 Good day to everyone. First, I would like to thank you for the opportunity to talk to you today. It's an honor and a privilege to talk to such a distinguished audience united by a joint commitment to the course of patient safety. It's a particular pleasure to talk at a conference that is co-convened by several societies of anesthesiologists and intenduists since I have a past as an anesthesiologist. It has now been more than 20 years since I left the operating theater, but I still consider the almost 20 years spent there as important formative years. After all, the core task for an anesthesiologist is to bring the patient safely through an operation. Many of the ideas on how to approach safety have been in use for a long time as common ways of working as a practicing anesthesiologist. My present role is being the CEO of the International Society for Fellows in Healthcare, ISQA. ISQA is an organization that rallies people. Our tagline is Knowledge Network Voice. For us, our most important working capital is our network of members, partners, ISQA experts, and the ISQA Academy. Through this network, ISQA has access to a large corpus of knowledge about healthcare quality and safety. The red thread running through all our activities is to make this knowledge available and usable to healthcare professionals all over the globe. Promoting and supporting patient safety is a core component of our mission. We want to contribute to ensuring that patient safety remains highly placed on the agenda for leaders and professionals in healthcare. We also want to contribute to generating and disseminating knowledge that enables healthcare providers to meet the challenge. The world is emerging after two years of pandemic, healthcare systems and individual healthcare staff worldwide have demonstrated an extraordinary capability to adapt, innovate, meet enormous, unknown and unforeseen challenges. They had to learn quickly to understand the new disease and how to manage it, search for drugs, develop vaccines, develop pathways to take care of large numbers of patients. Truly amazing things have been achieved. All of this is remarkable and notable, but it has come at a cost. The system and the people working in it have been severely stressed. One of the concerns that rank high on hospital managers agenda is concern about staff leaving, retiring or moving into other industries. Another is the topic of this conference, patient safety. In a recent perspective paper in the New England Journal of Medicine, Lee A. Fleischer and co-workers reported a substantial deterioration in the US on multiple patient safety metrics since the beginning of the pandemic. This includes collapse rates, catheter-associated urinary tract infections, ventilator-associated events, MRSA, bacteria, falls and pressure ulcers. All of them are examples of harm that is known to be avoidable, not only in theory, but also from solid and well-documented practice. The data presented in this paper were from the US, but I have no reason to believe that this situation is unique to that country. Accordingly, patient safety must be pushed to the top of the agenda for the entire world. The WHO is obviously leading acts on this endeavor. The WHO Global Patient Safety Action Plan 2021-2030 sets the direction towards eliminating avoidable harm in healthcare. It's an impressive catalog of strategies that will drive real improvement of safety. What will it take to translate these ideas into action and improvement for patients? So, Liam Dunlison, WSO Patient Safety in War in a talk to a WSO Policymakers Forum on the 23rd of February this year said that what is needed from policy makers to promote implementation of patient safety is that they show commitment from the top in multiple ways and all the time, provide infrastructure and mainstream patient safety. I will dwell on the notion of mainstreaming patient safety. This means that every time we think on how to deliver care, we must include considerations of how to deliver safety. But to integrate safety prudently into all our thinking, we must broaden and deepen our understanding of the concept. Some scholars talk of safety one and safety two. Safety one can be described as an approach where you strive to eliminate harm by finding and eliminating causes of harm errors. While there's clearly a merit in doing so, it can't stand alone as it's based on the assumption that adverse outcomes can be explained by linear cause effect change and that there's a way of an, as there is an a priori way of describing how to deliver safe care. Harm is caused by deviating from this best practice. In a complex system, this is not always the case. The safety one approach therefore needs to be supplemented by an approach that may be called safety two, where you study what it is that enable things to go right in spite of varying expected and unexpected conditions. The aim is here to improve the way in which actors in healthcare understand, anticipate and monitor what's going on and adapt the actions as needed and learn while doing so. This should not be a novel approach to an anesthesiologist. This isn't that we do what we do every time we're given anesthesia. One consequence of this is that there's not one single road that leads to patient safety. We need a multi-pronged strategy based on a deep understanding of safety, risk and what determines the performance of a complex system, such as healthcare, trying to influence a complex entity, human health. But we should also relate patient safety to another strong trend in the time person-centered care. We should not view those two as conflicting or competing or irrelevant to one another and the contrary, they're connected. One of the ways in which we can deepen our understanding of safety is to view it from the patient's perspective. We are stuck in the real world and we need to bring together and bring together with the understanding of complexity, safety, strategies for the real world. In 2016, two eminent researchers in the field of patient safety, René Amalberti and Charles Vincent wrote a book titled, Patient Safety, Strategies for the Real World. It's a freely available e-book and I warmly recommend it to you. They recognize that patient safety was challenged even before the COVID pandemic. I quote them, the combination of austerity, rising healthcare costs, rising standards and increased demand will place huge pressures on healthcare systems that will increase the likelihood of serious breakdowns in care. Innovations in the delivery of care in the home and community while providing new benefits will also create new forms of risk. Does this sound familiar to you? They urge us to reconsider how your safety risk and of how harm occurs. They find it useful to create safety in five levels. It is shown in this slide. The first level is the level of optimal care, the shared ideal vision of excellent care. This is what we try to encapsulate in standards and reference programs. But for many situations, it's not easy to design. As for example, in the case of a frail elderly patient with multiple chronic conditions and an added acute problem. Number two is a standard of care which experts would judge as those providing a good outcome for the patient and to be achievable in day-to-day practice. There may be some deviations from the ideal, but they're relatively unimportant for the overall outcome. Level one and two is where you want to be. And there is free safety may be compromised. There are frequent departures from best practice, often in the shape of shortcuts, trade-offs, and misses. Individually, these departures most of the time don't cause harm, but the potential for harm is increased and effects may accumulate over time. The need for shortcuts and trade-offs arises when there are conflict considerations. For example, between efficiency and safety or between the need to act and the desire to wait. If there are different conditions that demand different types of care, also there's a misalignment between expectations and resources. Level three is what some scholars call the illegal normal. It's not uncommon to find care at this level and the border and the accepted can gradually migrate so that the system gets towards level four, where we find departure from standards with the sufficient to produce avoidable harm, but where harm is still detected and mitigated or even reached onto level five, where care is poor over longer periods and places the patient at risk. Harm is not recognized or treated, but it is allowed to progress to become prolonged or even permanent or fatal. Notice that we may think of levels one and two as the areas of quality management and level four and five of the areas of safety characterized by the occurrence of defined patient safety incidents and adverse events. However, much of the harm is the result of a community effect of substandard care rather than a one clearly defined event. And this is in particular true for long-term care in primary health. It is important to realize that safety is not a constant characteristic of a system of hospital X. It doesn't make sense to say that the entire healthcare system or an entire healthcare system is either safe or not. What you can access is the safety of care at a given point and a given time. This is where the patient perspective becomes important. Safety may vary as you move along the timeline of a given patient journey and the patient is the only one that experiences the entire journal. This is particularly true for chronic conditions and with several providers, hospitals, primary care physician, home-based, based nursing care, family patients themselves all contribute to care delivery as scope producers. In this slide you see four patient journey. Arthritis, hip fracture, diabetes and depression. I won't go into the details about what the stories might be and why safety is up to it. I'm sure you can imagine such stories. But now I tell you that this was not about four different persons. It was one person with four conditions put the curves on top of each other and I'm sure you grasp that there might be connections. But would they be obvious to a diabetes team monitoring the safety of diabetes care? Just asking the question. In addition to the five levels of safety it's also useful to consider three different approaches to safety as shown in this slide. We have here different domains. One is the ultra-adaptive domain. This is where we embrace risk and manage it. We embrace risk not because we're reckless but because we take the risks to gain a larger benefit. Examples of this would be deep-sea fishing, military war time, Himalaya mountaineers but also some cases of rare cancer treatment or treatment of trauma. To work in this domain we need to understand what we're doing. We need to be experts that risk is managed by giving power to experts and by training through peer-to-peer learning. This is rather uncommon but does occur from time in health care. Much more common is perhaps the mid-domain where risk is not sought out but is inherent in the profession. Much of schedule, surgery and chronic care we belong to here. We can't predict and regulate everything. What we do is that we have good teams that work according to the principles of resilience, monitoring, adapting, learning, anticipating. But in some instances we're able to move to the domain of ultra-safe care where everything is very much regulated. Examples of this in health care would be provision of radiotherapy and blood transfusions. Here is the power led lives with regulators and supervision of the system to ensure that we grow by strictly defined processes. Once we understand where we are in terms of level of safety and the process of safety we can begin to design our strategy based on elements from five basic strategies all outlined in the book by Vincent and Alam Albersi I talked to you about. Two traditional ones, standardization of specific processes according to best practices to avoid specific harm. In other words, following standardized procedures strictly defining ways of behaving when performing safety critical tasks. This is what we do when we have surgical checklists, interventions to reduce catharsis and related infections and implement care bundles. The second strategy is general improvement of work processes and systems. The idea is here to reduce complexity, standardization of procedures, roles and communication lines, responsibilities is one way of doing it that is much of what lies behind actualization, for instance, but it's also about improving working conditions and organizational practices such as providing training, automation of key processes, design of equipment, structured handovers, reduction of noise and disturbance and improve levels and organization of starving. But we need to have more strategies in our toolbox. Risk control, eliminating risk is an obvious choice and we know it from anesthesia. We cancel anesthesia in case of an upper respiratory infection, we use different types of couplings with different gases and we restrict certain types of care to privileged providers. We define what we might call no-go conditions. In the fourth strategy, we rely on anticipating monitoring, adaptation and response. This is what we need for instance when we provide care for a patient with psychosis in the community. We can't write a book about how to do this. We need to move our way forward. Rapid response teams is another example of this building briefing and anticipation into clinical routines and promoting a team culture is one of the sub strategies here and apply methods to predict times of star sorts short of these relatives to demand so that we can adapt staffing to expected load. Expected load is not a way of handling it. Finally, when we have the fifth strategy mitigation, in some cases we need to accept that harm may occur but that we are prepared to react on it when we give hypothenticization therapy. We have a syringe of epinephrine ready. That's an example of that. In settings where care can be precisely delineated, strategies to control exposure to risk and to maintain standards will predominate but in contrast in more fluid and dynamic environments strategies to improve monitoring and adaptation may be more likely to make us achieve the desired level of safety. But it's important to say that within all five strategies you need a solid procedural underpinning. Standardization of roles, equipment, procedures is an important component, a toolbox if you like but in some cases you can't always describe exactly how to use the toolbox. Let me once again emphasize that across all these strategies goes the partnership with patients and families. Care will increasingly move out of hospitals and into the home. Typical problems for healthcare to address will be complex long-term conditions of multimorbidity, frailty and social challenges. Patients are partners with whom we co-produce care and with whom we share this decision-making power. Patients are perfectly able to understand and accept that we sometimes together embrace risk in the hope of achieving a substantial benefit and that we at other times strive for ultra-safety. In the real world, trade-offs are sometimes necessary but the right trade-offs can't be made without asking patients the core question of patients and what matters to you. Let me conclude with some remarks to policy makers, leaders and managers. And I will reiterate Salih and Donaldson's points that I mentioned earlier in this presentation show commitment from the top in multiple ways of all the times, provide infrastructure mainly in patient safety, maybe by using some of the methods I've described to you today and add to this involved patients as co-producers and partners. Leverage the power that is in this. Thank you very much for your attention. Good afternoon, my name is Luis Torres-Torresa, Quality and Patient Safety Coordinator of Hospital Español of Mexico. On behalf of the hospital, we would like to thank the Patient Safety Movement Foundation for this recognition as HRO champion with whom we have collaborated and shared the vision of zero preventable deaths by 2030. Patient safety must be a cornerstone in the current process and through health, personnel, patients and family members, we continue to develop a culture that favors the prevention and reduction of errors that cause harm to patients due to avoidable adverse effects. Over the years as Hospital Español, we have understood that the most common cause of medical errors in our patients is not in the individuals but in the system failures. And by working on safe processes, we have seen results that generate benefits for all. We work every day to reduce unwarranted variation in delivery of care while improving clinical outcomes and lowering costs. Achieving this level of clinical and operational excellence often requires a culture transformation. Fundamentally, changing an organization's attitudes believes goals and values and we continue to work every day to achieve this. In the hospital, we have quality and patient safety models that really guide us to implement the best practices to allow and to know and understand why failures occur. These errors help us to endear patient safety and establish strategies to address the root cause without missing the opportunity to learn from our mistakes. The work carried out since 2016 together with the Patient Safety Movement Foundation has made it possible to complement the actions with the quality and patient safety models, adding work processes with the objective that patients who receive treatment in our hospital can rely on the best possible attention because we understand that patient safety must be a priority in all the aspects of care. Our commitment is based on being a facilitator to achieve the well-being of people, help them improve their health and give them the best conditions for their management and recovery under a framework of continuous improvement. It's important to learn to meet the needs of our patients and recognizing that medical care take place in a complex and dynamic environment has also made us aware of the difficulties of daily operations and provide the organization's teams with the necessary resources and skills to handle these changing situations. Now, after years of experiences, we have come to understand that the key of helping to develop a high reliable environment goes beyond patient safety initiatives. We need to effectively address system issues. This includes at least the understanding of the behaviors and needs of the population, the design of safe processes, leadership, transparency and accountability. This is the only way to make sense of system failures and find ways to fix it. We are really grateful to be recognized by the Patient Safety Movement Foundation as a high reliable organization. As we continue with our path and conviction of improving and providing the best care for our patients. Thank you very much.