The Summit Session One Experience

Annually, the first quarter of the year marks the Patient Safety Movement Foundation’s highly anticipated World Patient Safety, Science & Technology Summit. Per usual, this year’s sessions were filled with empowering, crucial conversations with healthcare professionals and patient safety advocates committed to making a positive change in the medical field.  

This year’s summit united world leaders and experts in bringing together result-driven ideas and solutions to achieve the audacious goal of eliminating preventable patient harm. In addition, the summit also marked the Patient Safety Movement Foundation’s first 10 years of achievements and success.

As a student intern of the Patient Safety Movement Foundation, I had the honor of attending Session 1, a talk centered on “Overcoming Obstacles for Applying High Reliability Principles in Healthcare.” Moderated by Dr. Dave Mayer and led by Dr. Abdulelah Alhawsawi, Dr. Michael Privitera, and Mr. Keith Conradi, Session 1 explored various topics, such as patient safety’s application to different industries and thoughts on public health systems.

The panel began with introductions, beginning with Dr. Mayer, the former Chief Executive Officer of PSMF and executive director of the MedStar Institute for Quality & Safety. Also introduced were: Dr. Abdulelah Alhawsawi, a transplant and hepatobiliary surgeon and former Founding Director General of the Saudi Patient Safety Center; Dr. Michael Privitera, a consultation liaison psychiatrist; and Mr. Keith Conradi, the chief investigator of the English Healthcare Safety Investigation Branch. 

To kick start the session, Dr. Mayer shared a quote by Dr. James Reason: “to err is human”, also the title of the Institute of Medicine report. “James Reason says we can’t change the human condition, but we can change the condition under which humans work,” says Dr. Mayer, “HRO and resilient science has been studying this for over 30 years and have shown great success in other industries.” 

Branching out from the topic of other industries, a question was raised: over 30 years of research, what was it that could be learned from other industries that had successfully taken action and changed cultures to one dedicating safety as their top priority?

Mr. Keith Conradi, with his extensive aviation background, provided an interesting thought: “It’s not necessarily you, but it is the environment around you that actually contributes to where something may go wrong,” he said. 

Simply said, little errors aren’t a rarity; however, the system in place is what prevents them from becoming critical and causing harm. “Something that we often describe as a safety management system is pretty much mandatory in airlines across the world,” commented Mr. Conradi, “That means that it’s not only systematic, but it’s proactive.”

Mr. Conradi emphasized that healthcare would benefit from not simply reacting to circumstances, but rather taking a systematic approach. “One of the big things that we often are starting to recommend when we do investigations is that people implement a proper safety management system,” he said, in regards to his line of work. 

As a clinician, Dr. Michael Privitera found great interest in analyzing where most errors came from and discovered that “the most common causes of errors are system based, and that the most common reasons for clinician burnout are system based.” To Dr. Privitera, this posed the great question: what can we do about the system?

When it comes to medical error, unfortunately, some are human induced. Human casualties may happen because no person is completely perfect, but it is crucial that we take steps to prevent errors from happening at all. “How can we keep track of how long a person is working after the last patient is seen? So they’re better rested the next day?” questions Dr. Privitera. 

To Dr. Abdulelah Alhawsawi, focusing more on systems than individuals in the system may be a viable solution. In healthcare, there’s a larger focus on individuals in the system. “That’s another area that we could learn from [other] industries,” he says. 

Human errors could lead to “pointing fingers”- but in general, patient safety is not a simple black-and-white situation. On this topic, Dr. Privitera raised the point of “just the whole idea of not placing blame, but just to that effect, that it can happen.” 

Continuing on with the discussion of the individual, Dr. Privitera agreed on how there was much emphasis on the individual and the widely circulated idea that it’s simply on the individual’s error and ultimately their fault to bear. “But what about all the how upstream decisions may have affected resources?” asks Dr. Privitera, raising a thought-provoking question.

Ultimately, patient safety also comes in hand with “diffusing the issue of blame,” and as Dr. Privitera best put it, “realize this is human nature.” “We’re all in the human club. So this can happen,” he remarked. 

When it comes to the aviation industry, the system is better structured than healthcare; from training interviewers going to areas of mishap or danger immediately, whereas healthcare has a three to four week delay of schedule, the aviation industry has further acted upon their patient safety concerns. 

When asked about his experience in the aviation industry in regards to the system, Mr. Conradi shared that the aviation industry was able to harness much emphasis on simulation and simulated training. “We were able to embed that sort of culture every six months as pilots went through that particular emergency training and all the different scenarios,” he says. 

Another point noticed was the fact that in aviation, most states only have one regulator. Compared to the Federal Aviation Administration (FAA) of the United States, Britain has a Civil Aviation Authority. 

When coming into the field of healthcare, Mr. Conradi shared that he was surprised to see such a vast number of regulators. While the autonomy of various groups working as extended networks was an interesting concept, Mr. Conradi shared that it may potentially lay open space of mistakes to lead to harm.

Not only should systems be continually sought to be improved upon, accountability should be more seriously taken. “If we blame the system and process every time when there was preventable harm, that would almost be anarchy,” commented Dr. Mayer. With accountability, patient safety could be reduced in the future through actionable ideas. “We also as leaders have to be responsible and accountable to act on that and to ensure the safety of our patient population,” said Dr. Mayer.

Throughout this session, I was able to listen to different perspectives all over the world on their specific line of work and culture’s effect when it came to the healthcare system. It was truly enlightening to hear genuine questions raised in regards to the issue of patient safety and to hear potential ideas for the future as well. 

With our continued advocacy and passion for patient safety, we have the power to influence the healthcare system for the better. As affirmed by this session, to move forward, we must take responsibility to support positive outcomes for patients and individuals.

A huge thank you to the panelists, Dr. Dave Mayer, Dr. Abdulelah Alhawsawi, Dr. Michael Privitera, and Mr. Keith Conradi! On behalf of the Patient Safety Movement Foundation, I sincerely appreciate your words and support.