 Good afternoon. I'm Dan Cole, a professor of anesthesiology at UCLA and the current president of the Amnesia Patient Safety Foundation. And I want to thank the Patient Safety Movement Foundation for hosting this webinar. The purpose of which is to highlight the upcoming Patient Safety Awareness Week that's going to occur next month. We want to raise awareness of patient safety and develop this conversation to help stimulate the creation of safer healthcare systems. We have an exciting group of panelists to discuss selected patient safety topics and I'll introduce each one of them and then give each one the opportunity to make an opening statement about a topic that they consider of import. Sanos Masumi, she's the Chief Operating Officer at the Patient Safety Movement Foundation. Bernadette Wilson, she's a patient advocate, Patient Safety Movement Foundation volunteer and founder of Cognitive Performance LLC, a professional coaching and team training firm. And then finally, Brandon Lau is an Assistant Professor of Radiology and Associate Faculty in the Armstrong Institute for Patient Safety and Quality. And with that, let's go on to the meat of the webinar and I'll start with Sanos to maybe make a comment or two of things that she thinks important, maybe particularly in regards to raising awareness and particularly the safety culture. Thank you very much, Dr. Cole, for the kind introduction. Well, the Patient Safety Movement Foundation, we hope to be able to raise awareness around the topic of patient safety to be able to create safer healthcare systems globally. We can't solve a problem if no one knows it exists and overall general public still believes that our healthcare systems are pretty safe environment and preventable patient harms is a very rare event. Well, we conducted a survey a few years back. We found that 88% of general public don't know the enormity of the issue. And yet, the estimates show and indicate that in US alone, about 200,000 patients die every year from preventable adverse events, let alone those that they end up with long term disabilities and still the harm reaches the patients. Around 400,000 preventable drug related injuries occur each year in hospitals, 800,000 in long term care settings. And over 500,000 of these drug preventable drug related injuries happen among medical recipients. So, but just giving these few statistics, I think it is very obvious that this is a really big problem we're dealing with. And we know that the solutions are straightforward. We need to implement evidence based practices. Thank you. Bernadette, maybe you could give an opening statement and maybe comment specifically on mental well being and performance of teams and individuals. Absolutely. Thank you so much, Dr. Cole. You know, listening to you, Centon, I was thinking about so much how this is a human problem. It's a global problem. It's not just a hospital problem because it affects everybody internally and externally of the healthcare system. I think the problem in the way of like a Rubik's cube, you have a cube and maybe you get it in a perfect form and there's some colors and there's a system to it. But if you mix it up, there's a lot of angles and dimensions to solving this problem. And patient safety is the same way. We have to kind of look at it from internally within the organization what is going on operationally and what type of culture and I think that was something we spoke about earlier about the culture of the organization and how we can implement more compassion and awareness for our healthcare workers. I know one of our facilities here does a code lavender, which I absolutely love. So if there is a medical harm, people surround the person that may be the medical person that was involved with that and offer them support because as a person becomes full of stress, anxiety, we all lock down and if a whole team is that way around a medical harm or error or any type of high stress environment, more errors will continue and more damage to another person can happen. So that's more internally and externally it's more of what you also said is that awareness and bringing that awareness as a patient advocate when I speak to people, they don't even know that there is a harm. If there is something, I said you know that is a medical harm and they don't understand that and realize that. So just getting the clarification of what a medical harm is and then getting people to talk about it and tell stories because it really does affect the whole family, our whole community and as we see now with what's happened in the past with COVID, it affects us globally. Brandon, do you want to give us an opening statement and maybe even intertwine COVID and how that may have affected the patient safety movement? Yeah, you know, thank you very much for the introduction and I completely agree. I think that COVID has been unlike anything that we've ever experienced in our lifetimes and leading up to that, we've developed and implemented various interventions to try to improve quality, improve safety in healthcare organizations and when COVID came around, you know, it pretty much changed a lot of the culture of our day-to-day practices and we were forced to modify how it is that we were approaching healthcare delivery, trying to do the best for the patients who were coming into the hospital. And I think that it created a bit of a challenge to ongoing healthcare quality improvement and identifying opportunities for safety and as we're emerging from the pandemic, we're realizing that a lot of the culture in healthcare and practices are probably different now than before the pandemic began and we have to take a really good look at where our numbers are, where our opportunities to improve are and try to figure out how we can try to modify solutions and interventions that have worked before for the culture and practice that we have now. And while I don't think it's completely starting hoover in the world of healthcare quality improvement and patient safety, I think that we need to really have a clear understanding of what the data tells us are opportunities to improve and what our healthcare practices are now so that we can really pick up and drive that momentum that we had before to ensure that patients are getting the best, safest care in healthcare. Let me just bridge from that to another area of concern. That would be the healthcare workforce and particularly there's been predictions of mass accidents of people from the workforce. I think there was a recent AMC survey that came out that said 47% of physicians are 55 or older and COVID certainly has affected burnout and distress within our healthcare workforce and I know that the workforce has been stated as probably the top patient safety issue going forward. I wonder if you'd like to maybe comment on how we might address the workforce issues. I think workforce is absolutely critical to the culture of healthcare safety. One of the things that we're also noticing is an increased use of traveling nurses and nurses are some of the first healthcare workers who will see issues arise and one of the very interesting things that we saw beforehand is that the teams of nurses who would work together day in, day out understanding, developing, implementing practices to keep patients safe in hospitals because they are a team, they're a family, they're people who work together all the time and while I have absolutely the greatest respect for nurses and all of the work that they do, I think it is a different culture when there's a large number of traveling nurses who may be in one environment for a very short period of time and probably a different level of engagement of safety culture and innovation for what might work on individual hospital floors or within departments to identify where there are opportunities to try to keep patients safe and I think that it's really important as we're thinking about the workforce and rebuilding the workforce and re-energizing the workforce to think about how we can do better in team building between clinicians of different disciplines and also recapturing that feeling of all being in this together and all having a vision for how we can improve the safety quality and experience of the patients while they're in the hospital. Maybe we can jump to Bernadette and considering kind of a fragmented and very fragile workforce that is becoming more and more stressed with the demands of healthcare by the United States population. Any comments on things that we can start to do to sustain, improve the mental well-being of the workforce and also the performance of the teams? Okay, a couple thoughts there and just backing up on the previous conversation as well. I'm thinking that we need, did I freeze? I'll continue speaking, that we need to continue with the training and I was thinking about the nursing schools, local nursing schools making the patient safety culture priority number one. It just has to be the main core value and I think Dr. Cole you know this I think believe the medical creed is do no harm so making that coming back to that and that is number one. So if you have that as the upper message going through any healthcare system you go into there'll be less confusion. Then you look at the individual teams, you can implement down the line compassionate care principles of being able to take allowing healthcare workers to take time out, to have morning huddles, to discuss the stresses of the day, they should just be standard operating procedure. I always believe that there should be an operational manual, a safety operational manual that goes with any facility and that there is a team that really monitors this and oversees this and making sure that these protocols are followed. And one of the biggest things that I tell my clients when I'm working with them and I'm going into an environment is really to understand that they are in a high stress world, high stress environment. So it's very very important to take what we say called mini breaks to really stop, breathe, relax and refocus. So San Jose any comments on that issue before I ask you a specific question? I just wanted to briefly talk about the data transparency and how it ties to the workforce. I'm sure many clinicians and clinical team members still work in healthcare organizations where if there is an adverse events in one department they are not going to necessarily be informed about it and these lessons learned are not shared throughout the organization let alone outside and in a global fashion. So many individuals happen to experience the same errors, the same failures and the same patient harms that has happened in the past numerous times and they could have been prevented and along with the patient who we are trying to protect, we're also trying to protect our healthcare workers from having to deal with an experience, the trauma. The trauma is a widespread, the patient is obviously the recipient of it but healthcare workers also are the other end of the spectrum receiving the trauma and that's why I think data transparency or I should better say the lack of transparency in the current healthcare situation is one of the important topics we have to address and we have to talk about it to start moving the needle towards safer healthcare system. And let me follow up a question in regards to your opening in our comments Sanos. You mentioned some stunning figures about the death morbidity of preventable harm which would actually make preventable harm the third or fourth most common cause of death in the United States. That's right. Why wasn't patient safety received greater profile and great attention on par with cancer and cardiovascular diseases? That's a really good point and I think again it goes back to one, to not having transparent data. So when we talk about these figures like 200,000 people dying every day in the US annually, more getting harm due to medication errors and so on and so forth, up to this point we didn't have really good data collection processes so we don't know the exact number of harm. We don't know exactly when they are happening, where they are happening so connecting the, we haven't been able to connect the dots yet for the same purpose. The other topic I want to bring to the picture is aligned incentives. It hasn't started, we haven't started to pay our providers more for the quality of the care they're provided rather than the quantity of the care but still if you look at this globally, in majority of the cases providers are paid based on the quantity of care, based on the number of procedures they do, based on the number of patients they see on a daily basis. Until we fix the aligned incentives and data transparency and join it with incorporating gold standard of care, we continue to see the same number of patient harms and perhaps that's one of the reasons why patient safety hasn't received in the past decade, maybe hasn't received as much light as cancer interventions because they have a lot better methods of collecting data, a lot better interventions to put an end to many of the cancers. Brandon or Bernadette, any comments? I completely agree when it comes, as a data scientist, I completely agree that we woefully underutilized the data that we have to try to better understand what the opportunities to improve care are and I think that that is just an absolute travesty in healthcare. I think that challenges come in multiple different ways in this and one is that there isn't really a great standardized definition or measure that hospitals are consistently holding themselves accountable to. So in one area, one of my main clinical topics is diagnosis prevention and treatment of blood clots, venous thromboembolism and it's a measure of outcome and processes to prevent blood clots that's used by multiple different organizations throughout the world and all of their definitions, inclusion, exclusion criteria, what qualifies as a preventable blood clot versus an inevitable blood clot, they're all different criteria. So hospitals are holding themselves accountable to a variety of different measures, many of which don't actually make clinical sense or give actionable opportunities for improvement. So I do think that one of the key issues is having a consistent defined measure that hospitals are able to readily access their data and say this is what our outcome is or this is what our safety number is across multiple different domains and the second area that ties into data also comes to the electronic health record system. Even when you have the same electronic health record system, a lot of the ways that they get built and implemented at individual hospitals varies slightly. So as one example of this, we have a project right now that has been demonstrated to improve administration of medications to prevent blood clots within our own health system that we have attempted to share with 10 other hospitals around the country using the same electronic health record system that we have. We've shared our code for building reports, for building the tool that helps to facilitate this intervention and in every case that code has had to be modified based on their electronic health record system build. So it's not even as easy to just simply share an intervention that works at one hospital with a bunch of other hospitals thinking that it's a plug and play system. And I think that as a country, we need to do better at leveraging the incredible investment that we've put into adopting electronic health record systems to make data both transparent and easily reportable but also facilitate intervention implementation when we see that something works at one hospital or five hospitals. How can we spread it out to the thousands of other hospitals that could potentially benefit from that type of intervention? Maybe a question for Bernadette to kind of build on that. As you know, many surveys in the recent years have shown that patient trust, the public trust in healthcare systems and doctors as plummeted want to talk about rebuilding trust, particularly through patient safety and engagement. How do we best get patients a little more involved and engaged in their actual care? Okay, great. Those are two great questions. One, gaining the trust and how to get patients involved. And just backing up what Dr. Lall said, I was thinking about how many reporting avenues are out there now. You've got the U.S. news and you've got visitors and you have all these different measurement types. And so the consumer is going to be looking at those types. They're going to be looking at those ratings to see which is the best hospital. They may not be providing the best care, but they're going to be looking there. And then that may or may not lead to some mistrust depending on how the reporting was done and the statistics were reported. So the trust comes from honesty and transparency. If a consumer could go to a website or a patient goes to a website and actually see what their ratings are, how well they do in a certain procedure, how well they've reduced CLABSI, how safe is that hospital? That would help tremendously. I also encourage patients to go and ask questions and be extremely vigilant about their care. You have to assume that this is your care, your well-being, and your caretakers as well. So it's kind of a team effort. And on the other end, they have for whatever the physician prescribes to follow that. Often patients won't follow the advice of the physician and they may have readmission, which also causes more harm to individuals. So they understanding that the physician's advice is most sage most of the time, I mean it's right to question it, to always question it. And also there are books out there and there's material out there that there's checklist that people can bring into their doctor's office and talk to them about what is going to happen with anesthesia, who's going to be my anesthesiologist, is somebody going to be monitoring my anesthesiology and just really work so often, I know this has happened to me before, you just sign the form and you leave and you don't know what's going on. So to have that awareness will reduce the anxiety and I think it reduces it as a team and the healthcare professionals and the patients should be a team in their collaboration. And I know it's kind of a big ask because physicians are extremely busy and healthcare workers are extremely busy. And on the other side, each person wants to be treated as if they're the only one. So the merging of that coming together is the human part and we really again just have to slow down to provide good care and for patients to become more aware. Sanos, any comments on that? Yes, I just wanted to mention that I fully agree with what Bern did just mention that in healthcare is a really fast-paced environment, it's really dynamic, a lot of decisions are being made concurrently. So I think that if we master the science of safety in healthcare, like how other industries such as aviation or nuclear have done it, we have a better chance of serving our patients and serving our healthcare workers in a more holistic field. And I think there are three basics, ingredients in creating a safe culture. If we have a reporting system to help start with conducting a root cause analysis when a failure happens, if we have a promote a learning atmosphere which turns the errors into lessons to learn rather than a blame culture. And if we have a systematic assessment of a culture on a continuous base, these three together at least give us a foundation to start build a culture of safety where people, both patients and their family members and also clinicians, the whole clinical team feel comfortable to speak up and feel comfortable to sometimes stop a procedure, sometimes to bring something important to the attention of hospital administrators sooner than later. I just wanted to add that point. So one last question for Brandon and then I'll ask each of you to kind of make a closing statement. Chat GPT has just hit the field and you can get some amazing information off that, not necessarily all of it's accurate, but I can envision patients going to chat GPT getting a lot of information that helps to level the asymmetry that occurs. And chat GPT is only the first generation. How do you envision tools like AI to help the patient become better engaged and help to prevent safety events? That's such a great and timely question. I think that as we're learning more and more about how to harness artificial intelligence, machine learning, natural language processing on both sides as clinicians, researchers, patients, I think that there's an incredible opportunity to learn from the past what would potentially take a lifetime of sifting through documents, thousands, tens of thousands of free text documents of things that have been documented to try to understand where things might have gone wrong and identify potential interventions to prevent that from happening in the future. I think that there's incredible potential for it. I think one of the concerns for it is that you have to consider the quality of the information going into it. And usually the output that you get from that is only as good as your inputs. And if there are some questionable documentation practices, if there's a lot of variability in the way that people describe specific events happening or the way that things lead up to various events, it can actually heavily influence the results that you're going to get from it. I think that there's enormous potential for it. I think that we just have to be a little careful of how much stock we're putting in it right at this moment versus continuing to optimize it over the course of time to make sure that we're getting really high quality information out of it. So we have about three or four minutes left with that. I think I'll ask each of you to maybe give a one-minute client and closing statement of where you'd like to see us go. I'll start with Bernadette. Thank you. And I apologize if my screen has frozen one more time. I believe it's with the organization. It's organizational values implementing the patient safety culture first. And that's just globally with our educational system, healthcare educational system, and within the healthcare system environment. And then also using compassion and really being aware of what is going on with your own personal healthcare and when you are going into a hospital and speaking up and taking sole responsibility for your healthcare, knowing that it is your right to do so. And then also understand that the majority just about all of the healthcare workers are there to support you and they are also human too and they're overstressed. So it's okay to ask questions. And as team members, it's okay to slow down and really speak to each other and talk about what is happening. And if you see somebody, one of your co-workers in a stressful state of mind or have anxiety to slow them down, take a breath, breathe, take a break and come back to it. Because again, that's how errors occur. Brandon, Amanda? For me, and I go back to being in data science, for me, healthcare quality improvement and safety improvement is really going to be based in the data and understanding where the opportunities to improve are. I think the transparency is absolutely essential. We need to make use of this enormous body of data that we have to really make sense of it, transform it into information using a standardized measure across hospitals, across health systems, so that we can really compare hospitals to one another in a standardized way and then be able to drill down to individual practices and processes that we can give actionable information to individuals, be it physicians, nurses, patients from all of the data that we're collecting to really empower people with information to change the culture and change the practice to make it higher quality and safer. Thanos, any closing comments? Thank you. I just wanted to say that at some point in life, we will all experience what it is like to be a patient. So if you're informed, we can become our own patient advocates and we like our patients to team up with our clinical team in creating a safer healthcare system, because we are all in it together. Well, thank you all. I want to specifically thank Bernadette, Brandon, and Thanos for a very stimulating and enlightening panel today and also thank the Patient Safety Movement Foundation for hosting this conference. And with that, we will say goodbye. Thank you very much. Thanks. Thank you so much.