 We still don't know the real number. We know it's somewhere in the area between 200 and 400,000 deaths a year because of adverse events happening in health care, preventable adverse events. A transparent health care system is candid and honest even when it hurts. Candor, it's an open and honest approach to preventable medical harm. And then an event review process that details specifically the issues that cause the system and process breakdown that we could then fix and prevent others from being harmed the same way. How we reduce harm is that we start engaging wholeheartedly. Patients and families, patient groups, civil society, population-baked groups who've been harmed. There are three things that are very important to do. First, empower patients to ask questions. Second, to have transparency in the health care system. And third, to implement technology. This communication is often a leading cause that contributes to these events. So anything we can do to improve communication, improve handoffs between team members and between patients and their families and the team will help reduce patient errors. By prevention, by awareness and to treat those who are acutely ill as emergencies. We have to give them positive results and to be clear that we are doing our best effort to give them the better quality of our treatment. We need boards, we need governance to really step in and to take responsibility to drive patient safety improvement. To confront the idea that we're actually harming patients is very tough to swallow. The way out of that box is to understand this isn't about playing. It's about the design of systems that can protect us, caregivers, from our own human frailties. We need to start with looking at our system and all the components and subsystem within the health care system. More than anything else, we really need to look at the safety culture of this industry. We need systems that work for our patients and work for the clinicians who are helping to care for those patients. But more important than that technology is the way that we assess the interactions with the patients, interactions with the clinicians to ensure that patient safety is at the root of all of that and that we can measure what goes on in terms of harm. Part of that culture system is a fair and just culture so that if someone is involved in a harmful event that they feel empowered to and they feel safe to report it. We can incorporate the views of patients and families and those who care for them into every aspect of health care so that the health care system is truly designed around the needs of patients and families at every stage, before care, during care and after care, particularly if something goes wrong. We need the support of all stakeholders to create that culture of safety. This culture of safety needs to be based on the people. Take the idea of preventable harm and take that off the table and promote the idea of wellness in our society. We need to really think about health care as a holistic thing that we're providing people to make their lives truly better. We have to work together. We have to use all stakeholders with all the competence that they come from all the different angles. Doing the things we know, we know a lot but we are not implementing everything we know. It's a strict adoption of those evidence-based practices at the front line and that takes leadership, a culture of high reliability, where leaders have sensitivity to their operations, they have a reluctance to simplify the answers as to why things happen and dig deep for root causes. The challenge is really about getting everyone aligned against a competency framework. Regulatory and accreditation agencies can create more structural standards for quality and safety that include health care quality competencies, curriculum assessments that really make sure that people are accountable and committed to activating quality and safety in their own role and throughout the system. For patient safety to be a priority on the list, there are implementable protocols, incentives, bonuses, culture that really promotes patient safety at sort of every stage of the patient's journey at every moment of the patient's journey. I mean what we do know is that once patient safety is a priority, made a priority by the board, things do improve in these organizations. Another thing we feel very strongly about is that a much wider array of harm events is happening than what is currently tracked and reported and so we have to look broadly across the provision of health care and not just at a specified list of events. Patient safety today already provides us the infrastructure to be able to invite all of the stakeholders to collaborate and participate towards the same goal. Patient safety is a team sport. Time is now and we have the right players together. For innovation will make a difference where AI will be a leading role but also business model innovation will be key. If we reduce adverse events, we not only save lives, we also save cost of non-quality. As we're collecting more and more data through electronic health record systems, we need to make sure that we're capturing all of the processes that influence the outcome so that we can identify hospital by hospital, location by location, patient by patient, where the opportunities to improve are and develop the interventions that are effective at improving processes to ensure the best outcomes possible. It's really a global issue and I think when we say global that means down the street, community or across the world and I think that means sharing, learning from each other but we have to find out what is working and join together. But ultimately it's the integration of all of those into the culture of the medical environment and I hope the patients feel that they are privileged to tell us their concerns so that we can work together. Continue to bring patient safety into the mainstream so that every doctor and nurse and practitioner in any field of health care goes in to the work that they do every day with a mindset that zero harm is what they want to achieve. But also give our patients and our patient activists the skills and techniques to be able to challenge not necessarily the authority of decision making but actually be part of the whole process of decision making for their own care. First thing is to think differently. Patient safety and safety per se should be a state of mind, should be what people think about the whole time. People need to be listened to, they need to be respected, they need to be considered to know about their own families, their own bodies. The patient voice is elevated to a level that is part of treatment, part of health care. Always putting the needs of patients and families in the care system first. A belief that a team outperforms individuals and that team includes the patient and families. Doing your job, figuring out how to do it better. Always learning, always improving. We all go to school to get educated about how to be successful but we never think about being educated about how to be safe. I really believe in empowering the patient population. All of us will one day be a patient or we're current patients or past patients. Educate and advocate at the congressional level, the state house, your legislators, all politics is local and the most important thing that we can do is share our grief but also share our hope with those policy makers and show them that this is happening in their hometown, this is happening in their district, this is happening in their state. There are a lot of activities that are ongoing to reduce patient harm not only across the government but obviously private partnerships as well. We need to bring them all together to have a public-private partnership and collaboration with patients at the center with their voices always being heard because together we actually can use all of these levers to eliminate patient harm. Now we understand it has to be pervasive. It isn't one field's role to bring safety forward in healthcare. It is every person in every system and it is every patient and every family member. We have to believe that zero has to be at every measurement we're looking at not just the number of deaths but the way we act, the way we behave, there is zero tolerance for not stopping and doing the best we can. There is no one magic bullet to get down to zero. There's a lot of production pressures, a lot of things to get things done fast and I think there's a lot of things now that get in the way of us having that human touch. One of the things that we've always pushed for in this foundation is transparency and transparency of data. As they actually improve that mining of the electronic record they can even bring it up to real time and suddenly we're finding that things that we considered to be not preventable adverse events are suddenly being prevented. It's a powerful weapon to improve safety. Let's promote transparency in healthcare data. Comparing patient outcomes is the best motivator for change. Let's encourage payers to pay for performance and healthcare workers to focus on the quality of the care they provide. And let's implement guidelines that are evidence-based with proven track record for eliminating patient harm. Transparency, courage and love, you have to care for each other and it can't be just an algorithm, there's the human factor. The errors have happened because we weren't willing to try new things. So we're going to have to keep trying new things until we have a system in place at every hospital that is self-governing. Our job was to defibrillate the system to make it want to get its conscience back. We have one shot in this life and we should do what we can to not just be happy but make the world a better place.