Patient Safety Movement // Getting to Zero Preventable Deaths
This past weekend I had the honor of attending the 7th Annual Patient Safety, Science & Technology Summit in Huntington Beach, CA. This annual conference is hosted by the Patient Safety Movement Foundation (PSMF) and brings together the world’s best healthcare professionals, medical technology companies, and patients to engage in thought-provoking discussions to advocate and plan for zero preventable deaths by 2020.
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Why is this so Important?
As a board-certified critical care pharmacist, patient safety is top-of-mind daily in the hospital. Preventable medical errors lead to more than 200,000 deaths in U.S. hospitals each year; the 3rd leading cause of death behind heart disease and cancer. The economic harm beyond the harm to patients exceeds $1 trillion in excess healthcare costs.
Founder & Chairman of the Patient Safety Movement, Joe Kiani stated, “To err is human but to not put the proper patient safety processes in place is inhumane.”
With the help of experts, over 18 Actionable Patient Safety Solutions (APSS) have been created and are readily available to every hospital. It’s take to TAKE ACTION. These solutions address the most common and significant medical harms occurring every day in our hospitals. The 18 APSS are:
- Culture of Safety
- Healthcare-associated Infections (HAI)
- Medication Safety
- Monitoring for Opioid-Induced Respiratory Depression
- Patient Blood Management
- Hand-Off Communication
- Neonatal Safety
- Airway Safety
- Early Detection and Treatment of Sepsis
- Systematic Prevention and Resuscitation of In-Hospital Cardiac Arrest
- Optimizing Obstetric Safety
- Embolic Events
- Mental Health
- Falls and Fall Prevention
- Nasogastric Tube (NGT) Placement and Verification
- Person and Family Engagement
- Patient Safety Curriculum
- Post-operative Delirium in Older Adults
View all the APSS here and get involved today!
Key Takeaways from the Summit
- More than 90,000 lives were saved in 2018
- More than 4,710 hospitals committing to this movement
- 89 healthcare technology companies have signed the open data pledge
- Despite the APSS readily available to every hospital, only 4 hospitals have implemented all of them.
- 2 new APSS were introduced: #17 Patient Safety Curriculum and #18 Post-operative Delirium in Older Adults
- The outpatient world is our future – as I’ve said to many healthcare professionals and leadership teams, expand our Ambulatory Care Service lines. We would prefer to see our patients and be proactive (aka prevent) illness rather than reactive to it and treat it in the hospital-setting.
Summit Sessions:
Transparency from the Legal Perspective
Insightful panel discussion on how we can move towards a culture of transparency within our healthcare organizations. MedStar is an excellent example of how they have implemented the CANDOR (Communication & Optimal Resolution) toolkit for transparency during a medical error. More on CANDOR.
Key Takeaway: Make safety WHY we do things. Next time you ask an employee in the hospital why she/he is working, the answer can and should be “To keep patients safe”
Patient Safety Curriculum for Schools
Dean Steven J. Scheinman of Geisinger Commonwealth School of Medicine introduces the new Actionable Patient Safety Solution (APSS) #17 to encourage all programs (pharmacy, medicine, nursing, PT, OT, etc) to implement this curriculum to ensure our next generation of healthcare professionals are well educated on patient safety. Next steps include reaching out to professional organizations and licensing boards to incorporate the curriculum into all healthcare programs.
Healthcare Technology Leadership Panel
Wonderful initiatives underway to help with patient safety. One that particularly stood out was Kaiser Northern California’s Advance Alert Monitor (AAM) where an early warming system is set-up to predict a patient’s likelihood of impending deterioration (aims to give a 12-hour lead time). This system provides 24/7 nursing coverage and when a patient triggers a warning, the nurse can activate the Rapid Response Team in the hospital for the patient. More information found here.
Pushing Transparency and Aligned Incentives through Policymakers
It’s time to humanize the statistic with transparency and aligned incentives. Scott Morrish, the patient advocate, shared a compiling story from the UK and how he helped change healthcare policy in the UK (as a member of the Expert Advisory Group that shaped the UK’s Healthcare Safety Investigation Branch). Scott campaigns for a “Just and Restorative Culture” to deliver psychological safety – for patients and staff – to break the cycle of avoidable harm.
Key Takeaway: It’s not teaching people to do the right thing, it’s allowing them to. As Scott states, it’s not only the patients who suffer, it’s the staff and healthcare professionals who suffer. This is seen with burnout, guilt, suicides and loss of trust in the system. Learn more about healthcare burnout here.
Leading Causes of Preventable In-Hospital Deaths Panel
This panel emphasized common themes to preventable harm – transparency, honesty, communication, trust, learning and systems. With patient advocate, Carole Hemmelgarn, there was an excellent discussion on involving patients early in the process and allowing them to help with the re-design of the system. Starting each meeting with a patient story and changing the culture of an organization from the top-down can have significant results in the healthcare system, as evidenced by Helen Macfie, pharmacist and leader at MemorialCare.
Delirium
Highlighting post-operative delirium in older adults and the new APSS #18 initiative, this panel discussed ways to decrease the delirium rate in our hospitals. This aligns well with the Society of Critical Care Medicine (SCCM) initiatives and is an excellent resource for families, patients and staff through their THRIVE program about post-ICU syndrome. Learn more about THRIVE here.
President Clinton
It was wonderful and empowering to listen to President Bill Clinton speak and support the Patient Safety Movement for the 7th year in a row. His encouraging words to stay active in the movement, avoid the dangers of apathy and continue on our quest to ZERO preventable deaths were inspiring. Listen to his speech and discussion with Founder Joe Kiani on the Patient Safety movement YouTube channel.
What can you do?
- See if your hospital / organization has committed to the Patient Safety Movement and commit today
- Help your organization implement the Actionable Patient Safety Solutions (APSS)
- Advocate for ZERO preventable deaths by 2020 to your network via friends, family, colleagues and social media
- Help change the culture within your organization. Need a place to start? I personally recommend Simon Sinek’s Start with Why and Leaders Eat Last books – purchase here.
- Use the Ok to Proceed initiatives
- Visit OkToProceed.com for a 52-week curriculum for healthcare students, residents or professionals and purchase your own textbook copy
- Download the Apps
- PatientAider – for patients and families
- Patient Safety Solutions with APSS – for professionals
You May Also Enjoy:
- Reset Healthcare Burnout Webinar – register today!
- Goal Setting for Busy Professionals – free workbook!
- Day in the Life of a Critical Care Pharmacist – read here
- Top 5 Books for Leadership & Professional Development – read here
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Jessica Louie, PharmD, APh, BCCCP is the CEO of Clarify, Simplify, Align and Host of The Burnout Doctor Podcast. Dr. Louie uses her signature Burnout Doctor Method to coach burned out pharmacists & professionals to simplify because work-life balance is a LIE. Align work into your life & break free from people pleasing, perfectionism and thrive in life on YOUR TERMS.