 As you can see, I've traveled all the way to Sydney, Australia, to introduce our next speaker. Please welcome our good friend Peter Lachman, the Chief Executive Officer of the International Society for Quality and Healthcare. I'm very proud that ISQA is the Co-Convenor for the Patient Safety Movement Foundation virtual event, United for Safe Care. If we can come together to deliver safe care, then we can make a real difference for people in healthcare and for those receiving care. I believe that patient safety is a social movement and a public health issue that will require a united response by all of those. We have to learn from the people who deliver care and the people who receive care on how to be safe. ISQA is very pleased that together with the Patient Safety Movement Foundation, we are making a difference in bringing awareness to the importance of patient safety as well as the importance of a united response to this growing problem. We look forward to being with you during this virtual conference and hope you have a good learning experience with all the excellent speakers that are going to be there. Thank you very much. Hi, my name is John James. I live in Houston, Texas. I've retired from NASA now six years and presently I'm a patient safety activist. I've been asked to address the question, what does the public need to know about the last 20 years of patient safety work? Here's the way I see it through my not hole. In 2000, the IOM published a study called Two-Air Assume in which the estimated up to 98,000 people die as a result of medical errors in hospitals. What you should know is that that study was based on medical records from 1984 and that it is generally irrelevant to mistakes made these days. A couple years later in 2002, my 19-year-old son Alex has been a student at Baylor University died from multiple medical errors. Specifically, a guideline for potassium replacement was not applied to his care. His diagnosis of long QT syndrome was missed and his doctors never warned him not to return to running. He had collapsed while running. His discharge instructions showed only don't drive for 24 hours. Even in his follow-up visit, he was not warned not to run. Three weeks later, he died on a Baylor University campus while running. Later, I found out that his cardiac MRI was never properly done and I found that his medical records had been falsified. I asked the Texas Medical Board to look at his medical records and they deemed that his care met the standard of care in Texas and I was outraged and appealed. They returned with a conclusion that actually his care exceeded the standard. What you need to know as a patient is that the standard of care may be well unhinged from evidence-based, that is the best medicine and two, state medical boards are going to favor physicians or patients who complain. In 2003, a global trigger tool was developed by the Institute of Medicine and it was able to find far more preventable adverse events than direct physician review had revealed. From 2008 to 2011, four credible studies were done in which that tool was used and many deaths were recorded as a result of preventable adverse events. There is a better way to find medical errors. In 2013, based on the studies I just mentioned, I published a review in the Journal of Patient Safety in which I estimated that between 200,000 and 400,000 people died prematurely as a result of mistakes made during hospitalization. That does not mean they die during hospitalization. Often death occurs long after hospitalization. These may be errors of omission such as in my son's care to omit potassium replacement. Know that hospitals are not as safe as we like and that mistakes happening there may not occur before discharge. In 2015, I co-edited a book called The Truths About Big Medicine. The themes there included medical board failures, secrets of the national practitioner data bank, problems with physician peer review, dangerous medical drugs and devices, problems with medical imaging and so on and so on. What you need to know as a patient in the USA is that there are many ways that health care can lead to harm to you. I became frustrated and in 2017 I turned my attention more to empowering patients than to trying to fix the system. My focus was on informed consent which is what is sought by a reasonable patient in about half the states in the US. In 2019 two colleagues and I published a study in BUJ open in which we asked around the country through survey what patients wanted to know before an invasive procedure was done on them. What they wanted to know was far more than is normally included in informed consent. To reinforce that a study in 2020 showed that informed consent documentation in 25 hospitals averaged less than by quality points out of 20. What you need to know as a patient is that your power is in gain informed consent. So know how to do this, insist on it, insist on clear, crisp answers to your questions. Do your homework, know your questions, get safe care. Godspeed. Health care has developed in complexity and is prone to human error in the delivery of care. Medical issues have become more difficult to deliver and we have to develop systems that can decrease the harm to people and protect people who receive care. Part of this is working through the lens of human factors and to understand how work is done and then to develop reliable systems and processes to ensure that work care is delivered in a safe person-centered way. Part of our services need to be highly reliable in that they have to be standardized so that people get the right care every time and others you need to have to adapt rapidly to changing circumstances such we've had in the recent COVID pandemic. But at all times, patient safety must be central and risk must be proactively managed. There's much we can learn from each other and I think that if we understand that medical error can be reduced and can be mitigated against then we can make a real difference. I've been asked to explain what a high reliability organization is and that's an organization where if you make an error, this error could be lethal. Think about nuclear power stations, think about flying planes off an aircraft carrier, think about health care and what is a high reliability organization? That's where the correct, safe path has been plotted and then everybody involved in that industry knows their roles. They have practiced it, they have gone through it many times. If there is an error, it's drilled down to so it can't happen again. Every plane taking off that aircraft carrier takes off and lands safely. The nuclear power station, except for one we can remember from years ago, are safe. Health care system must be safe. There's a correct protocol to doing something. We call them APS. These are the best practices that have come from the safest hospitals across the world and we have them online, we have them published online and if every hospital were to follow those apps, we would have a very safe health care system. That's what a high reliability organization is. You know you can go into that organization. You know that the right practices will be done. You know that you will be safe. That's where we have to get our health care system to. Thank you.