 Good morning everybody and welcome to this the next panel a panel about Patient Safety in perioperative medicine this has much to do with anesthesiology of course and I'm I'm honored and I'm It's a pleasure for me to moderate this panel together with my colleagues I Should have used the prompt of course First I would like to start by telling you about two patients and two young physicians Well, let's travel back in time more than a hundred years To find the first of our two patients are lying on an operating table and in the middle of an operating theater an Old-fashioned surgical amphitheater in Massachusetts General Hospital in in Boston So this patient is waiting to be anesthetized and to be operated and From the seats of this surgical amphitheater up there a young surgical trainee at the time is Called down to to put the patient to sleep Harvey Cushing is his name and at the time he is called a junior house pupil That's their title so this young surgical trainee is is coming down and Is starting his work and as he later reports and I'm quoting him now is I Proceeded as best I could Under the orderly's directions So the operation was started There was a sudden great gush of fluid from the patient's mouth Most of which he inhaled and he died so This is a hundred years ago The patient died Right there on the operating table from a condition we call massive aspiration under the hands of a young surgical trainee unexperienced and during the procedure so Harvey Cushing and His friend Amory Codman another young surgeon to be We're shocked by This and and by other fatal mishaps they experienced as as trainees But they were told that such events were frequent and inevitable so in other words, they could not be prevented but as young physicians or Surgeons to be Harvey Cushing and Amory Codman could not accept this data school They decided to improve their anesthetic skills Surgeons improving their anesthetic skills They started on their own to train their technique To observe their patients much more closely and To document their observations thereby they developed one of the first anesthetic records in history Called ether charts at the time So as Harvey Cushing later reported they both became very much more skillful and thereby they pushed the limits of what can be prevented much to the benefit of their patients and Harvey Cushing as many of you probably know later became a very famous neurosurgeon and Amory Codman became Well-known surgeon as well But most of all he became one of the fathers of quality improvement in health care in the United States and He promoted the idea That the improvement of care should be based on patient outcomes, which he at the time called end results so and You know we have been talking about that yesterday. He published The results of his own surgical practice. He ran a little surgical private clinic in Boston Including his own errors A couple of hundreds of errors and five fatalities and you can imagine that not many of the hospitals He invited to Do the same actually followed his invitation and he later died impoverished So you can read all of that and much more in Michael Millison's book demanding medical excellence and in a couple of papers I'm happy to share with you But you may ask why consider these things these things that have happened long time ago I'll come back to this in just a moment but In the meantime, let's travel back in time to to the present remember Mrs. Kay The second patient that Stefan the head has presented in his talk So since the times of Cartman and Cushing the interoperative period and anesthesia have become very safe Not a hundred percent, of course. I know but very safe but complications continue to occur and they occur in the postoperative period and Sorry to check my notes and Most of all or most importantly 50% of them are thought to be preventable That is probably why anesthesiologists have expanded their role beyond the operating room to Intensive care for example and to pain management and this Room of improvement that is still there because 50% of them are preventable is Also a reason that we should reflect on what we can learn from history First of all, I think just every single preventable patient death is one too many and must be remembered even after a hundred years and second As the example of these young surgeons shows humans are not only prone to error and Part of the problem, but they can also become part of the solution by their ability to be compassionate by their ability to oppose a general acceptance of fatal mishaps as something inevitable and To work hard to find solutions and share them with others the European Society of Anesthesiology Together with the European Board of Anesthesiology and together with other partner organizations Has created a tool that Allows or that helps to become part of the solution the Helsinki declaration on patient safety in anesthesiology This is a very practical Framework of safety requirements for anesthesia departments and By this declaration by education By science and research By clinical guidelines as Stefan the head has already told you and by developing the professional role of Anesthesiologists our society can support professionals to achieve our goal of eliminating preventable death and complications in our patients and That's what our panel will be about and may I invite My colleagues and panelists now to join me up here Thank you for joining me here. I see I need still to introduce myself My name is Johannes Wacker I'm chairing the patient safety and quality committee of the European Society of Anesthesiology and I'm working as a consultant anesthesiologist in Zurich, Switzerland at his London Clinic at private hospital and And I think this is a very special group today here if we compare it with yesterday's panels We're all anesthesiologists We're all engaged in the European Society of Anesthesiology and I would like to invite you to Send in your questions. If you have any questions Addressing anesthesiologists. So we're we're happy to try to answer them May I ask the panelists to introduce? Themselves, maybe we'll start on the left side with dr. Zeff Goldick from Israel Good morning. My name is Zeff Goldick I am the vice president immediate past president of the European Society of Anesthesiology and I am the head of the anesthesia intensive care and pain department in Haifa, Israel And Good morning everybody. I'm Janneke Mellin Olsen and anesthesiologist from Norway working there I used to be the secretary of the European Society until the end of last year and then I moved on to be the president elect of the World Federation But I am lucky to still be allowed to be involved in the patient safety and quality committee of the ESA Morning, I'm Andrew Smith. I'm a consultant anesthetist in Lancaster Which is a small city in the Northwest of England. I'm also privileged to direct Patient Safety Research Unit funded by the UK National Institute of Health Research I'm Dave Whittaker. I was a consultant on cardiac anesthesia intensive care Manchester or infirmary I've been involved in safety organizations for quite a long time I'm currently the chair of the EBA patient safety committee and I'm on the ESA patient safety call committee that Johannes chairs Yeah, thank you for your introductions and I think Then sink decorations, of course a core topic for our panel here Janneke if We agreed on our ladies first if Your worries active and patient safety and like constantly on the move If you think about your own practice Could you tell us an example where you think that patient safety was really an issue and Maybe the Helsinki Declaration would have been helpful Yes, thank you. I would like to highlight One part of the Helsinki Declaration that we have touched upon already here and that's the role of patients and relatives I have noticed that people that are Involved in patient safety. We are all special people most of us are very nice and we are reflective and we are want to make a change and I have noticed that for many of us there is this defining moment When this interest started and I will share with you my defining moment When I was three and a half years old I had a brother and He was born with an esophagus that ended blindly and My mother knew at that time that if there was any chance for him to survive She had to be with him in the hospital But at that time there was no childcare or anything so I said mama you go to be with him in the hospital I look after my two-year-old sister and She she had no choice So I was babysitting my sister for six months when I was three and a half to four years old then he went through several operations and The surgeon said at one point that this tube through the abdominal wall into the gas Into the stomach was very hard to place so this must not be taken out and Yeah, that's fine. I was sitting outside the hospital with my sister. My mother was inside with my brother and He had to go to surgery once again and Then my mother said please remember do not take out that tube doctor so-and-so said it has to be in place and Then he was not there. So they just dismissed her. You know those mothers. They are always pushy So they took it out. They fought hard to get it back in again they thought they had succeeded but it went into the peritoneal cavity and They fed him and he developed peritoneitis and he died At that time my child was was over. I stopped playing I didn't start playing again until I was grown up and now I have more money to play with so that's in some way a good thing but but I Wanted to I stopped playing and I just wanted to change I wanted to make a difference and Some of that was when I've decided to be a doctor and also to be involved in this type of efforts and my message is Well, there are there is such things as a difficult mother, but that's a diagnosis of exclusion always listen to two relatives to mothers and Listen to what they have to say and work with them as part of the team And that's what we are doing as anesthesiologists working as tea as a team and all Stakeholders or all partners in that team are partners and that's how I'm guided in my clinical life and also in in my Organizational life, too. We are all partners That also includes The countries, you know the European society We are from less resourceful countries to very resourceful countries in Europe. We share experience We share this we do the Helsinki declaration together to spread to put everybody getting to a goal of minimal preventable harm thank you, Janika for this very personal example and I think it it also Shows the value of the Helsinki declaration as a tool because this what you mentioned is part of the of the Helsinki Declaration Ziff You're besides all your functions your immediate past president of our society you've all Always been very active in education, you know Did you think of an example of your own clinical experience that? Shows both the importance of patient safety. Maybe the Helsinki declaration end education Yes, I want to give two examples The first one I was sitting at the pre-operative clinic with my patient and explaining to him what is anesthesia and He asked How Dangerous is this operation and this anesthesia? How risky and Of course, I used the classical comparison with aviation and I said I will be I'm the pilot and I will Keep you safe in good condition. So he said yes doctor, but there is one big difference at the flight the pilot is flying together with me, so We were laughing of course and then when I went home. I was thinking This he's not completely right because You know the phenomenon of the second victim when something goes wrong to us And we have a difficult case and something goes wrong so this can change our entire life and Yesterday a gentleman brought the example here in this country 27 Doctors committed suicide after difficult cases The second example is I had a patient for my private practice with allergy to latex latex rubber so I Committed the the mistake to take such a difficult case to private practice, but this is another story. So I I Try to avoid all the latex components In our operation and I even decided to to do a spinal anesthesia Only the lower part of the of the body The operation was uneventful It was a hernia operation and then they took the patient to the recovery room and they called me urgently that the patient had a sudden drop in blood pressure and they of course we anticipated Anaphylactic shock because of latex So we could save him The patient and we realized that the cause of these anaphylaxis was They connected the patient to the pulse oximeter which sensor is plastic outside But inside it has a thin layer of rubber so equipment is Almost perfect these days. It's improving all the time But the best equipment is not better than the person using it so I Think this this is the the the message We can take that the equipment is becoming more and more perfect and is helping us a lot But we have to concentrate more in the human errors Which can be done by education for example as I understand for instance as Steph the hurt said before We we Invest a lot of efforts at the European society in education. We have a European diploma. We have masterclasses and scientific activities and research Thank you very much for this example there and and David Whitaker David you have you're very active in patient safety Events in initiatives as well and by the way by the way Ladies and gentlemen the three Sitting next to each other Yannick Andy and David have been very instrumental in developing Helsinki decoration on patient safety in anesthesiology David You've been quite active in medication safety lately You've been Part or maybe the driving force for a European board of anesthesiology recommendations on safe medication use Could you give us an example that involves medication safety we can learn from Yes, I'd like to talk about Guidelines the European Journal of anesthesia, which is a society's journal this time last year published the European Board recommendations for safe medication practice and this and then a bit later on as we heard yesterday March the WHO launched their Third global patient safety challenge So it was very much in line with what's going on and I just the guidelines were published Just a simple two-page Simple recommendations and then to help implement them, which is the important thing with guidelines There's a 13-point checklist that departments can use to help implement them and I'd like to highlight the first guideline recommendation, which was that all syringes Used in routine anesthesia critical care medicine emergency medicine and pain medicine should be clearly labeled and And it's quite a simple recommendation. Perhaps I could just ask the audience The show of hands if you need an injection on Monday morning, would you want the syringe to be clearly labeled? So it's quite simple, but a number of Patients have suffered severe harm and died because unlabeled syringes have been used and To give you an example In 2010 less than a mile from where we are here a young ten-year-old girl had a Arterial venous malformation on a cheek and this was going to be a blade it was a cosmetic operation and The in the x-ray room the doctor had two ten mil syringes one had X-ray contrast in and the other had colors glue and he got them mixed up Nobody spoke up and he injected the glue into the girls carotid artery And she was blinded one eye severe brain damage and She's going to be in a wheelchair for the rest of her life And not only was that catastrophic for her, but it resulted in the highest ever NHS litigation payout of 24 million pounds So when people tell me that unlabeled syringes are expensive I tell them that the two ten mil syringes at Great Ormond Street Hospital cost 12 the cost the NHS 12 million pounds each and Throughout Europe hospitals still don't provide the ISO colored labels for All syringes to be labeled and this is something that you know, we'd like to work on with the global safety challenge With the WHO and the patient safety movement Thank you very much David for this example Not quite from anesthesia, but that goes far beyond as anesthesia probably also The contents of the guidelines published by the European Board of Anesthesiology So any You're besides your clinical work as a consultant anesthetist You you've always been very active in teaching Education and in research So could you give us an example how from your your own experience or practice how? Research could be important for patient safety Yeah, I mean well Yannick had talked about defining moments didn't he and I think one is by moment of revelation really and The thing that really comes to mind is a an occasion When I was working as a trainee anesthetist in a large teaching hospital, so this is a few years ago and One of the theatre lists I was quite frequently rusted to work at Was for the dental surgeons who are taking wisdom teeth out of otherwise healthy young people And I don't know about the rest of you But I find that they these young people were anxious about the surgery out of all proportion to the seriousness of the problem I mean, it's a big operation for them, I suppose, but it's nothing to do with cancer or heart disease It's not major life-threatening operation and Typically you'd be on the second or sometimes even the third string of anesthetic to try and get them to sleep properly when normally One is perfectly adequate And I remember one particular occasion there was a girl a student at the local University who was Terrified when she came into hospital. This is her day case procedure. So she wasn't going to stay very long And I tried to explain what was going to happen in the anesthetic room or what she'd be like afterwards I tried to reassure her and she came to the anesthetic room still very anxious and we put the cannula in we put the monitor ring on and Having started the injection of anesthetic suddenly she sat bolt upright on the trolley and tried to clamber off it and It was only the quick thinking of my anesthetic assistant who managed to pull her back down We've got her safely to sleep that avoided her ending up in a heap on the floor So when I got to do the list the following week I thought I'd try and do something different and to make it more pleasant for the patients and certainly safer for the induction That's the easier. I prescribed them all a sedative pre-medication And I was working my way along the list in the day case ward Prescribing this on the chart and I got to the last patient and I could see sister on the ward Collecting the charts up and shaking her head and frowning She got to me. She said You can't give them a pre-med doctor. We never get them out of out of hospital on time Well, I tried to explain why I was doing it. She she was quite insistent and so they didn't get the pre-meds that week But what it did do was drive me to the library that evening and I worked through the paper copies of index medicus this obviously dates the story before electronic databases and To cut a long story short. I found that quite a number of research articles which showed that you could quite Easily give patients sedative pre medications and not delay their discharge To her credit when I took sister of the evidence She didn't stand in the way of what I wanted to do anymore And I think what that revealed to me I think is that it when the scientific evidence behind our practice whether it's clinical or in patient safety We should really make the most of it. So it set me firmly on the path of evidence-based medicine And that's that review actually turned out to be one of the first reviews for the Cochrane anesthesia review group but it also taught me that knowledge is a powerful ally in clinical and organizational life and It also taught me not to take no for an answer as well Thank you very much for showing that research is actually Not generally important, but it can also be a tool in daily life Well, I think I mean one of the nice things about being able to be involved in the USA's guidelines committee For instance, just to make sure that the knowledge we have is put into practice And I think that's a really important function of the society in general Well, thank you for this first round of of examples and I Think that probably for for the audience it has become clear that the Helsinki Declaration on Patient Safety and Anesthesiology is sort of a centered piece for safety activities within the European society Besides all the other foundations that Stefan DeHert has already mentioned. It is in his talk education research and Could you think and I'd like to start a more open conversation now? Could you think? On other examples of how the Helsinki Declaration can can be used to make a change make a change at the cutting edge of clinical work, especially of anesthesiologists, but also in the perioperative field Please Well, I think what you can say is that it's a tool for the anesthesiologists out in the field That they can go to their administrators to the politicians and so on and to say that this is The standard, you know, this is European agreed standard and it's being used that way But I would also like to comment on what Zev said said about the second victim Because what I have noticed is of course we share as doctors we share with the patients the same Feeling when something has gone wrong. This must never happen again And that's how we can make the partnership if we deal with the aftermath of an accident in the right way Working with the patients and so on it helps us heal and they help the patients and the relatives heal and for that we need practical tools because when a Error has happened or a mishap or Disaster has happened. We are so shaken that we don't know how to react properly So to have those tools and these are also described the the Comprehensive tool for how to deal with patient safety in the Helsinki Declaration So we are in the same boat Now we are launching the Helsinki Declaration follow-up project together with the industry In the first example I gave to you How can the industry know that they have to Give us Sensors without rubber inside. We have to tell them we have to work together. We have to Plan together how to improve and to avoid preventable preventable death. This is the first thing The second thing is as I said before regarding the human errors Because of stress because of fatigue because of we have more and more operations Every day so we have to we are not robots and We have to improve and concentrate how to avoid these human errors because the equipment Is helping a lot but We we have to Be very very careful and concentrate When we work every day because the anesthesiologist not only administering drugs is To be prepared like Steph said before to react There are Anticipated problems and there are Unanticipated problems and these these problems for this reason. I think anesthesia is one of the longest Specialties it takes many many years to be an anesthesiologist because we have to be a little bit cardiologist neurologist internal Doctors internal medicine doctors and so on and so on searches and to combine all these these qualities Thank you, sir. Yes, I think I mean the vision the vision the declaration is is a set of practical tools But it's also it's also a vision set out for anesthesiology Originally in Europe, but I think in the same way that your movement invites people to to sign up and commit We never actually done that formally But it's interesting that about three-quarters of anesthesia societies throughout the world have actually signed up to it So its reach has been much further than Europe, but more importantly, I think within Europe It sets out expectations and standards which allows Countries that aren't so well resourced Something to aim for and something to take to their politicians and policymakers and say this is how we should be doing it So it's about it's about improving standards more generally as well I think especially across the diverse continent that we we're in at the moment another thing recommendation the Helsinki Declaration was to For all departments to produce an annual safety report And that would give them At least once a year an opportunity to sit down and review what had happened over the last year We asked them to maybe identify three incidents that there was learning from last year and Three ambitions for improving safety for next year and this will produce a process but another another feature of the the ESA which I'd like to mention is international cooperation and Whenever in any any country in Europe whenever the patient has a cardiac arrest the nurse in the ward rings a telephone number to alert the resuscitation team and Different hospitals use different numbers and Two years ago. We did a survey and 181 hospitals in Europe use a hundred and five different numbers And they're not numbers you'd think of like double two double two double four double four They were eight one six nine and seven eight four two things that people couldn't remember The the Danish group did a survey only 60% of the nurses could remember the number in their own hospital to ring And only 50% of the doctors So an 80% of the people in the survey we did said we thought it should be the same number throughout Europe And so together with the European Resuscitation Council and the EBA the assays Recommended that all the hospitals in Europe should use the same number Double two double two. This is already Happens in the in the UK the Republic of Ireland Denmark Parts of Finland all of Turkey the Health Minister in Turkey recommended it and Last year Herman grow the German Health Minister He wrote to all the German hospitals and recommended that they use as well and they're starting to use it so this is something that Other host of the country's Australia parts of Australia use double two double two There's interest in South Africa, and maybe there's something that could work with the patient safety movement to develop an apps or something in the future Thank you very much for these inputs in the meantime and a number of questions have been sent in For example, there's one about CRM. So CRM crisis resource management a Critical component of great providers has been shown to decrease morbidity and mortality Can you share how we can make a movement to require all providers have CRM skills to save lives it likely saved MRF's life well the first Patient Stefan the head is presented Anybody wants to comment on that? Well, I mean crew resource management training if you're talking about training a whole hospital or a whole health system That's possible. It's expensive. It's probably worthwhile But I think sometimes with the patient safety stuff It's easy to be daunted by the the size of the task ahead of you and very often It's good to start small and use things that already within your practice and just augment them So you're strengthening what people do already really And what comes to mind with that is is particular with regard to the World Health Organization a surgical checklist in that It's been mandatory in this country for a number of years now and people do it But they don't always mean it and one of the things that you need to encourage people to do and encourage your colleagues to work within it to achieve is To make it work for them and for instance, this may be a British thing but the first step is for everyone to introduce themselves and And We're quite modest and we don't like to do that But I actually think it's quite important because you need to know who everybody is and it tells you first of all It says what we're about to do isn't routine for the patients that are coming. It's Very it's very it's very special. It's very significant to them It's not just it's not just a job as it is for us And it's a moment just to remember just to remember that Everyone's name, you know who they are it has to be proof against local and agency and temporary staff because that's all we rely on a lot and Immediately if you make the most of those briefings and people understand what their roles are and Who you might need to turn to if things go wrong? It's not crew resource management as such we don't call it that But that's the same purpose and we need to do what we do at the moment Right and better before we start investing in biggest bigger more expensive things as my view Thank you. I think you want yes Because I can come with an example from my own country, Norway, which you know is quite large and scarcely populated And people get injured on the roads all over and the hospital some of them are very small And they don't see that many trauma patients But then there is a low-scale simulation, which is actually about team communication in the emergency rooms Started several years ago. It's called best best there and systematic trauma training. So that's being done It's pure communication just just training on a simple doll and Communication and that has spread throughout the whole system and when it started in my hospital We saw that how we received surgical patients or trauma patients became so much better That there we started also with internal medicine and so on and it started with pediatrics and so on so that you could see the Benefits in and we can also see how we can use that Simple training we do in the trauma room in the operating theater in the ICU whenever there is a Crisis situation the same simple training has been used in Botswana in Indonesia and all over so it's it's feasible For many situations, but we need to be aware of this Team communication skills. I would take it a stage further And I think every morning before an operating list the first five minutes the team that are there that day Should go through a quick scenario and a phallaxis looking to have rexia something like cardiac arrest David Seidemann who organized the medical teams for the London Olympics? They had teams of four people a doctor a nurse physio perhaps and every morning before when they met Before they started they went through a little scenario To make sure that they were you know all on message things I I used to meet all the patients that are scheduled for heart surgery In coming week and I have a meeting with them and I explained The how is it going anesthesia the operation bypass, etc. And one one guy asked me Tell me doctor heart surgery is a Very very dangerous procedure and Why isn't it possible to choose people that will Operate me and Anesthetize me So you know at the public hospitals you cannot do it. So I said I used again the example of aviation. I said Flying is a very Problematic thing. It's it's it's very dangerous as well. And you never know who is the pilot but the company If it's a serious company will designate a Person who is Capable to do that and responsible for the flight So is the name the brand name and the name the prestige of the company the same is in in our hospitals Thank you, Jeff in the meantime a number of other questions have come in and I'm I'm afraid we can't answer all of them But maybe just a very short answer if you have one There's there's one Saying would you say operation in a small hospital is a risk? And if so, why are they still open? Is there a short answer to that? Well often it's local politics Often the look in the United Kingdom often the hospital is the biggest employer in the town So the whole sears things like that, but they have been various studies. So maternity units, for example If you go below two thousand deliveries, then maybe the team isn't isn't doing enough and there's been some Andrew might like to tell us there's been some Episode incidents in the United Kingdom and big reports into the maternity services and trying to rationalize those and this applies Pediatric cardiac surgery in this country. We probably only need three or four hospitals to do it I think there's about seven at the moment as a plan to to reduce them. So the surgeons Can work in bigger teams not just single single surgeons and that again all the perioperative care and everything is made much better if Things are rationalized really. Thank you. Do you have a short answer? I think it was very interesting what has been presented a couple of times here in the UK the safest hospitals We're not necessarily the biggest ones So there are some benefits with smaller hospitals of course to a limit So you have to tailor what you are doing to the size of your hospital We probably don't have a clear answer why they're still open. This was the question Very difficult question, of course. So I'm Apologize where we don't have enough time to answer or discuss all of your valuable questions May I ask a last round of our panel ask the panelists to Think about a take-home message for the audience If you want to start a Yanike, well, first, I feel I have to say if you think my mother is a You know a bad mother. She's not a bad mother She did as good as she could and I have told her when she has the bad conscious that I'm so happy I'm the person I am and many others have benefited from our Disasters just so you know that then I want to say with my with the with the patience and doctors together for 20 years I tried to to make the politicians install this Investigation board as you have decided to do here in the UK and It was very hard because doctors we are only we have second agendas and so on But then when there were patients and relatives hitting the headlines in the newspapers Then the politicians made their move another very good example on how we can create Union a common goal with the Patients and the relatives and go together to help the politicians make the right decisions Thank You Yanike Zeph Well, as I said Anesthesia is not only administering drugs We are keeping the patient alive and we are working at teamwork together with the surgeons with the nurses and Anesthesia is a very Operative discipline, so we have to see the patient before the operation We have to plan carefully our our work we have to continue with the patient during the operation and the post-operative visit is Is very very important and not always we are doing it, so I think that Our our Specialty is a very integrated discipline which integrates a lot of Aspects of medicine and This is a very Responsible discipline Thank You Dave David any message Martin Bromley who had spoke yesterday said that standardization is an effective mechanism of Reducing human errors in complex situations and so standardization is my message Standardized station of the labing of syringes may be even going to pre-filled syringes So all the drugs are standardized with the ISO colored labels and standardize our Cardic arrest telephone number to double two double two so think global act local Thank You David very clear Andy your message. I guess my message comes back to to knowledge And I mentioned research evidence earlier in the science and that's important But there are lots of other sources of knowledge we need to draw on to do the job right and there the knowledge and experience of patients For instance, they're also the knowledge and experience professional expertise that we all Use all the time, but we're not always aware of and the standard operating procedures that Steph mentioned earlier Which shall allow you to work smoothly in an emergency without having to directly think about it All these sorts of knowledge are there and they all interact to provide Safe high quality care Muir Gray was the chief knowledge officer of the National Health Service and until a few years ago And he said once knowledge is the enemy of disease. I think that's true But I think in our context knowledge is the enemy of risk the more we know the better Thank you also very clear so as We're coming to the end of our panel. I Hope that we have been able to demonstrate that we as Individual anesthesiologists and as a society Don't accept fatal mishaps or complications as something inevitable medical and technological solutions are Important essential to advance patient safety, but they're tools tools in hands of professionals that who create patient outcomes at the clinical front line and and on a daily basis and The Helsinki declaration is Is a tool that our society provides To help professionals to achieve our goal of eliminating preventive preventable death and complications in our patients Thank you