Day 1 of the Patient Safety Movement Foundation’s annual Summit, held on the campus of UC Irvine for the first time, drew many attendees from around the world to discuss the most significant issues facing the global patient safety community. The day’s keynotes, presentations, and panels emphasized the critical roles of leadership, transparency, and community in advancing healthcare safety. A poignant personal story highlighted the severe consequences of medical errors and underscored the necessity for legislative action and innovative solutions to address health disparities and enhance maternal care. Discussions centered on fostering a safety culture through collaboration and acknowledging the emotional impact on clinicians. Speakers advocated for moving away from external metrics toward approaches that emphasize patient and provider values, while panels examined the integration of safety culture, the use of real-time data, and system-wide collaboration to improve safety.

Day 2 of the Summit continued to address key issues in healthcare, including the increasing reliance on platforms like TikTok for health information, healthcare worker burnout, and the role of AI in organizing medical data to enhance patient outcomes. Panels highlighted the need for resilience programs for healthcare providers, effective leadership in combating burnout, and the potential of AI and technology to ease doctors’ workload. The importance of patient and family engagement was underscored, and there were calls for standardized safety measures. Experts also discussed the need for systematic improvements in incident investigations by applying global lessons learned. The event concluded with a focus on transparency, technology, and leadership as drivers of sustained progress in patient safety.

We extend our heartfelt thanks to all our speakers and panelists for their invaluable insights and outstanding contributions throughout the two-day summit. PSMF is deeply grateful to all the sponsors who made this event possible.

Please enjoy summit videos and presentations at: Summit 2024

Introducing the Membership

Join the Movement, Transform Healthcare

To expand the vital work of the Patient Safety Movement Foundation, we’ve transitioned to a membership model. We offer free membership to patients, families, caregivers, and healthcare professionals affected by medical errors who share our mission of transforming healthcare safety.

For deeper engagement, we offer two premium tiers: Advocates and Champions. Champions are change agents committed to integrating best safety practices across healthcare. As a Champion, you’ll gain access to an exclusive forum where experts collaborate on solutions to critical adverse events. This platform offers real-time problem-solving, expert-led discussions, and seamless networking with like-minded individuals.

In today’s healthcare landscape, the need for a platform focused on patient safety has never been greater. Our forum offers practical insights, actionable strategies, and fosters a culture of continuous learning.

Explore our membership tiers on our website, and feel free to reach out with any questions. Join us in shaping the future of patient safety here: PSMF Membership.

Embrace the Next Chapter

Physician Assistant Week 

October 6-12, 2024

By Shepard B. Stone, MPS, DMSc, PA, FAHA, DFAAPA, AFAsMA

From Combat to Care: The Evolution of the Physician Assistant Profession

The history of the PA (physician associate or physician assistant) profession in the United States goes back to 1965 (https://pahx.org/timeline/; internationally https://pahx.org/international-pa-timeline/). It grew out of the realizations that there were an inadequate number of primary care physicians AND that there was a pool of skilled, but not civilian credential-able, individuals who provided medical care to military servicemembers in combat and austere environments. The thought was to provide these individuals, whose formal academic credentials might have been limited, with an education patterned after that of physicians with training in the basic, preclinical, and clinical sciences and supervised clinical rotations. They would then work with physician partners (initially supervisors but now collaborators) who would provide support for the newly graduated PA.

Over time, the applicant pool grew to include other clinicians, such as nurses, emergency medical technicians, and operating room technicians. Similarly, the applicant pool’s academic credentials became more standardized, with a bachelor’s degree the current requirement. The graduation credentials have also evolved from only the awarding of certificates. Some programs offered associate’s and bachelor’s degrees. Master’s degrees became the standard, and now doctoral degree programs exist. PA training has increased in duration, from two years to nearly three in some programs. As an aside, it is interesting to note that some medical schools are offering the Doctor of Medicine degree in three years (https://www.acceleratedmdpathways.org).

The concept was a success. From the one initial program, there are now 310. (https://www.arc-pa.org/entry-level-accreditation/accreditation-process/accredited-programs/). The number of graduates (as of 2023) exceeds 145,000 ( https://www.bls.gov/oes/current/oes291071.htm ).

The original goal of augmenting the number of primary care clinicians evolved with PAs migrating from offices to clinics, outpatient centers, hospitals, and educational institutions (all of these being civilian as well as governmental, non-military, and military). These new venues offered the opportunity to provide specialty care. Formal post-graduate training was neither available nor required of PAs before entering these practices. The training was acquired on the job, an apprenticeship as it were. Over time, post-graduate residencies/fellowships have become available, but these are both voluntary and optional (https://www.arc-pa.org/postgraduate-accreditation/currently-accredited-postgraduate-programs/ ).

There are barriers to the best use of PAs: state-level regulations. They are often outdated and no longer applicable. They do not enhance patient safety. The best regulation of PA practice is at the practice level itself. The concept of “Optimal Team Practice” helps all and hurts none.

As the PA profession has matured, so have its practitioners. (There are those who have been in practice since the 1970s). Their knowledge and experience are acknowledged by their patients and colleagues. They often become de facto consultants for those both inside and outside their area of practice. This recognition of expertise helps assure the patient the highest level of care available no matter what credential the clinician possesses. Being able to augment the quantity of care while maintaining its quality and safety has been a raison d’être of the PA profession since its inception.

National Pharmacist Month

October 2024

By Dr. Jerika Lam, PharmD. APh, AAHIVP, FCSHP, Associate Professor, Department of Pharmacy Practice, School of Pharmacy, Chapman University  and Dr. Reza Taheri Professor and Associate Dean, Professional Affairs and Student Success, School of Pharmacy, Chapman University

Safeguarding Health: The Critical Role of Pharmacists in Patient Safety 

In celebration of American Pharmacists Month, we would like to highlight the essential role of pharmacists to ensure patient safety by safeguarding medication safety and promoting access across the continuum of care. This occurs at both individual patient care and health systems levels. At individual patient care level, pharmacists ensure access to medications, provide medication information, evaluate their safety and appropriateness, manage complex treatment regimens, assess health status of patients, and coordinate care transitions. At health systems level, pharmacists lead medication safety and quality improvement programs, enhance patient outcomes, address drug shortages, and implement patient safety and stewardship initiatives, such as antimicrobial, opioid, and pharmacogenomics.

Pending federal and state legislation have the potential to further expand pharmacists’ clinical services as healthcare providers. For example, H.R. 1770 bill, also known as the Equitable Community Access to Pharmacist Services Act, allows patients to access testing and treatment services that pharmacists are licensed to provide such as point-of-care testing, administering vaccines and treatments for COVID-19, influenza, pneumococcal, and respiratory syncytial virus. Specifically, the bill provides for continued coverage of pharmacist services relating to evaluation and management of patients. This would ensure broad and equitable population access to care in preventing communicable diseases. Similarly, the 340B PATIENTS Act (H.R. 7635) is a bipartisan legislation that aims to protect and strengthen the 340B drug pricing program and prohibits drug manufacturers from imposing restrictions or denying sales to 340B contract pharmacies. The program requires drug manufacturers to offer discounted prices on outpatient drugs to eligible healthcare providers (e.g., rural hospitals and community health centers) that serve low-income and vulnerable populations. The program has several significant impacts on patient safety that include ensuring patient access to affordable medications and supporting safety-net providers to continue offering essential services (e.g., mental health care, substance-use disorder treatments, and emergency services). Overall, the 340B PATIENTS Act ensures that vulnerable populations continue to receive the care and medications they need at reduced costs.

At the state level, several legislative bills recently passed that expand pharmacists’ scope of practice in California. Senate Bill 339 (SB 339) aims to make HIV prevention more accessible and affordable to all persons with the goal of reducing the transmission of HIV in the state. The bill allows pharmacists to furnish up to a 90-day supply of HIV pre-exposure prophylaxis and post-exposure prophylaxis under certain conditions and mandates that healthcare service plans and health insurers cover the costs of these HIV preventative medications, including related pharmacist services and testing. Another bill, AB 317, requires commercial health plans to provide payment for any covered service performed by a pharmacist and provided at a network pharmacy.

Pharmacists are among the most accessible healthcare providers. They are ideally suited to serve as access points between the community, hospital, and other health systems to optimize medication treatments and adherence, promote patient self-management and monitoring, and improve patients’ healthcare experiences and results. Overall, the roles of pharmacists as stewards of medication and patient safety continue to advance to benefit patients and our communities.

Healthcare Supply Chain Week

October 6 – 12, 2024

A critical yet often overlooked component of patient safety and quality of care is the healthcare supply chain. A 2023 survey by the American Society of Health-System Pharmacists® revealed that over 99% of hospital and health system pharmacists experienced a drug shortage that year, 95% of the respondents categorizing the shortage as critically or moderately impactful. Moreover, 309 drugs were found to be in shortage at the end of the second quarter of 2023, the highest in nearly a decade. Fractured global supply chains and lack of access to raw materials are among the cited causes of drug shortages.

Ensuring needed medicines, devices, and other medical equipment reach doctors and their patients consistently and in a timely manner requires an extensive and multifaceted global healthcare supply chain. Its sophisticated network of systems, components, and processes must all work together while allowing for contingencies and unforeseen delays.

National Health Care Supply Chain Week was established to celebrate excellence in every link of this vital chain. A program of the Association for Health Care Resource & Materials Management (AHRMM), the week helps draw attention to the important role of healthcare supply chain professionals and recognizes their contributions to patient care as well as to healthcare organizations and communities. To learn how to participate in Health Care Supply Chain Week, visit the AHRMM website.

Breast Cancer Awareness Month

October 2024

This year, more than 360,000 people will be diagnosed with breast cancer. October’s Breast Cancer Awareness month reminds us that early detection methods are increasing survival rates, with a five-year relative survival rate of 99% when caught at the earliest stages. This is especially important for women under 45, who account for approximately 10% of breast cancer cases in the US.

In 2015, the CDC launched the “Bring Your Brave” campaign to draw attention to breast cancer detection and prevention for younger women (18 to 44). It’s especially important for younger women to learn about any family history that can predispose them to a higher risk for breast cancer. Of particular concern, breast cancer that develops in young women is more likely to be found at a later stage, when it is often more aggressive and harder to treat, according to the CDC. Women with a family history of breast or ovarian cancer as well as Ashkenazi Jewish women are advised to speak to their doctors about their risks. At the same time, healthcare providers should be aware of risk factors for early onset breast cancer and communicate with their younger patients how to manage their risk.

To learn more about risk factors and prevention and to read real stories about young women whose lives have been affected by breast cancer, visit the “Bring Your Brave” website.

Key Insights from the Mirror Mirror 2024 Report

A Portrait of the Failing U.S. Health System
Comparing Performance in 10 Nations

The 2024 Commonwealth Fund report, titled “Mirror, Mirror,” is the eighth edition of the series. This report compared health system performance across 10 countries, including the US, using 70 measures in five areas: access to care, care process, administrative efficiency, equity, and health outcomes. Australia, the Netherlands, and the UK emerged as the top performers, while the US ranked last and significantly underperformed.

The US stands out for its exceptionally high healthcare spending, exceeding 16% of GDP in 2022, with projections to surpass 20% by 2035. In contrast, the top-ranking countries spend significantly less on healthcare. Access to care is strongest in the Netherlands, the UK, and Germany, with the US facing challenges related to high out-of-pocket costs and a fragmented insurance system.

In terms of care process, the US ranks second, behind New Zealand, due to strong preventive care and patient safety measures. However, administrative efficiency is highest in Australia and the UK, while the US performs poorly in this area. Equity is best in Australia and Germany, but the US ranks lowest, with substantial income-related disparities in healthcare access and treatment.

Health outcomes, including life expectancy and preventable deaths, are poorest in the US, which also lags in managing COVID-19 compared to Australia, New Zealand, and Switzerland. To improve, the US should focus on expanding coverage, reducing administrative complexity, investing in primary care, controlling costs, and strengthening public health infrastructure, drawing lessons from higher-performing countries.

You can read the complete report published here: Common Wealth Fund

Chair’s Column

Dear Friends and Colleagues in Patient Safety:

What a month! September through October is always a busy season in all our worlds, with back from vacations, back to school, back to university, and for many, the start of the conference season for all our societies and specialties across healthcare—this year being the rule rather than the exception!

I am sure that all those who were able to attend our 11^th World Patient Safety, Science & Technology Summit found the setting and environment at UC Irvine’s Student Center to be a great venue and one that created the feel and culture of a learning system: always the hallmark of a successful educational experience. The complete Summit videos and presentation slides PDFs are now available to anyone on PSMF’s website. .

We had some great keynote and featured speakers and panelists who gave their all in their preparation and presentations, and I am sure we will look forward to further opportunities to hear from them again in the future. One of the important messages to come across during the Summit was the need for the Foundation to become more financially independent, and we believe that the pathway to a membership system will both secure the PSMF as an organization and allow it to grow and further support the needs of patients and families, as well as those of healthcare workers in many different countries.

Indeed, one of the standouts from the Summit was the recognition for Professor Pater Lachman, who has been leading the Fellowship Program, which continues to grow and support the learning and professional development of a fantastic cohort of healthcare professionals from across the world.

I had the great opportunity to visit the White House the following week to attend the White House patient safety forum, alongside Joe Kiani and Mike Ramsay. As a non-US Citizen, it was very impressive to see the way the White House staffers who had worked on the patient safety report of the Presidential Council of Advisors on Science and Technology had managed to craft such an informed agenda alongside patient activists and patient safety experts from across the US. In fact, there were some of our speakers and panelists from the previous week’s Summit in attendance! We all now sincerely hope that action will follow policy, and that executive action will be put in place to ensure the continued efforts of PCAST to change and improve the delivery of safe healthcare across the US, and, subsequently, to be an example to other countries throughout our world.

My month was then completed last week with a visit to attend the 40^th Annual Conference of the International Society for Quality in Health Care, ISQua, which took place in Istanbul. I was privileged to have been asked to give the opening plenary and chose the subject of Patient Safety: A Journey Through Collaboration, Leadership and Partnership. I firmly believe that as we go forward in all our endeavors to improve the safety of our patients, we can only do this with strong and expert leadership, through active collaboration with all the societies and organizations who have the same ends in sight, and that we must continue to strive to do this in partnership with our patients, their families, and our colleagues in all the dimensions of healthcare.

The Patient Safety Movement Foundation was also able to take the opportunity to sponsor a workshop at ISQua to highlight the 2023 Global State of Patient Safety Report, commissioned by our friends at Patient Safety Watch in the UK. They had charged the Institute of Global Health Innovation at Imperial College to bring together a report based on publicly available data as to the state of patient safety across the globe, and in that effort, the report brings together data from patient safety indicators recognized by OECD, the World Bank, WHO, and the Global Burden of Disease database held by the Institute for Health Metrics and Evaluation. This hugely impressive work is now available as a website report with a live dashboard demonstrating performance at country level and insights from systems and settings across the globe. Definitely one to watch!

And we still have October to look forward to . . .

In the News

• The White House announced new patient safety programs on World Patient Safety Day, including the formation of the National Action Alliance for Patient and Workforce Safety, headed by AHRQ, and new measures for the CDC and CMS, according to Fierce Healthcare.
• New Delhi Television in India joined WHO and many other global media outlets in recognizing and highlighting the importance of World Patient Safety Day.
• NBC News reports that the rate of maternal mortality cases in Texas rose by 56%, compared with just 11% nationwide, during the 2019–2022 time period, coinciding with the state’s implementation of bans on abortion care.
• A new documentary film, The Pitch: Patient Safety’s Next Generation, examines the challenges faced by tech startups and entrepreneurs in getting their life-saving technologies accepted by the healthcare industry, as reported by Time Magazine.
• Medical experts say Georgia abortion laws that prevented doctors from performing an emergency yet routine dilation and curettage procedure likely led to a mother’s preventable death, according to an article in ProPublica.
• A recent study reveals the average wait in the US to see a GP in 2023 was around 21 days, two to ten times longer than in Europe, while wait times for non-emergency surgery were generally much shorter in the US (28 days) than in Europe, according to Statista.

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 

The PSMF’s efforts over 11 years have made advances that were evident at the latest annual Summit, for example, when the CMS speaker directly credited PSMF with the new calls for implementation of our APSS to eliminate preventable death and harm in healthcare. Unfortunately, in spite of all the amazing leadership of Joe Kiani and others, the goal of zero preventable death is far from achieved. The long-discussed analogy of losing two planeloads of people every day to preventable death in healthcare is still true. Medications, my area of expertise, are still widely misprescribed, erroneously administered and used, creating harm and preventable deaths for many reasons. While our progress in the White House and federal agencies and in many other countries around the world is heartening, we still have an enormous amount of work to do.

I donate to PSMF to help support the continued advancement of our important mission. New passionate leaders are needed, and the work to save lives from preventable harm can never be given up. I was very proud to be a small part of the PSMF volunteer force through my involvement of many fabulous Chapman University School of Pharmacy faculty who participated in my work groups and years of annual Summits. Leading in patient safety is also part of the mission of CUSP. It was rewarding to see that the approach of using the patient voice to motivate change is still driving PSMF at this year’s Summit. It was also rewarding to see so many of the attendees and leaders I have met over the decade still working hard on the challenge. I also noted that so many of us involved from the earliest days of PSMF are now patients ourselves, who now see firsthand the excellent efforts of so many healthcare providers, while at the same time we watch for where APSS are in place and working in our care. We strive and pray for 100% safety focus and success in care delivery and will never stop working toward 0x2030.

Ronald P. Jordan, FAPhA

Founding Dean Emeritus, School of Pharmacy,

Chapman University