committed to zero preventable deaths by...

c o m m i t t e d t o z e r o p r e v e n t a b l e d e a t h s b y 2 0 2 0

PATIENT SAFETY MOVEMENTBOARD OF DIRECTORS

BOARD OF DIRECTORSDiverse in professional background but united by a shared mission, our Board of Directors is comprised of leaders in health technology, public policy, healthcare delivery, information technology, safety innovation, and patient advocacy.

Joe KianiFounder, Chairman, and CEO of Masimo Corporation

Robin Betts, MBA-HM, RN

Assistant Vice President Quality & Patient Safety for Intermountain Healthcare

Jim BialickImmediate Past President, Patient Safety Movement Foundation & Patient Safety Movement Coalition

David Mayer, MD

Vice President, Quality and Safety for MedStar Health

Jim MessinaCEO of The Messina Group

Charlie MiceliVice President, Chief Supply Chain Officer, The University of Vermont Health Network

Steven MoreauPresident and CEO of St. Joseph Hospital

Michael A.E. Ramsay, MD, FRCA

Chairman, Department of Anesthesiology, Baylor University Medical Center; President, Baylor Research Institute

PATIENT SAFETY MOVEMENTSTEERING COMMITTEE

Patient Safety Movement Foundation | www.PatientSafetyMovement.org | @0X2020

STEERING COMMITTEEThis committee advises the Patient Safety Movement and makes recommendations to the Board of Directors on how to best fulfill our mission of ZERO preventable deaths by 2020.

Thomas KallstromWilliam PeruzziLaura Batz TownsendMike RamsayAline ChibanaSharon SutherlandDrew FullerKapil ParakhLinda DingesNat SimsCharles MurphyElaine ShamirRobin BettsJackie GonzalezLenore AlexanderEd McCabeDan BrothmanEvan LambMichael BeckerPaul JansenRoger WuSteve BarkerValerie BegnocheJohn BaucheAugusto SolaStacey Orsat (Taggart)Helen HaskellAnnamarie SaarinenSarah KirbyEd SalazarMimi ToomeyTodd HeidenClaire McCormackThomas BostromBrent NibargerAriana LongleyIrene PaigahJim Bialick

Matt Dolan

AARCAlameda Health SystemBatz FoundationBaylor Scott & White HealthBrazilian Patient Safety FoundationCleveland ClinicEmergency Medicine AssociatesGoogleHannibal Regional HospitalHarvardInova Heart and Vascular InstituteIntegrity Partners & AssociatesIntermountain HealthcareJ29 AssociatesLeah’s LegacyMarch of DimesMasimoMasimoMasimoMasimoMasimoMasimoMasimoMasimoMasimoMasimo InternationalMothers Against Medical ErrorNewborn FoundationPalmetto Health Baptist ParkridgePatient AdvocatePatient AdvocatePatient AdvocatePatient AdvocatePatient AdvocatePatient AdvocatePatient Safety Movement FoundationPatient Safety Movement FoundationPatient Safety Movement Foundation Board Member Philips

Dave OlsenKen RothfieldDaniel ArnalErin StieberNancy MyersBarbara QuinnPat MerryweatherPeter CoxKai ZacharowskiHiloni BhavsarMichael AndersonSriram BharadwajPatricia RothPaul PhrampusAnna NoonanCharlie MiceliRachael RaynesLori NotowitzJesse DylanThomas Zeltner

Providence Health & ServicesSaint Vincent’s HealthCareSENSARSmile TrainSumma HealthSutter Medical Center, SacramentoTelligen QIN QIOThe Hospital for Sick ChildrenUniversity Hospital FrankfurtUniversity Hospitals Case Medical Center University Hospitals Case Medical CenterUniversity of California Irvine (UCI) HealthUniversity of California San Francisco (UCSF) University of Pittsburgh Medical Center (UPMC)University of Vermont Medical CenterUniversity of Vermont Medical CenterUniversity of Vermont Medical CenterUniversity of Vermont Medical CenterWondrosWorld Health Organization (WHO)

PATIENT SAFETY MOVEMENTHEALTHCARE PROFESSIONALS

HEALTHCARE PROFESSIONALSBe the Change

Healthcare professionals are the frontline of patient safety. Their experience, insight into challenges, and commitment are absolutely essential to achieving the goal of ZERO preventable deaths by 2020.

With the input of leading clinicians, technologists, and patient-safety specialists, the Movement has identified solutions to the leading patient safety challenges that exist in our hospitals. These Actionable Patient Safety Solutions (APSS) are freely available and can be rapidly implemented today.

We call on healthcare organizations to implement our APSS or share with us their own best practices so that we may highlight their leadership and so that their experience may empower other institutions to make a commitment to 0X2020.

Make a commitment today at PatientSafetyMovement.org/commitments

HEALTHCARE ORGANIZATION STATE HOSPITALS COMMITMENT NAME

Advanced Resuscitation Training CA 6 The Advanced Resuscitation Training (ART) program has been featured at the Patient Safety Movement conference in the past and is the foundation for APSS 11.

Alameda Health System CA 7 Reduce the Rate of Hospital-Acquired Pressure UlcersCHOC Children’s Hospital CA 1 Improving Hand Hygiene rate in the NIC; Preventing Patient DeteriorationEisenhower Medical Center CA 1 Reduce Healthcare-Associated InfectionsHoag Memorial Hospital Presbyterian CA 2 Avoidable Harm

Hospital Quality Institute (HQI) CA 400 Eliminate preventable harm to hospitalized patients; Reduce death from sepsis; Eliminate preventable mortality and morbidity in maternity care

Loma Linda University Children’s Hospital CA 1 Right Sizing Technology for Pediatric PatientsOrange Coast Memorial Medical Center CA 1 Targeting Zero: Reducing Central Line Associated Blood Stream Infections in the Critical Care UnitSan Francisco VA Medical Center CA 81 VA_AnesQIPSharp HealthCare CA 7 Culture of Safety; Eliminate wrong patient, side and site surgery and proceduresSt Joseph Hospital CA 1 Dramatically reduce the incident of hospital acquired conditionsUCSF Medical Center and UCSF Benioff Children’s Hospital CA 2 UCSF is committed to systematically improving early identification of patients with sepsis or at risk for sepsis in order to

provide more rapid and appropriate treatment to reduce morbidity and mortalityWestern Medical Center Santa Ana CA 1 Maternal Antenatal Steroids: Getting to a Reliable 100% ComplianceMedstar Health DC, MD 12 Hospital Acquired Infections

Mayo Clinic Florida FL 1The Blue Angel Standard; Minimize transfusion by eliminating pre-operative anemia in patients presentig to the OR for elective joint replacement; Sepsis and Shock Response Team (SSRT): A Multidisciplinary Approach to Bundle Adherence and Patient Safety

Sinai Health System IL 8 Culture of SafetyTelligen Medicare QIO IL 134 Reduce Avoidable Death and Harm

Brigham and Women’s Hospital MA 1 Improve the overall quality and safety of the preparation and testing of compouded sterile products in the pharmacy department

Massachusetts General Hospital MA 1 Fully Integrated Clinical Systems to Minimize Medication Errors – “Closing the Loop” with Intravenous Drug PumpsEmergency Medicine Associates & Emergency Medicine Patient Safety Foundation MD 1 Safer Sign Out – A high-reliability tool for physician handoffs in the emergency department

Hannibal Regional Hospital MO 1 Safe Practice in Maternal Neonatal Patient Centered Health CareEnglewood Hospital and Medical Center NJ 1 Early identification and treatment of sepsis to reduce mortality

Join the more than 1,600 healthcare organizations have already made a commitment to achieving 0X2020.

PATIENT SAFETY MOVEMENTHEALTHCARE PROFESSIONALS


HEALTHCARE ORGANIZATION STATE HOSPITALS COMMITMENT NAME

Greystone Park Psychiatric Hospital NJ 1 Zero harm to patient by 2020Society for the Advancement of Blood Management NJ 1 Reducing donor blood transfusion, which can lead to unnecessary patient harmMercy Hospital of Buffalo NY 1 Mercy Hospital targets 100% monitored beds; Reducing failure to rescue in the post-surgical and medical populationOrange Regional Medical Center NY 2 Patient Blood Management ProgramChildren’s Hospitals’ Solutions for Patient Safety OH 89 Eliminating Serious Harm in Children’s HospitalsCleveland Clinic OH 6 A Value-Based Approach to Induction of Labor

Summa Health System – NewHealth Collaborative OH 1 Integrating high reliability behaviors into patient centered medical homes to reduce preventable errors in the primary care delivery system

University Hospitals Case Medical Center OH 1 Journey to Highly Reliable Sepsis Care

Memorial Hospital of Texas County OK 1 Failure to Rescue: Post operative Respiratory Depression; Medication Errors; Red Blood Cell Transfusion; Hand-off Communication

University of Pittsburgh Medical Center PA 20

Getting to Zero – Eliminating Surgical Site Infections; Eliminating CLABSI; Reducing Failed Transitions; Patient Blood Management Program; Preventing neonate/infant mortality by the reduction or elimination of elective deliveries greater than or equal to 37 but less than 39 weeks gestational age unless medically indicated for the health and safety of the mother or fetus; Emergency Physician Airway Management Training and Standardization of Guidelines; Best Code Airway Management

Baylor Scott & White Health Care System TX 46 Journey to No Preventable Deaths, No Preventable Injuries and No Preventable RiskDel Sol Medical Center TX 1 Transfusion Reduction InitiativeHouston Methodist TX 1 Safer Care for a Better Experience and Better Outcomes

Intermountain Healthcare UT 22 Reduce Central Line Associated Blood Stream Infections (CLABSI); Reduce Adverse Drug Events with Harm; Reduce Catheter Associated Urinary Tract Infections (CAUTI)

Inova Heart and Vascular Institute VA 1 HAIR: Healthcare-associated Infection Reduction

University of Vermont Medical Center VT 4 Alignment of Supply Chain and Information Systems Contracting and Supplier Management Processes to Ensure Interoperability of Medical Devices and Clinical Software; Culture of Safety; Hand-off Communication Improvement

Hospital-acquired Pneumonia Prevention Initiative (HAPPI)

CA, IL, IN, MA, MI, NC,

NY, TX, VA16 Reduction of preventable non-device related hospital-acquired pneumonia

Medical University of Vienna, Vienna General Hospital (AKH) Austria 1 Algorithm triggered multidisciplinary perioperative management to optimize patient outcome

A.C. Camargo Cancer Center Brazil 1 Implementation of Rapid Response Teams at Surgical Ward; Implementation of a Difficult Airway Team at an Oncology Center

Hospital for Sick Children Canada 1 Preventable Cardiac Arrests in our Critical Care EnvironmentToronto Western Hospital/University Health Network Canada 4 Preventing surgical complications with excellent Hand Hygiene

Sign Up to Safety England 350We are a national campaign covering the NHS in England – our aim is to reduce avoidable harm by 50% and save 6000 lives – bottom up movement approach to change using innovative campaign methodology to support a community of over 270 organisations

University Hospital Heidelberg Germany 1 Heidelberg Interdisciplinary Patient Safety Symposium; TEAM – BriefingCloudnine Hospital India 16 Patient Safety Through Technology

IRCCS Istituto Ortopedico Galeazzi Italy 1 Advanced intra/post-operative monitoring systems in order to improve transfusion appropriateness, increase patient safety and reduce complications

Tokyo Women’s Medical University Japan 1 Reduction of Post-operative Respiratory Depression and Respiratory FailureVilnius University Faculty of Medicine Lithuania 1 Optimization of Perioperative Fluid Therapy and Transfusions[pdf] and UpdateHospital Mocel Grupo Angeles Mexico 8 Security Protocols in Respiratory TherapyRotary International Nigeria 8 Reduce Infant Mortality in Nigeria

The Scottish Patient Safety Programme Scotland 300 The Scottish Patient Safety Programme (SPSP) is a unique national initiative that aims to improve the safety and reliability of healthcare and reduce harm, whenever care is delivered.

SENSAR Spain 55 Spread of the Patient Safety Culture in Anesthesia, Critical Care, and Pain Management throughout all hospitals in Spain

Smile Train Uganda, India, Haiti 13 Safer cleft surgery in the developing world through hospital partnerships and empowerment

Ibero American Society of Neonatology (SIBEN)Latin

American Countries

40To decrease blindness due to retinopathy of prematurity (ROP) in Latin America [pdf] decrease preventable neonatal deaths in countries of Latin America and decrease severe bronchopulmonary dysplasia (BPD) in Latin American countries

PATIENT SAFETY MOVEMENTANNUAL SUMMIT

SUMMITOur annual World Patient Safety, Science & Technology Summit is the preeminent patient safety conference in the country. Committed clinicians gather with leading medical technologists, passionate patient advocates, and innovative policymakers to challenge the status quo, exchange ideas, and refine patient safety protocols.

Past Speakers

Joe Kiani Founder and Chairman, Patient Safety Movement Foundation Founder and CEO, Masimo Corporation

David Mayer, MD Vice President, Quality and Safety, Medstar Health

Vice President Joe Biden47th Vice President of the United States

President Bill Clinton Founder of the Clinton Foundation, 42nd President of the United States

Mark Chassin, MD CEO, The Joint Commission

Richard Carmona, MD, MPH, FACS 17th Surgeon General to the United States (2002–2006), Distinguished Professor, University of Arizona

Kai Zacharowski, MD, PhD, FRCA Director of the Department of Anesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt

Patrick Conway, MD, MSc Deputy Administrator for Innovation and Quality & CMS Chief Medical Officer

Thomas Zeltner, MD Special Envoy of the Director General of the World Health Organization (WHO)

Peter Pronovost, MD, PhD Sr. Vice President for Patient Safety and Quality, Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital

The 5th Annual 2017 World Patient Safety, Science & Technology Summit will be held in February in Orange County, CA. Please visit PatientSafetyMovement.org/summit for more details.

PATIENT SAFETY MOVEMENTANNUAL SUMMIT


John Waite

McKenna Lee & the Microfixers

Past Musical Guests

Alison Krauss

Alan Bergman

PATIENT SAFETY MOVEMENTHEALTHCARE TECHNOLOGY

HEALTHCARE TECHNOLOGYMake the Change

Unfortunately today, many medical devices and information systems do not always communicate with one another meaning that vital, potentially life-saving, patient data may not be available when a provider or patient needs it. This is not a technology problem; it is instead the result of a business decision designed capture market share for a single product, even if it is at the expense of patient safety.

It is our goal to unlock medical device data to facilitate the creation of a Patient Data Superhighway that will support providers making clinical decisions and allow for the innovative development of algorithms that will serve as a safety net for patients that may otherwise slip through the cracks in a care setting.

The Movement is calling on all healthcare technology companies to lead the market by openly sharing the data their product is designed to generate, without prejudice.

Many companies have risen to this challenge and signed the pledge, others have gone even farther and now only do business with those that have made a similar commitment.

Sign the pledge today at PatientSafetyMovement.org/commitments

HEALTHCARE TECHNOLOGY COMPANIES STATES PLEDGE SIGNED

Cercacor CA 2013CRISI Medical Systems, Inc. CA 2014ExCor Technologies,LLC CA 2013Hygenix CA 2013Kolkin CA 2013Masimo CA 2013Modulated Imaging, Inc. CA 2014NeurOptics CA 2014Oracle CA 2014Perceptimed CA 2014Predixion Software CA 2013Rapid Healthcare CA 2016RGP Healthcare CA 2014S.E.A. Medical Systems, Inc. CA 2013Sotera Wireless CA 2013ZOEX NIASG/NASG CA 2013Patient Valet CA 2015

Join the leaders from the healthcare technology industry in taking the pledge to share their data.

PATIENT SAFETY MOVEMENTHEALTHCARE TECHNOLOGY


HEALTHCARE TECHNOLOGY COMPANIES STATES PLEDGE SIGNED

Medical Simulation Corporation CO 2015Securisyn Medical CO 2014GE Healthcare CT 2013Iradimed FL 2015Stibo Systems GA 2016Data Diagnostix LLC HI 2014ICUcare LLC IN 2013Certa Dose IN 2015Innara Health KS 2013Admetsys MA 2014BrainStem Biometrics MA 2013EarlySense MA 2013Philips Healthcare MA 2014Zoll Medical MA 2013IBM Watson Health MA 2016CorCardia Group Inc. MN 2013KinectIQ MN 2016Cerner MO 2013Dynalabs MO 2015DebMed NC 2014Monarch Medical Technologies NC 2016Welch Allyn, Inc. NY 2014CODONICS INC. OH 2013CrossChx OH 2016Dräger PA 2013Airstrip TX 2016American Medical Risk Company TX 2015ATL Technology, LLC UT 2013Medical Intelligence Holding Corp UT 2015SonoSite, FujiFilm WA 2013True Process WI 2016Deltex Medical Group plc United Kingdom 2014LiDCO Group Plc United Kingdom 2013

ACTIONABLE PATIENT SAFETY SOLUTIONS (APSS)

ACTIONABLE PATIENT SAFETY SOLUTIONS (APSS)Achieving 0X2020 will require fundamental changes throughout the continuum of care. We work with leaders from the healthcare professional, healthcare technology, patient advocacy, public policy, and payer communities to identify key patient safety challenges and develop actionable solutions that can be realistically implemented in the short term to address them.

We have developed APSS to address the following key challenges:

Failure to Rescue: Post-operative Respiratory Depression

Sub-optimal Neonatal Oxygen Targeting

Healthcare-associated Infections

Anemia and Blood Transfusion: A Patient Safety Concern

Early Detection of Sepsis

Airway Safety

Hand-Off Communications

Culture of Safety

Medication Errors

Failure to Detect Critical Congenital Heart Disease (CCHD)

Optimal Resuscitation

Download and share our APSS at PatientSafetyMovement.org/APSS

Optimizing Obstetric Safety

PATIENT SAFETY MOVEMENTPOLICYMAKERS

POLICYMAKERSStand up for Change

From both human and financial perspectives, the cost of preventable patient death is staggering:

• More than 200,000 deaths per year affecting millions of family members, friends, and colleagues.

• Up to $1.26 trillion per year is spent to treat medical errors.

But, as with any challenge of this magnitude, the opportunity to achieve positive change is equally vast. The Patient Safety Movement is a big tent organization that invites the contributions of the broadest spectrum of policy professionals: Patient advocates. Public officials. Public health professionals. Healthcare reformers. The Patient Safety Movement welcomes you all to the fight.

Follow our progress at PatientSafetyMovement.org

MISSIONThe Patient Safety Movement Foundation is singularly focused on eliminating the more than 200,000 annual preventable patient deaths in the US by 2020 (0X2020).

TOGETHER WE WILL REACH ZERO PREVENTABLE DEATHS BY 2020

The Movement is a commitment-based organization that connects the dots between people, ideas, and technologies that are traditionally siloed in our healthcare system. We encourage commitments from healthcare organizations to implement actionable patient safety solutions and pledges from healthcare technology companies to share their data. Together we share the mission of:

1. Unifying the healthcare ecosystem;

2. Identifying the challenges that are killing patients to create actionable solutions;

3. Asking hospitals to implement Actionable Patient Safety Solutions;

4. Promoting quality and safety transparency;

5. Asking medtech companies to share the data their devices generate in order to create a Patient Data Super Highway to help identify at-risk patients;

6. Correcting misaligned incentives; and

7. Promoting love and patient dignity.

ONE PLUS 24,672 LIVES SAVED

At our 2016 World Patient Safety, Science, and Technology Summit we announced 1,624 healthcare organizations and 45 healthcare technology companies had made public commitments to 0X2020 resulting in one plus 24,672 lives saved.

We say “one plus 24,672” because it is important to remember that our commitment is to every life saved, not to the elimination of a statistic. We are extremely proud of our progress to date and prouder still that the world will be enriched by 24,673 more of our loved ones this year.

Achieving 0X2020 will require these numbers to grow by orders of magnitude every year, and in 2016 we are committed to reaching one plus 50,000 lives saved.

PATIENT SAFETY MOVEMENTMISSION

PATIENT SAFETY MOVEMENTPATIENTS & FAMILIES

PATIENTS & FAMILIESSee the Change

We continue to gather and publish moving Patient Stories of preventable deaths in the hospital. These stories put a human face on the mortality numbers and serve as powerful reminders for every stakeholder in patient safety of the importance of putting an end to these preventable tragedies.

Emily JerryAge: 2Cause of Death: Medication Error

Leah CoufalAge: 11Cause of Death: Failure to Rescue

Dave BunoskiAge: 59Cause of Death: Anoxic Brain Injury Due to Airway Mismanagement

Joan DonnellyAge: 43Cause of Death: Postpartum Eclampsia

Read and watch all of our patient stories and videos at PatientSafetyMovement.org/patient-stories

committed to zero preventable deaths by...

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