 My daughter Leah was incredible. She was the life of our family as I look back. When you see pictures of her and video of her, her spirit just comes through. She was alive. We never knew why she carried a purse. We used to tease her about it because she was so little to carry a purse. And then we found out it was because she had snacks for her little sister in the purse. And in the mornings when I'd get the girls up for school and I'd always say, Leah, Leah, come on. No, Mom, I'm so tired. And I'd go in her room and I'd pull off the cover. She'd be all dressed. Her hair would be in braids. She'd just be messing with me. But that's who Leah was. She just, she was remarkable. She had a pectus caronatum, which is where people call it pigeon chest. Chest comes out. And so every morning she'd get up and put on a t-shirt and be uncomfortable. I took her to a doctor. And they said, well, you can do something about it. But they didn't tell me. Like, there was no need to. And that it was really a major surgery. So we did that. And a lot of things went wrong that day. So we went to the room. And she was on an epidural for pain. So they kept increasing her fentanyl and whatever to the highest amount. And she was in pain. So she wasn't getting pain relief. If she was just getting her 80-pound body saturated with narcotics, my husband had to leave to go home to our other children. And he said to the nurse, I really don't want to get in anybody's business. But my child is way over-medicated. And I don't want anyone to give her more medicine. And the resident said, if you're not going to allow me to increase her narcotics, I'll give her something for anxiety. Because she has to take deeper breaths. Maybe she's just scared of the pain. So it turned out that the resident had written in order for two milligrams of Adavan every two hours. And if you're familiar with Adavan, two milligrams of Adavan would put a grown man to sleep. She never spoke again after that first injection of Adavan. She was not on any monitors. The law is every two to four hours you take somebody's vitals and monitor them. I had been awake for 30 hours. And I remember sitting in the chair. It was midnight. I was watching Saturday Night Live. And I always remember Al Gore was the guest host. And I dozed off. And I woke up some time around too. And she was dead. I screamed. And they came. And for 40 minutes, they're pounding on her chest to resuscitate her. And I'm sitting in the hall crying because I know she's dead. I've seen her. And I called my husband to come back. And I have a memory of my husband walking down the hall of the hospital. And I was sitting on the floor. And I looked up. And I said, Leah died. He fell to the ground and took a couple of people to pick him up and put him on a bed. And when I went home that day and told my other daughters, basically that was the end of our perfect family as we had known it. This was so avoidable. Had she been on a monitor, they would have detected that her breathing was deteriorating. And the dose of narcotic was way too high. And something would have triggered an alert before she died while I was sleeping. And monitoring is so easy. Nowadays, I mean, the new technology is so simple and inexpensive and not invasive. And to find somebody dead in bed is inexcusable. I knew I couldn't live my life and not do something. So I focused on what I want to be. Leah's law, which I think is so simple, continuous post op monitoring for patients on opioids. 800 children will die this year because they're not on a monitor after surgery. That's so easy. You're not supposed to bury your children and especially not healthy children. So I can't not do this for her, even if Leah's law never becomes a law, just to inform people. If you're in a hospital, demand a monitor. Leah's video is really hard for me to watch. It really hits home. It hits home because of many reasons. One, the day unfortunately Leah was being buried, my daughter had a surgery at the same institution with the same surgeon. And while the surgeon was brilliant as he was for my daughter, as I'm sure he was for Leah, a simple lack of monitoring took her away from us. And it hits home because I invented, I'm a co-inventor of measured through motion and low perfusion pulse oximetry. And by revolutionizing pulse oximetry to make it work even when patients move, we know this technology can be used to help monitor patients on opioids. So to not care enough to make monitoring a requirement for every patient that's been given opioid, I think it's wrong. And I think it's inhumane, especially since we know every institution who implements continuous monitoring of patients on opioids saves money too. In fact, the Dartmouth-Hitchcock study showed $7 million a year savings because they reduce rapid response team activation by over 50% and they reduced ICU transfers by over 50%. So we can do this, we need to do this. We've been working with legislators around the party lines, whether it's Democrats or Republicans to align incentives and increase transparency so that things like continuous monitoring for people getting opioids in hospital and even at home will become a standard. And while we're still not there, there's been a lot of incredible effort done by many senators, by many members of Congress, including Senator Whitehouse and someone that I consider a great friend here in California, Senator Barbara Boxer. When she was in the Senate and she heard Leah's story, she decided to write a letter to every hospital in California asking them what are they doing about medication errors and patient safety. And she went to the hospitals that had done a lot of good work, like UCSF, to congratulate them and publicly acknowledge the efforts that they had put in place to combat medical errors that were killing so many people. So it gives me a great pleasure to introduce you our favorite Senator, Barbara Boxer from California and a great friend of mine and someone who's a fighter for all the people who don't have a voice. So without further ado, here's a message from Senator Barbara Boxer. Thank you. When I heard from the patient safety movement that medical errors were the third leading cause of death, I was stunned. I was shocked, I didn't even believe it. I said, prove it to me, and they did. More than 200,000 people a year die of medical errors. So behind the numbers killed by heart disease, cancer, then comes medical errors. So I said, what can I do? I was a Senator then, it was a long time ago. And they said, well, you need to support legislation to make sure that we don't reward hospitals that have these very bad outcomes. So I did that and did it and did it. We did get something into Obamacare, not enough and more needs to be done. I met with so many families who had lost loved ones because of medical errors. And when you stop to look at what these errors are, it's stunning. A lot of things we're learning, by the way, from COVID, which is simply washing your hands. We had situations in hospitals where hands weren't being washed, that's a leading cause of problems. And it would go on from there, mistaken medicine, giving the wrong medicine to the wrong patient. These are simple things, but we have to crack down where there are problems. And we can get this down to zero. We've been making progress with the leadership of the patient safety leaders. I've been so proud to be a small part of this. I lost my own dad so many years ago at a younger age than he would have lived to. I know that because his brothers and sisters all lived to ripe old ages. He died at 69 because somebody gave him kind of a medical regime that was not, had not been tested. So I carry this issue in my heart. What would it be if we finally said, if you don't have good sanitation, you're gonna lose funding? What, how bad can it be if we say, if you don't make sure patients that are lying in beds get turned over so they don't get bed sores? What could it be? What could it be? What's wrong with it? If we finally had a situation where rooms were sanitized and disinfected as patients moved out. So some of these things are so simple, making sure that you give the right medicine to the right patient. So I hope and pray that this year, as we deal with COVID, which is so difficult, that we can make a real change here and make sure that we get these unnecessary deaths down to zero. I hope you'll be with me in this and thank you for all you do. I'm delighted to introduce two great senators of our United States of America to our program today. Senator Sheldon Whitehouse and Senator Todd Young. Senator Young, who will be speaking next has worked with us for many years and has worked with Senator Whitehouse to understand the problems we face in our hospitals when it comes to patient safety and help craft legislation to hopefully fix the problems in a big way from improving the transparency to aligning the incentives. I'm grateful for both of these senators, both Republican and Democrat, to be working together so closely to help the patients of our country. Senator Young. Thank you so much, Joe. I wanna thank you for your leadership and thank the entire foundation for your leadership with respect to the patient safety movement and making sure that we continue to make a difference, not just in policy circles and on Capitol Hill, but really you should all understand that I know the real work has been done in the trenches and on the front lines by individuals like you, been advocates for patient safety, some of you for a number of years. And to the extent we can be force multipliers up here on Capitol Hill working with all of you to develop legislation that aligns incentives between our healthcare providers on one hand and the patients on the other. We wanna continue to do that. So I've been briefed that we have over 200,000 of our family members, our neighbors, our parents, our mothers, our fathers, our siblings who walk into a hospital on an annual basis and they never walk out again. That's why all of you are involved in this cause. That's why I certainly am involved in it. And we wanna prevent these preventable errors, whether they're hospital acquired infections or so-called never events from never happening again. I share your goal, which is making sure we reach a zero. That is zero preventable errors by 2020. It's gonna take of course a lot of work to get there, but I think that we have an incredibly powerful lever at the federal level with respect to how we compensate medical providers. And this obviously was brought to my attention by Joe and others at the foundation. And we've been working towards that end, changing the compensation system ever since really that first meeting. It's unacceptable to me that it takes, estimates vary somewhat, but it takes roughly 15 years for best practices of clinical research to find their way into actual clinical practice. And we can compress that timeline significantly here again if we align incentives appropriately. So I do believe that our legislation will not only help prevent errors, but also lead to this incentive where we shorten the timeframe that best practices make their way into clinical practice and thus prevent complications and even deaths. So I will continue to work with the Department of Health and Human Services. We've been working on legislation for some period of time now. Joe I have to say, and I say this commendably Joe, Joe has been persistent, vigilant, even at times impatient. And I share your impatience with the bureaucracy here. And we've been fighting through some of that. And I think we're very, very close to arriving where we need to be to end up seeing this legislation signed into law. We will also, I should add, I know some of you have an interest in whether we've been working with other agencies of government, but it's our offices and pension working with other offices and my colleagues on both sides of the aisle to reach out to Department of Defense, Department of Veterans Affairs and other agencies that have a very strong role in the healthcare space and to make sure that they too are part of this movement and properly incented to adopt appropriate clinical protocols that will prevent errors and suboptimal treatment. Hi, this is Senator Sheldon Whitehouse on World Patient Safety Day. I am here to stand with the Patient Safety Movement Foundation and healthcare groups around the country who are fighting to make sure that we reduce Americans' exposure to hospital-acquired infections and other such hospital-acquired injuries. If this were a disease, it would be one of the leading dangers in America and to address it is gonna require all of us to work together. So please join me in supporting of the patient safety movement and protecting our loved ones. Thank you so much. We need our elected officials to work with us to address this terrible problem of safety in hospitals and health centers. We've seen with the pandemic just how dangerous it can be when a health center has trouble controlling infectious disease. Well, there are many other things that can go wrong in a healthcare system and we need support and we need help and we need legislation to make sure that we can protect future generations of Americans from the kinds of problems that are such a terrible, debilitating stress right now on our healthcare system. So for example, we need to have public reporting of infection rates by facility for every nursing home, every hospital, every ambulatory surgery center, dialysis center, hospice. We need all of that information. All of us deserve that information as Americans and it will be very useful to all of the facilities so they can track their own infections and public health officials, such as the CDC, can find those hotspots and send support into the facilities that are having problems. We need to get that together as a country. We should be the greatest place on earth to prevent an infection. That should be the United States and that's gonna start by knowing where the infections are happening now. So we are all in with Unite for Safe Care to do everything we can on the public sector, among lawmakers, as well as among the business community, employers and all of us who work in and with the healthcare system side by side to improve the care of all Americans. The biggest single change we could do is to adjust our laws so that there is absolute clarity for doctors, nurses and other health professionals between the ordinary human errors that all of us make in our working lives and gross negligence, which should never be acceptable. And at the moment, because that line is blurred in medicine, too many medical professionals are fearful that if they're open about a mistake, that could end up costing them their career. We can change that with some simple adjustments to the law as have worked extremely effectively in other industries, the airline industry, the nuclear industry, the oil industry, where they've learned that actually being forgiving for the ordinary human error that we're all prone to is the way you make it possible to be open about mistakes, to learn from them and make sure they're never repeated. Unite for safe care. What does this mean? Okay, I'm a hospital doctor by training. And I can tell you, we gave lip service to safety for 20 years since this became, you know, into the public consciousness. It's still not in our consciousness enough. We talk about it, improving outcomes, patient safety, all of that. And hospitals are still the most dangerous places on earth and you look at during the pandemic, they're dangerous not just for patients, they're dangerous for staff. They've been dangerous for staff and patients for a long time. There's violence against healthcare professionals and there's violence against patients in the form of medical errors that are preventable. And why after all these years have we not been able to make it better? The main reason is we don't get paid for quality. You can invent technology that improves safety. You can, and I've talked to these entrepreneurs on my show and they too are one safe, but nobody gets paid for patient safety. Nobody gets paid for quality. You're incentivized to do procedures to patients, not to keep them safe. You're paid to do things to people, not for people. And that fundamental misaligned incentive means that we now have a system that has emerged that is chaotic, unsafe, has a culture of retribution against healthcare professionals that make mistakes instead of a culture of a just culture where we actually support each other. We go through a process and go, if this wasn't a malicious mistake, you should be educated, you should be given a chance that we should be able to apologize to our patients without being afraid of being sued. These are such fundamental human values for our patients and ourselves as caregivers and yet we haven't gotten there. That's why I think the Patient Safety Movement Foundation is so important because as we educate the public, we also educate healthcare providers and we change our fundamental conception of what it means to take care of patients safely. Safety should be the absolute highest priority like it is in the airline industry, but in the process of that, we should be supporting each other as caregivers instead of adding yet another click box or another piece of work that we have to do and we're already overwhelmed, burning out, suffering moral injury from having to serve the employer master, the patient, our own conscience and that's tearing us apart. That's not good for patients. So I think that with Patient Safety Movement Foundation with the Unite for Safe Care Campaign, World Patient Safety Day, all of this together, it's now our time during this pandemic. Never let a crisis go to waste. During this pandemic is our time to step up and say we're going to do better for our patients and for each other starting today and that means lobbying our politicians for different payment models that pay us to keep patients well and keep them safe. And if we start with that and are given the tools, resources and autonomy to accomplish it, we'll do it, but we need that guidance. All right guys, thank you so much for letting me speak here and we out. Thanks so much for inviting me to participate in the World Patient Safety Day. You know, mistakes happened in every field of work, but when they happen in healthcare, they often lead to suffering and even death. That's what happened to five-year-old Gabby Galbo of Monticello, Illinois. Gabby died on May 11th, 2012 from septic shock after an infection caused by a tick. It went untreated by multiple doctors during many, many hospital visits. Had multiple medical heirs not been made in Gabby's care, she would have celebrated her 14th birthday on July 28th of this year. Tragically, this is not an isolated story. Every year, 200,000, up to 400,000 Americans die as a result of medical heirs. Today, I'm proud to join with the Patient Safety Movement Foundation to raise public awareness about the need to improve our healthcare system for both patients and healthcare workers. Sadly, the coronavirus pandemic is shining a spotlight on this issue. We've seen how shortages of personal protective equipment and testing kits have literally threatened the lives of healthcare workers and patients across the country. To date, more than 900 healthcare workers have died from COVID-19 in the United States. The majority of them were people of color. More must be done to both protect our frontline workers and the patients they treat. As we look for ways to improve our nation's healthcare system, we must figure out better, more effective ways to protect healthcare workers and minimize medical heirs. Thanks for all you're doing to save lives today and every day. So the question is, is it time for a National Patient Safety Authority? I say it's time to try something new. It's clear we've failed in changing people and their behavior at the frontline and imparting true quality safety engineering principles every day in the way we do work. So let's think about changing systems. What if we made our systems safer? That's what we do in nuclear energy and cybersecurity and bioterrorism and air traffic control. We change the environment, we change policies, we make our systems failsafe. We have a model at the federal level, an agency called the National Transportation Safety Board that has made transportation more reliable, more predictable and self-correcting. We can use this model, think of their solutions, airbags, anti-collision technology, failsafe self-regulating valves, smoke detectors. Think policies as well. They helped us raise the drinking age to 21. They set standards for school bus construction. They introduced alcohol and drug testing. Let's think about this. Astronauts don't get themselves to the moon and back safely. Their equipment does. The potential for harm is predicted and solutions applied. The equipment corrects itself, it's autonomous. Of course, humans will always have a role, but we can relieve humans of much of their workarounds that are tiresome, their unreliable equipment, their critical information gaps. It's 2020. We have technology that could help us and we need to apply it. We have predictive analytics, big data, machine learning, artificial intelligence. We can make safety autonomous. Over 15 federal agencies and numerous independent organizations now collect information on safety. Some of it is more reliable than others, but even the best data aren't aligned. It's time for a centralized approach to using the reliable data that we collect and applying it to solutions. That's what the National Transportation Safety Board does. So if we added in the functions of the Transportation Board, research, investigation, education, and we put them together, we'd have a powerful National Patient Safety Authority. It's not punitive, it doesn't issue regulations, sanctions and penalties. It just comes up with good solutions. And then it's up to our Health and Human Services Department, our Centers for Medicare and Medicaid Services, the CDC, OSHA, the FDA to apply them and to apply them universally. That's how we fix our systems. That's how we get safe. I'm all in favor of a National Patient Safety Authority. Thank you.