Newsletter, April 2024

Letter from the CEO

We were very hopeful that US President Joe Biden would announce the implementation of all or some of the recommendations that the President’s Council of Advisors on Science and Technology (PCAST) had made on patient safety. The State of the Union Speech on March 7 did not mention them, but understandably, the president had plenty of other political issues to address. However, there do appear to be studies on the horizon that examine changes to improve safety in healthcare.

The National Quality Forum (NQF) announced this month a “Focus on HARM” patient safety initiative to address the high rates of avoidable medical errors and preventable patient harms that continue despite decades of efforts to remediate these events. The NQF refers to the OIG report that found that 25% of Medicare patients were harmed during hospital admission and 43% of these events were considered preventable. The Focus on HARM (Harmonizing Accountability in Reporting and Monitoring) will begin by reexamining the most egregious events or “never events.”

NQF Board Member Dora Hughes MD, MPH, Acting Chief Medical Officer and Acting Director of the Center for Clinical Standards and Quality for CMS, stated, “Reducing preventable harm to patients starts with having accurate data so that common, recurring systemic problems contributing to harm events can be quickly identified and addressed.” The NQF will establish a consensus-based unified framework to track and report patient safety events.

This month, CMS also issued a proposed rule updating Medicare payments and policies for inpatient hospitals and long-term care hospitals. The new policies are to support underserved communities, ease drug shortages, and promote patient safety. The increase in operating payment rates for certain acute care hospitals in FY2025 is projected to be 2.6%. The Secretary of the Department of Health and Human Services, Xavier Becerra, stated, “Hospitals should be a place you go into and get the care you need, regardless of whether you’re struggling to afford your rent, the color of your skin, or what else is going on in the world around you.”

Maybe with analytics to assist with transparency of data, AI to help deliver accurate outcomes and safety data, the implementation of evidence-based practices, partnerships with patients to prevent care disparities and adverse outcomes, and a bipartisan proposal to create a National Patient Safety Team, the PCAST recommendations will be implemented. Will the CMS increase in funding be enough to cover the costs of implementing these measures, creating a culture of safety, the analytics to gain accurate outcomes data, and the realignment of staff to quality and safety? Fewer complications, better outcomes, reduced length of stay, reduced disparity of care, and improved staff morale may all contribute to lower costs.

Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, PSMF

Our Founder, Joe Kiani, and our Chairman, Dr. Mike Durkin, were speakers at the 6th Global Ministerial Summit convened on April 16-17 in Santiago de Chile.

Kiani’s compelling address titled “Empowering Patient Safety Through AI” illuminated how predictive algorithms assist clinicians in identifying patient safety issues proactively, preventing potential crises.

National Stress Awareness Month

April 2024

The Patient Safety Movement Foundation recently interviewed Dr. Steven Siegel to discuss strategies for reducing stress among healthcare teams and other employees within health systems. Dr. Siegel is the Chair of the Department of Psychiatry and the Behavioral Sciences at Keck School of Medicine of USC, and Chief Mental Health and Wellness Officer at Keck Medicine of USC.

Autism Awareness Month

April 2024

According to the CDC, about 1 in 36 children has been identified with autism spectrum disorder (ASD). Globally, around 1% of the world’s population has autism spectrum disorder (more than 75,000,000 people). ASD is found in all racial, ethnic, and socioeconomic groups, though it is nearly four times more common among boys than girls.

In 2007, a United Nations General Assembly resolution officially recognized April 2 as World Autism Awareness Day, encouraging member states to raise awareness about autistic individuals throughout the world. The UN action had been preceded by the establishment of National Autism Acceptance Month in April 1988 by a proclamation from US President Ronald Reagan. Autism Acceptance Month reminds everyone to use their voice and platforms to spread messages of acceptance and inclusion, while helping connect people to the support services they may need.

One useful tool is the CDC’s Milestone Tracker app. It aids in the early identification of developmental delays and disabilities, including autism, in children from 2 months to 5 years. Encouraging families to use the app, which gives information in English or Spanish, can make a real difference in supporting children with autism, as the app lets caregivers know what next steps to take and when. The CDC also has an Autism and Developmental Disabilities Monitoring (ADDM) Network that collaboratively tracks the number and characteristics of children with autism, all the way up to age 16, in multiple communities across the US. Partners using information from the ADDM Network can help advance initiatives, policies, and research in their local communities that help children and families with autism.

National Minority Health

April 2024

People from racial and ethnic minority groups tend to experience a disproportionate burden of preventable disease, death, and disability compared with non-Hispanic White people. Unless healthcare systems, leaders, and government agencies actively work to address these disparities, the gap may only worsen in the years to come, as the US population becomes increasingly diverse as currently projected.

National Minority Health Month was established in 2002 by resolution of the US Congress “to promote educational efforts on the health problems currently facing minorities and other populations experiencing health disparities.” The US Department of Health and Human Serviceshas been leading the way in this endeavor. Their theme this year encourages everyone to “Be the Source for Better Health” by “Improving Health Outcomes Through Our Cultures, Communities, and Connections.” The theme highlights how the social determinants of health (environment, culture, history, and circumstances) impact the overall health of racial and ethnic minorities, including American Indian/Alaska Native populations.

It is important to know how to provide care and services that are responsive to diverse cultural beliefs and practices around health, patients’ preferred languages, socioeconomic circumstances, and environmental factors. When patients and communities receive quality care that is culturally and linguistically accessible, they are better positioned for healthier outcomes.

World Health Day

April 7, 2024

Insights into Excellence: Navigating Quality Healthcare

By Jannicke Mellin-Olsen, MD, DPH

“My health, my right,” the slogan for 2024’s World Health Day, is but a dream for the 24% of the world’s population that live in fragile contexts without access to quality essential health services. Fifteen per cent of all deaths in low- and middle-income countries are due to poor quality care. But even in high-income countries, 10% of patients are harmed when receiving hospital care. Behind these figures are individuals—a beloved child, mother or father, a husband or wife, a friend—who are irreplaceable. There is no quick fix to these problems, but apathy is not a choice.

The only solution then is to approach the problem bit by bit. All stakeholders must work together. We must listen to the patients’ and their relatives’ voices. Healthcare workers must be empowered to do the right thing every time. They can do that only if they are supported by organizational and technical factors in a culture of trust and no-blame. Hospital owners, politicians, and society structures must change so that patient outcomes and well-being in a safe environment are the most important outcome factors.

Chair’s Column

Dear Friends and Colleagues in Patient Safety,

I am just surfacing from the three-day immersive that was this year’s Ministerial Summit on Patient Safety that was held in the great city of Santiago, Chile, on April 17–18.

This was the sixth Summit in the series, which started in London under the sponsorship of the Rt Hon Jeremy Hunt for the UK government, and the most recent having taken place in Montreux, sponsored by the Swiss government in 2023. At this meeting in Chile, the baton was passed to the government of the Philippines, which accepted the challenge of hosting the Ministerial Summit for 2025.

I had the pleasure of meeting the Minister from the Philippines, Dr. Teodoro Javier Herbosa, MD, who is also a physician, and he was full of enthusiasm for the opportunity that this will offer their health systems. Their country has a long and distinguished history of supporting the rest of the world with well-trained doctors and nurses, and I am sure this will be another very successful Summit.

As you will note from the website, the Summit was held over two very full days of keynotes and workshops, filled to the brim with information on how countries have risen to the challenges of implementing strategies to reduce avoidable harm. The Summit was attended by over 40 nations and delegations, and had in-person registrations of over 400 experts, patients, family member organizations, activists, and specialty organizations, as well as healthcare staff of every dimension, along with many more online registrants.

The meeting was opened by the Minister of Health for Chile, Dr. Ximena Aguilera Sanhueza, a surgeon and epidemiologist, whom I was able to meet alongside her ministerial colleague, Dr. Osvaldo Salgado Zepeta, an otolaryngologist, who holds an interesting brief to develop healthcare networks for Chile.

There were many excellent presentations, but for me, the three standouts were delivered by Sir Liam Donaldson, Dr. Neelam Dhingra, and our own founder, Joe Kiani. Joe delivered one of the highlights of the Summit, a discussion on the use of AI and predictive analytics in the management and recognition of deterioration, which, as we all recognize, is one of the most common causes of avoidable harm to our patients (link).

In representing the Patient Safety Movement Foundation, I was asked to join a workshop to present our strategy and achievements in reducing harm, and we were privileged to do this alongside, among others, the International Society for Quality in Healthcare, represented by Professor Ezequiel Garcia Elorrio, and the Joint Commission International, represented by Dr. Abdulelah Alhawsawi.

We were brought together to also outline how our individual contributions would go to support the development and implementation of the GPSAP, the Global Patient Safety Action Plan.

Another significant moment at the Summit was the launch of the Patient Safety Rights Charter, which had been through many iterations since WHO had started bringing us together online and in person over the last couple of years. It is now finally in print and available for use, and our aspiration must be that it will enable patients to be fully engaged in all decisions made on their behalfs by our healthcare professionals. I hope it will help us go further in stripping away the hierarchy that sometimes prevents our patients from being seen as the most important people in their relationships with healthcare providers, be they nurses, doctors, physicians, clinical scientists, or administrators.

We often use the word “empower” when we discuss our objective to support the patient and their family in our quest to reduce avoidable harm; I hope we can now start to go further and faster in this model and remove the “em” and replace it with “power,” such that we give power to our patients, as an active source of energy in their health and care experience.

Yours,

Mike Durkin, OBE, MBBS, FRCA, FRCP, DSC

In the News

• A video commentary posted on Medscape discussed the impact of stigmatizing language (e.g., “difficult patient”), highlighting that the presence of such language was associated with roughly a doubling of the risk for diagnostic errors.
• An interview with Dr. Brian Anderson, CEO of Coalition of Health AI (CHAI), on MobiHealthNews considered the challenges of developing ethical standards for AI technology’s use and the importance of keeping patient safety at the center of discussions.
• Members of Congress in a letter to the Veterans Affairs Secretary expressed concern over allegations of “gross medical incompetence” and retaliation against employees who reported patient safety issues at Hampton VA Medical Center, as reported by 13 News Now in Norfolk, Virginia.
• A new study found that large language models used for medical assessments cannot adequately back up claims, failing to produce references needed for doctors and patients to verify a GenAI assessment and guard against the highly prevalent rate of “hallucinations,” as reported by Stanford University.

We Want to Hear Your Story

If you or your loved ones have experienced a medical error, please share your story with us. We have over 100 patient stories on our website: https://psmf.org/patient-stories/

Donor Testimonial 

Medical errors continue to present a significant global health challenge. Through my own experiences, I’ve witnessed the profound impact that initiatives focused on improving patient safety can have on individuals’ lives. I support the Patient Safety Movement Foundation (PSMF) because I firmly believe in its mission to enhance patient safety globally. Through my involvement with the PSMF as a healthcare professional and as a Fellow, I’ve collaborated with committed peers to promote both global and local practices and policies aimed at eradicating avoidable harm in healthcare. I firmly believe that every contribution toward fostering a culture of safety is crucial in building high-reliability health systems and organizations to ensure timely, equitable, and safe care for all.

Luis Torres Torija Arguelles M.D., MBA
Master of Public Health Candidate
Co-President I Public Health Leadership Student Association
Gillings School of Global Public Health
University of North Carolina at Chapel Hill