A LETTER FROM DR. MICHAEL RAMSAY
Dear Patient Safety Advocates,
I am excited to share some updates about the work we have been doing and introduce you to our new Chief Operating Officer – Dr. Sanaz Massoumi PhD. We are so fortunate to have her on the team. Dr. Massoumi joins us from Keck Medicine where she was Director of Regulatory and Patient Safety, Quality, and Outcomes Management.
A lot has happened since the last time we connected. In June this year, we urged CMS to reject a proposal to suppress public access to patient harm information already being reported on the CMS care compare website. Multiple patient safety organizations joined in this effort and recently CMS shared that they no longer plan to support this suppression of reporting. This is a huge win for patient safety!
However, the Patient Safety Movement Foundation did strongly support the CMS proposal to move forward with the measure to incentivize hospitals to track and improve continuous monitoring of patients receiving opioids during their hospitalization. We believe the implementation of these measures will result in fewer patients experiencing adverse events associated with the administration of opioids, such as respiratory depression, which can lead to brain damage and death. This was another huge win for patient safety. No patient should be found dead in bed in our hospitals, as a result of respiratory depression from prescribed opioids – yet it still happens!
We are currently working to restructure our PSMF commitment model, strengthen our network and optimize operations. We are also dedicating time to create awareness of how prolific medical errors are in every city around the world. A recent survey found that many people are not aware of safety concerns in hospitals. I believe many clinicians don’t even know the exact number of preventable harm and death in their own hospitals due to a lack of transparency.
We need transparency of data, aligned incentives, implementation of Actionable Evidence-Based Practices, and a National Patient Safety Board (NPSB). An update on the progress made on the NPSB is provided below. Please join the World Health Organization and us in highlighting World Patient Safety Day on September 17th. Please also watch for International Overdose Awareness Day on August 31st.
Like other physicians, I took an oath to “first, do no harm.” That means ZERO harm! We need to create a healthcare system that supports that oath. Every hospital should have tested protocols in place like our Actionable Evidence-Based Best Practices to prevent errors from becoming fatal. We can get to zero preventable harm if we support the office of the inspector general’s June letter that recommends that “evidence-based best practices to improve patient safety are instituted.”
Michael Ramsay, MD. FRCA
Sanjeev and Ekta Neupane were doing very well in their careers in Dhapasi, Nepal and the timing just felt right to start their family. When Ekta became pregnant, they were able to afford to go to the esteemed international hospital in their city to get the very best care. Their son Rihan was born premature weighing only 2.85 kilograms. After 30 minutes, he had uncontrolled breathing and was placed on a ventilator. Rihan was placed in the NICU for twenty-one days and they gave him high doses of a variety of medications. He finally went home but ended up back to NICU after developing a fever. After a spinal tap, they found him to have meningitis. Five surgeries later, they told the family his brain was not functioning and there was nothing else they could do. Rihan is at home and in a vegetative state and all his parents can do is monitor his vitals and make sure he is not in pain. The doctors and hospital took no responsibility for what had happened. Sanjeev is committed to improving patient safety in his city and is constantly contacted by mothers wanting to avoid a similar fate for their baby. Full Story & Video
National Patient Safety Board (NPSB) Gains Traction
The National Patient Safety Board (NPSB) we proposed gains bipartisan support from Rep Barragan (D, CA) and Dr. Burgess (R, TX). The House Sponsors have introduced the Bill whilst advancing support in the Senate with Senator Collins (R, ME), Senator Lujan (D, NM), and Senator Whitehouse (D, RI).
The goal of the National Patient Safety Board (NPSB) is to prevent and reduce patient safety events in healthcare settings. As a non-punitive, collaborative, independent agency, the NPSB is modeled after the National Transportation Safety Board (NTSB) and the Commercial Aviation Safety Team (CAST). Its goal is to dramatically improve the understanding of major sources of harm and bring everyone together to create solutions.
The NPSB would also have a public-private partnership team, the Healthcare Safety Team, to gain consensus on patient safety measures, autonomous data collection technologies, and solutions. To identify and anticipate major sources of harm, the NPSB would not require additional data submission by healthcare providers and would not rely on voluntary reports of patient safety events. Rather, through the Healthcare Safety Team, the NPSB would help public and private entities adopt patient safety data surveillance technologies—automated systems with AI algorithms—to capture Big Data and relieve the burden of data collection at the frontline, while also detecting pre-cursors to harm.
Due to the current widespread rate of patient safety events, the NPSB would first focus on understanding the pre-cursors and solutions to major sources of harm instead of conducting studies of all individual incidents. The autonomous, preventive solutions would be designed to avert harm before it occurs.
The NPSB would not regulate and would not serve as an accreditation, licensing, or public reporting body. Its independence from these bodies would also promote the non-punitive, collaborative nature of the NPSB’s functions. The NPSB would also include non-punitive protections for healthcare workers and providers. For example, information from the NPSB’s study reports would not be admissible in civil proceedings. To show your support for this Board, please contact your local representatives.
Michael A.E. Ramsay, MD, FRCA
Chief Executive Officer
Dr. Michael Ramsay is the organization’s Chief Executive Officer, having been previously appointed Chairman of the Patient Safety Movement Foundation, taking Joe Kiani’s place in 2020. In addition, he sits on the PSMF’s Board of Directors and serves as the Chair of the “Failure to Rescue: Post-Operative Respiratory Depression” workgroup. Full Bio
Sanaz Massoumi, PhD
Chief Operating Officer
Dr. Sanaz Massoumi is the Chief Operating Officer of the Patient Safety Movement Foundation. She draws on her unique expertise to work with healthcare leaders, policymakers, innovators, patient safety partners, and patients to advance patient safety around the world. Previously, Dr. Massoumi served as the Director of Patient Safety and Regulatory and Patient Safety Officer at Keck Medicine of USC in Los Angeles, overseeing Keck and Norris hospitals. Full Bio
Consuelo Tolentino serves as PSMF’s Executive Assistant, assisting the organization’s COO, Dr. Sanaz Massoumi, and CEO, Dr. Michael Ramsay. She also performs bookkeeping duties as the finance and marketing coordinator for PSMF’s accounting department. Full Bio
Donor Engagement Manager
in her capacity as Donor Engagement Manager for PSMF, Tamara Kenworthy works to create strategic and effective fundraising plans, identify donor prospects, and develop relationships with the Foundation’s core donor base of individuals, corporations, and institutions. Full Bio
Quality and Patient Safety Strategist
As PSMF’s Quality and Patient Safety Strategist, Armaan Meshkati develops plans to achieve a streamlined commitment model and process map for the Actionable Evidence-Based Practices (AEBP). Armaan collaborates with key stakeholders to ensure that AEBP blueprints are peer reviewed and practical to enhance the outcome of care and improve safety at hospitals. He is also in charge of managing the fellowship program. Full Bio
Nabil Soliman, CMA
Accounting and Finance Manager
Nabil Soliman is a Certified Management Accountant (CMA) who serves as PSMF’s Accounting and Finance Manager, overseeing all accounting operations, including planning and implementation of financial strategy and budgeting. He also handles the Foundation’s financial accounts, payroll, and financial assets. Full Bio
Finance & Data Coordinator
As Finance & Data Coordinator for PSMF, Collin generates reports on all aspects of the organization’s activities, supports the Accounting and Office Manager with a wide range of accounting tasks, plans and designs email communications in close collaboration with internal and external stakeholders, and performs various data management and analysis duties. Full Bio
Mike Durkin, OBE, MBBS, FRCA, FRCP, DSC, Chairman of PSMF, Senior advisor on Patient Safety Policy and Leadership, Institute of Global Health Innovation, Imperial College London
Steven J. Barker, PhD, MD, Chief Science Officer, Masimo Corporation, Professor Emeritus of Anesthesiology, University of Arizona Health Sciences Robin Betts, RN, CPHQ, MBA-HA, Vice Chair, PSMF, Vice President, Safety Quality & Regulatory Services, Kaiser Foundation Hospitals and Health Plan, Kaiser Permanente Northern California
Alicia Cole, Patient Safety Consultant Javier T. Davila, MD, MFS, Ambassador, PSMF in Mexico, Former Medical Director, Mexican Social Security Institute, Head of Medical Education, Research and Health Public Policy
Omar Ishrak, PhD, Executive Chairman and Chairman of the Board of Directors, Medtronic, Chairman of the Board of Directors, Intel Philip D. Lumb, MB, BS, MD, MCCM, FCCP, Professor of Anesthesiology and Trauma Surgery, Keck School of Medicine at University of Southern California
Joe Kiani, Founder and Immediate Past Chairman of PSMF, Founder, Chairman & CEO of Masimo
Sarah Kiani, Director, Masimo Foundation for Ethics, Innovation, and Competition
David B. Mayer, MD, Executive Director, MedStar Institute for Quality and Safety
Jannicke Mellin-Olsen, MD, DPH, Past President, World Federation of Societies of Anesthesiologists
Jim Messina, CEO, The Messina Group
Najmedin Meshkati, Ph.D, MS, Professor of Civil/Environmental Engineering, University of Southern California
Charlie Miceli, CPM, Treasurer, PSMF, Chief Supply Chain Officer, Network VP of University of Vermont Health Network
Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, PSMF
Abbasseh Towfigh, MPD, Executive Director and Secretary, Ayeneh Foundation
Vonda Vaden Bates, Patient Advocate, CEO, 10th Dot
In 2012, Joe Kiani founded the nonprofit Patient Safety Movement Foundation (PSMF) to eliminate preventable medical errors in hospitals. His team worked with patient safety experts from around the world to create Actionable Evidence-Based Practices (AEBP) that address the top challenges. The AEBP is available without charge to hospitals online.
Hospitals are encouraged to make a formal commitment to ZERO preventable deaths, and healthcare technology companies are asked to sign the Open Data Pledge to share their data so that predictive algorithms that can identify errors before they become fatal can be developed. The Foundation’s annual World Patient Safety, Science & Technology Summit brings together all stakeholders, including patients, healthcare providers, medical technology companies, government employers, and private payers. The PSMF was established through the support of the Masimo Foundation for Ethics, Innovation, and Competition in Healthcare. For more information, please visit psmf.org.