New CEO of the Patient Safety Movement Foundation, David Mayer says every hospital needs to implement the 18 Actionable Patient Safety Solutions.

From day one of our Movement, our goal was to eliminate preventable patient deaths in US hospitals by the year 2020. With 2020 one year away, there is an urgency to engage every clinician, hospital administrator, patient advocate and medical technology CEO to help us. The 7th World Patient Safety, Science & Technology Summit in January allowed us the opportunity to celebrate our progress and successes, thank the many hard-working contributors, and highlight best practices we call Actionable Patient Safety Solutions (APSS). We stressed the importance of planning for ZERO instead of just wishing it will happen. One of the core messages this year was that we can’t change the goal date and that we need every hospital to implement all 18 APSS today.

Patient Safety

What does planning for ZERO look like? We can look at the four hospitals that are 5-Star Hospitals, making commitments around all APSS. CHOC Children’s Hospital in Orange County, California, University of California Irvine Medical Center, Parrish Medical Center in Florida, and Hospital Español in Mexico City.

We can also look at the progress made by the 4,710 hospitals around the world that have implemented at least one APSS. Cumulatively since 2013, these hospitals have saved 273,077 lives.

Planning for ZERO also means planning for as many things as possible to go right in every hospital setting. That was the focus of one Summit panel that described this approach as a Safety II perspective. So rather than a Safety I perspective of simply working to make sure nothing goes wrong, hospitals need to start shifting their focus to a Safety II approach of ensuring everything goes right.

A new APSS and a key component of planning for ZERO (and sustaining that number) is making sure every person entering the health field is properly educated on patient safety early in their training. At this year’s Summit, Dr. Steven Scheinman, Dean of Geisinger Commonwealth School of Medicine, introduced our APSS on Patient Safety Curriculum for Schools. This core patient safety curriculum was designed so it could be adopted by any educational program in all healthcare professions (nursing, pharmacy, behavioral health, medicine, etc.). It was developed by an incredible team of academics, clinicians, patient safety experts and patient advocates to close a critical gap in student training. It is available for download on our website without charge for any student and school interested.

Planning for ZERO also requires full transparency in the event of a harm incident, the topic of a Summit panel titled “Pushing Transparency and Aligned Incentives Through Policymakers.” Many years ago, I was part of a team that helped create a program called CANDOR which stands for Communication & Optimal Resolution, which represents a paradigm shift from “delay, deny and defend” to early communication with patients and families leading to timely resolution and shared systems improvements. Since being implemented at MedStar Health in 2012, CANDOR has reduced serious patient safety events by about 65% and reduced the cost of care associated with serious safety events (including medical liability) by more than $70 million since 2012.

Another essential piece of the planning-for-ZERO puzzle is the creation of a patient data superhighway. By securing Open Data Pledges from as many healthcare technology companies as possible (while respecting patient privacy laws), researchers and engineers can create predictive algorithms and decision support tools so clinicians can identify an issue before it becomes fatal. With the recent signing of Baxter and Mindray, we now have 90 companies agreeing to share data.

I joined the Movement in January and I couldn’t be more grateful for our many partners, individuals and organizations alike, that continue to fight to save patient lives by reducing unintentional but preventable harm, overcoming systemic inertia and proving that a culture of patient and caregiver safety is possible, worthwhile, and a moral obligation. I think it was important to have our co-convening organizations - American Society of Anesthesiologists and the European Society of Anaesthesiology by our side at our Summit. Anesthesiologists were among the first to show what’s possible when people don’t want to put up with the status quo, and thanks to their determined efforts and those of the Anesthesia Patient Safety Foundation, the risk of death from general anesthesia has dropped to almost zero.

I am also grateful for the support and direction of former U.S. President Bill Clinton, who has attended every Summit since our inception. In his closing remarks he reminded everyone “to please stay active in this, please get more people active in it, and don’t give up.”

We are not going to give up. We are not going to move the goalpost. But with 2020 less than a year away, we need every hospital, every health professional and policymaker, every medical device company, every educator, to join us. You can make a difference. You can plan for ZERO. 

Originally published in Issue 2, 2019 of MT Magazine.