate to each other and if we can't get this right after trying all these centuries really, we can't do anything, so let's do it.