The Patient Safety Movement mid year planning meeting was held on June 10, 2016 at Fairfax Inova Hospital in Falls Church, Virginia.
Joe Kiani, founder of the Patient Safety Movement Foundation, welcomed all to the meeting and reiterated the objectives and goals of the movement and what we were to accomplish during the meeting.
There was an impressive lineup of speakers and organizations represented. Dr. Charles Murphy, Chief Patient Safety Officer for the Inova Heart and Vascular Institute discussed how team training can improve patient safety and the steps Inova have and are taking to ensure patient safety. Dr. Emily Marko, Director of the Inova Medical Simulation Center, showed a video of one of their team training exercises, the after action review and the results that have been obtained through simulation training.
Dr. Terry Fairbanks, Director Human Factors in Health, at MedStar Institute for Innovation emphasized the need to understand human factors and the role they play in evaluation and how and what is actually being measured through assessment.
Dr. Teo Forcht Dagi, Chairman of the Council in Surgical and Perioperative Care emphasized the need for all organizations to work together for the common good and share ideas and results. The Honorable Sheldon Whitehouse, Rhode Island pledged his support and discussed the ‘Patient Safety Improvement Act of 2016 (S. 2467) where it stands and what needs to be done to have bill passed.
Dr. Scott Betzelos, VP\\Chief Safety Officer, Inova Fairfax Medical Campus shared some of Inova’s success and reevaluation of how they train staff to ensure patient safety and their next steps in individualized medicine.
Dr. Jeffrey Shuen, Director, Center for Devices and Radiological Health, Food and Drug Administration (FDA) highlighted progress the FDA is making in moving device approval through the FDA system which garnerd significant applause from the audience.
Conrad Grant, Chief Engineer, Applied Physics Lab (APL) and his son Dr. Michael Grant, Director, Enhanced Recovery after Surgery, Johns Hopkins Hospital, shared their ideas of incorporating engineering practices into surgical procedures and healthcare and what they are doing at Johns Hopkins to ensure patient safety by incorporating engineering principles.
At lunch the above speakers were on a panel and fielded questions based on their discussions from the audience. A lively Q and A followed and then the audience and panel participants broke into working groups based on the Patient Safety Solutions: Creating a Culture of Safety; Healthcare Associated Infection (HIA’s); Medication Errors; Failure to Rescue: Monitoring for Opioid Induced Respiratory Depression; Anemia and Transfusion; Hand-off Communication; Suboptimal Neonatal Oxygen Targeting; Failure to Detect Critical Congenital Heart Disease(CCHD); Airway Safety; Early Detection of Sepsis; Optimal Resuscitation; Optimizing Obstetric Safety.
The 2016 Midyear Planning Meeting brought together over 100 medical experts, administrators, patient advocates and government officials from around the world for presentations and discussions on critical topics in patient safety. The meeting concluded with a discussion and vote to select the new challenges where patient death can be easily prevented if proper protocols are followed during patient care. Attendees nominated 15 new challenges. They voted to include the following three challenges as the next most pressing issues in patient safety: Venous Thromboembolism (VTE), Mental Health and Pediatric Adverse Drug Events.
Venous Thromboembolism (VTE)
Venous thromboembolism, consisting of deep vein thrombosis (blood clot formation in a deep vein) and pulmonary embolism (a blood clot that travels to the lungs), is one of the most common preventable cause of hospital-related death. It is estimated that more than 50,000 patient deaths in the United States are attributed to VTE. For example, when a blood clot travels to the lungs, patients have 30% to 60% chance of dying from it.
Approximately 61.5 million Americans experience a mental illness in any given year. Outcomes of mental health care provided in hospitals lag behind outcomes achieved in large trials of evidence-based treatments. Recipients of mental health treatment are more vulnerable to unintended harm and less likely to advocate for themselves. Areas of potential harm include misdiagnosis, insufficient treatment, adverse drug reactions, harm resulting from seclusion and restraint and incidence of suicide. Between 1970 and 2000, the number of public psychiatric hospital beds dropped from 207 beds per 100,000 people to just 21 (Agency for Healthcare Research and Quality). A 2010 survey of 603 hospital emergency department administrators by the Schumacher Group found that 56% of emergency departments (ED) are “often unable” to transfer behavioral patients to inpatient facilities in a timely manner.
Pediatric Adverse Drug Events
The Patient Safety Movement already has a Medication Errors APSS but it was determined that Pediatric and Neonatal Adverse Drug Events needs to be a separate focus. Adverse drug reactions (ADR) in children can have a significantly more severe effect when compared to adults. ADRs can lead to prolonged hospitalization, permanent disability or death. The error rates are highest in the neonatal intensive care unit. Children are usually less able to physiologically tolerate a medication error due to still developing renal, immune and hepatic functions. Children cannot communicate effectively to clinicians regarding any adverse effects that medication may be causing. Common errors include improper dosing, omission errors, unauthorized/wrong drug, prescribing errors, wrong administration technique, incorrect preparation, wrong dosage form, and wrong route. Additionally, many health care settings are primarily built around the needs of adults and lack trained staff oriented to pediatric care.
The three new challenges will be added to the current list of 12 challenges and Actionable Patient Safety Solutions (APSS), and addressed at the Patient Safety Movement’s 5th Annual World Patient Safety, Science and Technology Summit on February 3 & 4, 2017 at Laguna Cliffs Marriott Resort and Spa in Dana Point, California. The Summit brings together clinicians, patient advocates, hospital administrators, safety officers, medical technologists, public policy experts and government officials from around the world to commit to eliminating preventable patient deaths by the year 2020. At the last summit, the Foundation reported that commitments representing over 1,600 hospitals resulted in 24,643 lives saved in 2015. The Patient Safety Movement also reported in January nearly 50 companies signed the Open Data Pledge to share their data to promote patient safety through interoperability. The Foundation is looking to double these numbers in 2016. This year, the Foundation has established Regional Networks to mobilize leaders across the world to reach more hospitals, so they can reach their goal of ZERO preventable deaths by 2020. Currently, 19 Regional Network Chairs representing over 60 countries are positioned across the world to gather momentum for the Movement. At the mid-year meeting it was announced that the European Society of Anesthesiology (ESA) is now working with the Foundation to lead patient safety efforts across Europe.
“This was the best Midyear Planning meeting yet. We couldn’t be happier with the outcomes and are grateful for the participation and contributions of all those in attendance,” said Joe Kiani, Founder & Chairman of the Patient Safety Movement Foundation. “We are making great progress, but still have much work to do. Like the other 12 challenges we have addressed with our Actionable Patient Safety Solutions, (APSS), VTE, mental health, and pediatric adverse drug events, have processes to prevent human errors from becoming fatal. But, these processes are sometimes made unduly complicated and significantly underused by hospitals in our country and around the world. We look forward to working with experts in each category to create easy to implement APSS for these new challenges. We firmly believe that if every hospital in the world adopts these APSS, we will be able to eliminate preventable patient deaths.”
Joe Kiani continued, “We thank Inova for co-convening this midyear planning meeting with us. We also want to thank Senator Sheldon Whitehouse for introducing the ‘Patient Safety Improvement Act of 2016 (S. 2467)’. If it becomes law, this will be a huge step towards reducing preventable deaths. We are also encouraged by the direction the FDA is moving in creating a new regulatory paradigm with their National Evaluation System (NEST) for new innovations. We believe this will speed up our nation’s access to innovations that can save lives and at the same time, maintain patient safety as a priority.”