 Thank you, Joe. Ladies and gentlemen, good morning. It's an honor and a pleasure for me to be here with you today. As you already heard, my name is Steve DeHert. I'm a professor of anesthesiology at the Ghent University Hospital, and I'm very proud to serve as president of the European Society of Anesthesiology for the upcoming two years. This meeting is for me a great opportunity to share with all of you some of the contributions my specialty, anesthesiology, and for the different societies of anesthesiologists have made two patient safety, and more specifically, perioperative patient safety. Indeed, anesthesiology is not just about putting a patient to sleep. Anesthesiologists actually are key players in perioperative patient safety. Just to give you a few numbers, thanks to our continuing efforts, we were capable of reducing mortality related to anesthesia, to anesthetic events by 97%. We are about at 3,000 in the 1950s, and now we are about at 1 in a million. This is a tremendous advance in patient safety. And why has this occurred? Well, I will quote here the Helsinki Declaration on Patient Safety in Anesthesiology. This is because anesthesiologists safeguard the patient's best interests whenever they are at the most vulnerable period, be it in anesthesia, intensive care, medicine, pain, or critical emergency medicine. These are the things we are dealing with as anesthesiologists. If I ask you the question, what does an anesthesiologist do, the first thing you will probably think about is putting patients asleep and hopefully getting the patients awake again. This is, of course, true. This is part of the job. But I hope to convince you that we do much, much more than just putting patients asleep. That's one part. We are also very much involved in the preoperative period. This means a period before anesthesia. We look at the patients. We discuss with the patients. And based on the entire picture, the physical condition of the patient, the circumstances where the patients live, we develop an anesthetic strategy, a perioperative strategy that will make sure that this patient has a safest procedure that one can imagine and deserve, of course. And even more important, we are also responsible for the postoperative phase. The trajectory is not finished after that the patient has gone under gun surgery and has waken up. There is a whole period, at least 24 to 48 hours, where we need to take control of the patient. I will show you a few examples later on where you will see that this is a very important part of our profession as anesthesiologist. But let's start with the pre-interoperative phase, the phase of the operation and the anesthesia itself. Let me tell you a brief story of a young guy that came in our day clinic a few months ago. Let's call him Mr. F. Mr. F is a 30-year-old male who suffers from a condition which we called chronic hydrodionitis superativa, which means that there are separating boards in his skin and they need to be removed. Mr. F has already undergone this operation a few times before, so we can know his condition and you might be interested to know that Mr. F has become the proud father of a little girl two weeks before and he has also another child, a two-year-and-a-half boy. So here is this young guy, father of two children, happy at home, and he comes in the operating theater for what we call a completely routine operation. Everything goes smoothly, there are no delays, so from administrative point of view, we are completely clear for routine operation without any problems, takeoff, landing, without any problems. So the guy, the man is brought in the operating theater where the attending anesthesiological team is waiting for him. The attending anesthesiological team is myself, a supervising anesthesiologist, a young trainee, third year, so he's already capable of doing things, and the nurse assistant. Of note, the nurse had already been present at two previous operations of Mr. F, so she knows a patient and they discuss with each other, talk with each other. We do the preoperative checklist, nothing wrong to see, everything is okay, and we start the induction, because it's a routine case. I tell my assistant, my trainee, it's good, you're capable of doing it, I leave it up to you and I will be here looking at you and sitting next to you, and it starts. Give the injection, what we expect, all to be normal, and then almost immediately after the administration of the anesthetic drugs, Mr. F develops big, big problems, and because if Mr. F develops problems, this means that we as anesthesiological team are also in trouble. What is happening, it starts to convulse, it's the blood pressure drops, there is nothing we can imagine what happened. We use completely the same drugs as have been used before, so we rule more or less out an allergic reaction to these drugs. But what is the cause? Is it a cardiac arrest? Possibly, but the problem is that because it's convulsions, we cannot rely on the monitoring, on the blood pressure, on the ECG, on the pulse oximeter, so we really don't know what is happening. And here you are with a complete anesthetic team dealing with a catastrophe in this young man without knowing what to do, so-called without knowing what is the cause. Well, luckily for us, we have, thanks to the anesthesiological societies, we have guidelines, we have sending operating procedures. Here's an example of such an algorithm that helps you to react to such situation, even complete and expected situation. You just follow the situations, you just follow the guidelines, and you know what to do. And here, that's what we did, what is the first direction in the guidelines. It's say, call for help. And that's what we did. Call for help, and then we started the resuscitation. Now, I will leave you the story of Mr. Ref for a few minutes and tell you later on what happened with him. What do I want to underscore with this example? Well, no matter how many times you check and you recheck the equipment, the condition of the patient, it's not you can never exclude that at a certain moment, a complete routine scenario turns out into a disaster scenario. Some people like to compare what is happening in anesthesia with what is happening in the aviation industry. That's okay, we know that from the aviation industry, the introduction of a very rigorous checklist have resulted in a dramatic decrease in airplane crashes and airplane accidents. And actually, we do more or less the same. We have our checklist, we control everything and we can diminish the incidents occurring by wrong medication, by equipment failure and so on. But what people tend to forget is that a patient is not a machine. Biological systems are infinitely more complicated and more unpredictable than machines, than planes. So you cannot make the entire parallel with the aviation industry. Okay, you know that we are dealing with perioperative problems. And anesthesiologists, by definition, are trained, we are really very well trained to deal with these acute catastrophes during the operation and during surgery. The problem is that this knowledge of a catastrophe that hangs above you is present is an important psychological burden to the entire team. And therefore it's very important that the team, but also the patient and also the relatives of the patient know that anesthesiologists are trained doctors and that the anesthesiology team is a trained team. So they are capable of dealing with all potential catastrophes. Now, let me go back to Mr. F. What is a thing you probably remind you of, Mr. F? For all the details I have given you, probably the sole thing that you remember is the fact that he's a young father of two children. This gives some kind of recognizability, not also for you, but also for the team that is dealing with Mr. F. You need to take into account that my nurse and my assistant had the same age. So for them, it's a really psychological burden to see that this guy is developing problems. They could be in the same situation. They can easily imagine that they are in the same situation. This is a kind of very important psychological burden. And then again, it's good to know that you have a trained anesthesiologist with years and years of experience under his belts. So at this stage, you might be interested to know what an anesthesiology team is, what an anesthesia team is. Well, at least in Europe, they mostly consist such teams with physician anesthesiologists, trained physician anesthesiologists. Sometimes a trainee, if you are in a situation of an education hospital, and an assistant, almost always an assistant, be it a nurse or a technician. Now, what does this anesthesiological team do? The role is, first of all, to evaluate the patient. Before you start or before we start the operation, the anesthesia, we know the patient. We know all the medical history of the patients. We know the diseases of the patients, the medication, and so on. Based on this information, strategic plan is developed and is administered during the operation and after the operation, of course, there is continuous diagnosis, monitoring of the patient to prevent any problems to occur or if they occur to treat them as good as possible. So you have this team. This team is, of course, very good to treat the patients, but it also is a unique opportunity to give education and training to the next generation of anesthesiologists. We will not live forever. After us, there need to be anesthesia also. So we train these anesthesiologists and you need to know that anesthesiology, training to anesthesiology is rather arduous and takes a long time. People really need the training and the training is given by us, senior anesthesiologists, who have thousands and thousands of anesthesias under our belt. But in addition to this training, to this demonstration on how to work, to this education at bedside, there is also need for continuous medical education. We need to be sure that our colleagues remain up to date, that they know the recent advances, that they know about recent changes and adaptations. And there is a place where anesthesiological societies can play an important role, not can play, play indeed a very important role. Perhaps you are now wondering what a professional scientific society could be. Well, let me give you an example close by, which is our society, the European Society of Anesthesiology. What is our task, generally, is to promote and coordinate the scientific, educational and professional activities across Europe, and this in order to continually improve. This is an important point, improve the standards of practice and as a consequence, improve patient safety. There are several pillars by which we can do this. One of the pillars is research. We develop our own clinical studies, we administer research grants, we publish the results of our studies in different publications, in different scientific papers, among others, our own journal, the European Journal of Anesthesiology. We disseminate the knowledge to all our members, all over the world, via the website, via the newsletter, and so on. Another important part of a scientific society is to give an education, to provide the tool to the members to have continuing medical education by e-learning, for instance, simulation classes, master classes, and so on. And a very important also, and I already mentioned this, is a production of guidelines. Guidelines help the individual doctors to know how to treat the different issues that may occur. Let's go back for a minute to the case of Mr. F. What Mr. F developed was a very rare condition, so rare that a lot of anesthesiologists will never encounter this in their daily professional life. So they cannot rely on their own experience, they need to rely on standing orders that are given by the scientific societies. And it's thanks to these guidelines, the following of these standard operating procedures that people, persons like Mr. F, for instance, can survive a disaster like what's happening in the case. I will come back to Mr. F later on. What I want to do now is to give you a little story to demonstrate you that a role as anesthesiologist goes beyond the intraoperative phase. We are also responsible for the preoperative and the postoperative period like I already said before. The case I want to give you is the case of Mrs. K. Mrs. K is an 80-year-old lady who needs to undergo a second hip replacement because of atrosis. She's scheduled for an elective operation. She lives together with her husband, but her husband has been diagnosed with Alzheimer's disease a few months ago. So actually, she's the one who needs to take care of her husband. The couple is capable of still living at home. They have some domestic help, some social help twice a week, but they can live more or less independently at home. They have a daughter living abroad, so not available, and there are also no other relatives to take care of them or to help them if there is a problem. Like almost all persons of about 80 years, Mrs. K has some additional comorbidities, other diseases that are present. She's hypertensive, she has type 2 diabetes, hypercholesterolemia, and because of all these conditions, she needs to take a lot of medication, what we call polypharmacy. So Mrs. K, even if she's independent living, she's still a rather person which is significantly at risk. And because of this, the increased risk and the age of the patient, she's referred to the preoperative anesthesiology clinic. And what does she see, do we see there? Mrs. K has also an additional problem, which is anemia, not sufficient red blood cells. This makes this elective operation very dangerous, even more dangerous than it's normal. We don't want to operate an old lady for a hip replacement when she's anemic. So the anesthesiologist takes a very wise decision, says I will postpone this operation for six weeks and we will try to optimize Mrs. K by giving her some iron to increase the red blood cell count. This is done after six weeks. It appears that it appears that blood tests are completely normal and Mrs. K gets her operation without any trouble. Sorry about that. So Mrs. K gets her operation and now I want you to imagine two different scenarios. Think about it as a DVD game where you have, depending on the circumstances, a complete different outcome when you have different circumstances. So in the first universal, let's say, Mrs. K is admitted in a high-care hospital. This high-care hospital has a facilities for continuous monitoring, has a facilities of sufficient staff, so Mrs. K is controlled after the operation, is very closely controlled and very closely monitored. Now in the middle of the night, Mrs. K develops bleeding, heavy bleeding, at the level of the operation wound. What happens? She starts to bleed, she gets hypertensive, saturation decrease and the consequences because she's monitored, that the monitors go in alarm. Immediately, there is the attending staff. Mrs. K is treated promptly and there is no problem at all. Everything is okay. She can leave the ward the day after and the hospital a week later back to her husband to take care of him. Now we mentioned an alternative parallel universe where Mrs. K is not in the high-care hospital but she's in a low-care hospital. This hospital or this situation has no resources or very little resources. No money for monitoring, no money for staff. And there, Mrs. K, after the operation, goes immediately to the ward, develops the same story. In the middle of the night, she starts to bleed, gets hypertensive, gets hypoxic. Now, nobody sees it. There is no monitoring. It's only the morning after when the nurses are around that she discovered that Mrs. K is in big trouble. At that time, she's completely exsanguinated and she needs resuscitation. She's resuscitated, brought to the intensive care unit where, fortunately, she develops pneumonia due to antibiotics-resistant strain. And she lingers between life and death for weeks and weeks. So what do I want to prove? Or what do I want to underscore with this example? First of all, preoperatively, there is the importance of the highly tailored care. I've shown you that Mrs. K has a lot of comorbidities and that these comorbidities need to be taken into account. We decided to postpone the operation to optimize her blood count to prevent any transfusion to occur. So this is an active action taken by an anesthesiologist. But Mrs. K is not only Mrs. K as a patient. She lives together with her husband and her husband depends on her. So the longer Mrs. K is absent from home, the more strain this will put on a familial and social situation. Certainly the situation of Mr. K. So we need to take into account that certainly for this type of persons, we need to make the hospital stay as short as possible. What is the second message I want to give you? There is an absolute need for appropriate human and financial resources. You have seen in the high care hospital, Mrs. K is promptly treated and there is no complication afterwards. In the low care hospital, if you cannot monitor our patient, if you cannot treat our patients, there is a big problem because these patients will die or at least develop important morbidities. So you might be curious to know what happened to the two patients I presented to you. Well, Mr. F, Mr. F survived. He was diagnosed. We resuscitated him successfully. And apparently from the clinical picture and the blood values, it appeared that he has developed an anaphylactic shock. So he had the fourth time that the medication was used. He had developed one of the agents that we use, an anaphylactic shock. He could leave the hospital the day after and he's living happy with his family and with his two children. What happened to Mrs. K? Well, Mrs. K is a little bit a composite character. You have seen that the outcome of Mrs. K critically depends and of patients like Mrs. K critically depends on the resources that are present to treat, to monitor, and to follow these patients. So I come back to my initial point. What is the role of anesthesiologist in perioperative safety, in perioperative patient safety? Well, I have convinced you that we play a role preoperatively, intraoperatively, and postoperatively. And it is this integrated approach that makes it possible for us as anesthesiologists to take care of the patients and to give the patients a safe perioperative course. And societies try to continue to even improve this patient safety by working together with other anesthesiological societies, other anesthesiology group, healthcare professionals, institutions, patient associations, and with you, the public. And it's only in this way that we are capable of improving perioperative patient safety for the sake of all of future patients. Thank you very much for your attention. Ladies and gentlemen, please welcome Johannes Wacker. 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 honored and 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 lying on an operating table and in the middle of an operating theater, an old-fashioned surgical amphitheater in Massachusetts General Hospital 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 put the patient to sleep. Harvey Cushing is his name and at the time he is called a junior house pupil. That's the title. So this young surgical trainee 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, were shocked by this and by other fatal mishaps they experienced as Chinese. 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. Harvey Cushing, as many of you probably know, later became a very famous neurosurgeon and Amory Codman became a well-known surgeon as well. But most of all, he became one of the fathers of quality improvement in healthcare 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 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 in poorest. 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 the present. Remember Mrs. Kay, the second patient that Stefan DeHert has presented in his talk. So since the times of Cartman and Cushing, the interoperative period and anesthesia have become very safe. Not 100% 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 100 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 DeHert 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 Heers-Landen Clinic at Private Hospital. 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 happy to try to answer them. May I ask the panelists to introduce themselves? Maybe we'll start on the left side with Dr. Zef Goldig from Israel. Good morning. My name is Zef Goldig. 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, Mellyn Olsen, an 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. Good 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 Institutes of Health Research. I'm Dave Whittaker. I was a consultant on Cardiac Anesthesia Intensive Care at Manchester Royal Infirmary. I've been involved in safety organisations for quite a long time. I'm currently the chair of the EBA Patient Safety Committee, and I'm on the ESA Patient Safety and Quality Committee that Johannes chairs. Yeah, thank you for your introductions. And I think the Hensinki decorations, of course, a core topic for our panel here. Janneke, if we agreed on our ladies first, if you're very active in 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 decoration 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 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 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 threw the abdominal wall 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 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 peritonitis and he died. At that time, my child 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 I wanted to, I stopped playing and I just wanted to change, I wanted to make a difference and somehow that was when I've decided to be a doctor and also to be involved in this type of effort. And my message is, well there is such things as a difficult mother but that's a diagnosis of exclusion. Always listen to 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 a team and all stakeholders or partners in that team are partners. And that's how I'm guided in my clinical life and also 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, Janneke, for this very personal example. And I think it also shows the value of the Helsinki Declaration as a tool because that's what you mentioned as part of the Helsinki Declaration. Ziff, Your, besides all your functions, your immediate past president of our society, you've always been very active in education, you know. Do you think of an example of your own clinical experience that shows both the importance of patient safety, maybe the Helsinki Declaration and 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'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, 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 mistake to take such a difficult case to private practice, but this is another story. So I tried to avoid all the latex components in our operation and I even decided to do a spinal anesthesia, only the lower part 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 is the message we can take, that the equipment is becoming more and more perfect and it's 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 DeHert said before, we invest a lot of efforts at the European society in education, we have a European diploma, we have master classes and scientific activities and research, of course. Thank you very much for this example, Steph and David Wittaker. David, you're very active in patient safety events in initiatives as well. And by the way, ladies and gentlemen, the three sitting next to each other, Janike, Andy and David have been very instrumental in developing the Helsinki Declaration on Patient Safety in Anastasiology. David, you've been quite active in medication safety lately. You've been part or maybe the driving force for the European Board of Anastasiology 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 Anastasia, which is a society's journal, at this time last year, published the European Board recommendations for safe medication practice. 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 the guidelines were published just as 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 it's quite a simple recommendation. Perhaps I could just ask the audience to show of hands. If you need an injection on Monday morning, would you want the syringe to be clearly labeled? Yeah. Yeah. Exactly. 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 10-year-old girl had a arterial venous malformation on her cheek, and this was going to be a blade. It was a cosmetic operation. And in the x-ray room, the doctor had two 10-mil syringes. One had x-ray contrast in, and the other had coarsed glue. And he got them mixed up, nobody spoke up, and he injected the glue into the girl's 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 10-mil syringes at Great Ormond Street Hospital 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 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 anesthesia, probably also the contents of the guidelines published by the European Board of Anesthesiology. So, Andy, besides your clinical work as a consultant anesthetist, you've always been very active in teaching, education, and in research. So could you give us an example from 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 a moment of revelation, really. And the thing that really comes to mind is 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 were taking wisdom teeth out of otherwise healthy young people. And I don't know about the rest of you, but I find that 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 a 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 of anesthesia. 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 a sister on the ward collecting the charts up and shaking her head and frowning. And she got to me and she said, you can't give them a pre-med, doctor. We never get them out of hospital on time. I tried to explain why I was doing it, but she was quite insistent. And so they didn't get their 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 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 her wants to do anymore. And I think what that revealed to me, I think, is that when there's 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 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 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 USAID Guidelines Committee, for instance, is 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 examples. And I think that probably for the audience, it has become clear that the Helsinki Declaration on Patient Safety and Anesthesiology is sort of a centerpiece for safety activities within the European society, besides all the other foundations that Stefan DeHert has already mentioned. This is in his talk, Education Research. 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 be used to make a change at the cutting edge of clinical work, especially of anesthesiologists, but also in the perioperative field? Please, Janneke. Yeah, 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 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 takes us heel and they help the patients and the relatives heel. And for that, we need practical tools. Because when an error has happened or a mishap or a 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 as 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 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 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 have to be very, very careful and concentrate when we work every day. Because anesthesiology is 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 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 cardiologists, neurologists, internal doctors, internal medicine doctors, and so on, and so on. And to combine all these qualities. Thank you, sir. I think, I mean, the vision, the declaration is a set of practical tools, but 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 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 policy makers and say, this is how we should be doing it. So it's about improving standards more generally as well, I think, especially across the diverse continent that we're in at the moment. Another thing, recommendation, the health thing in 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 feature of the ESA, which I'd like to mention, is international cooperation. And whenever, in any country in Europe, a 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 105 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 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, and 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 ESA recommended that all the hospitals in Europe should use the same number, double two, double two. This has already happens 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 Grower, the German Health Minister, he wrote to all the German hospitals and recommended that they use it as well, and they're starting to use it. So, this is something that other countries, Australia, parts of Australia use double two, double two. There's interest in South Africa, and maybe this is something that could work with the patient safety movement to develop an app or something in the future. Thank you very much for these inputs. In the meantime, 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 has presented. Anybody wants to comment on that? Well, I mean, I'm 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 staff, it's easy to be daunted by the size of the task ahead of you, and very often it's good to start small and use things that are 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 particular with regard to the World Health Organization and 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, I'll let that be the case. And, Ray, nice to see you all. Thank you. But 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 special, it's very significant to them. It's not just a job as it is for us. And it's a moment 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 what 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 bigger, more expensive things, that's my view. Thank you. I think Janne, can you watch? 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 hospitals, 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 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 we started also with internal medicine and so on. And it started with pediatrics and so on. So you could see the benefit in... And we can also see how we can use that simple training we do in the trauma room, in the operating theatre, 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 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, anaphylaxis, malignant haverexia, something like cardiac arrest. David Seidemann, who organised the medical teams for the London Olympics, they had teams of four people, a doctor and nurse, physio perhaps. And every morning, when they met, before they started, they went through a little scenario to make sure that they were all on message and things. 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 how is it going, anesthesia, the operation, the bypass, et cetera. And 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 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 responsible for the flight. So it's the name, the brand name and the name, the prestige of the company. The same is in our hospitals. Thank you, Zef. In the meantime, a number of other questions have come in and I'm afraid we can't answer all of them. But maybe it's just a very short answer. If you have one, there's one saying, what do 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 in the United Kingdom, often the hospital is the biggest employer in the town. So the whole sea of things like that. But there have been various studies. So maternity units, for example, if you go below 2,000 deliveries, then maybe the team isn't doing enough and there have been some, Andrew might like to tell us, there have been some episodes, 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 and there's a plan to reduce them. So the surgeons can work in bigger teams, not just 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 to that? I think it was very interesting what has been presented a couple of times here. In the UK, the safest hospitals were not necessarily the biggest ones. So there are some benefits with smaller hospitals according to a limit. So you have to tailor what you're doing to the size of your hospital. But we probably don't have a clear answer why they're still open, this was the question. Very difficult question, of course. So I apologize, we don't have enough time to answer or discuss all of your valuable questions. May I ask a last round of our panel, may I ask the panelists to think about a take-home message for the audience? If you want to start, Janneke? 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 conscience that I'm so happy I'm the person I am and many others have benefited from our disaster, just so you know that. Then I want to say with the patients and doctors together. For 20 years I tried 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 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 a union, a common goal with the patients and the relatives and go together to help the politicians make the right decisions. Thank you, Janneke. Zef? Well, as I said, anesthesia is not only administering drugs. We are keeping the patient alive and we are working teamwork together with the surgeons, with the nurses and the anesthesia is a very operative discipline. So we have to see the patient before the operation. We have to plan carefully our work. We have to continue with the patient during the operation and the post-operative visit is very, very important and not always we are doing it. So I think that our specialty is a very integrated discipline which integrates a lot of aspects of medicine and this is a very responsible discipline. Thank you, Zef. 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. Standardization of the labelling of syringe may be even going to pre-filled syringes so all the drugs are standardised with the ISO-coloured labels and standardised our cardiac arrest telephone number to 2222. So think global, act local. Thank you, David, very clear. Andy, your message? I guess my message comes back 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 they're the knowledge and experience of patients, for instance. They're also the knowledge and experience of professional expertise that we all use all the time but we're not always aware of. And the standard operating procedures that Zef mentioned earlier which 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 until a few years ago and he said once that 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 the hands of professionals that who create patient outcomes at the clinical front line and on a daily basis. And the Helsinki Declaration is a tool that our society provides to help professionals to achieve our goal of eliminating preventable death and complications in our patients. Thank you.