1. Section Editor(s): Kiani, Joe

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A health crisis in our country is taking over 200,000 lives every year. It's devastating families and clinicians in every city and state, but because we only hear of an incident happening once in a while in the news, many believe it's a rare occurrence. The fact is that it happens 500 times a day. The third-leading cause of death in our country is preventable hospital deaths. Most troubling and encouraging at the same time is that, unlike cancer and heart failure, we can put processes in place in our hospitals to avoid them!

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The Patient Safety Movement Foundation launched in 2012 with the stated goal and commitment of reaching zero preventable patient deaths in the United States by the year 2020. We teamed up with some of the best patient safety experts, hospital administrators, and patient safety advocates around the world to develop and disseminate easy-to-implement solutions to ensure that no patient is ever needlessly harmed again. We developed 13 Actionable Patient Safety Solutions (APSS) that are being implemented by more than 3,500 hospitals around the world. Last year, these hospitals reported over 69,000 saves as a result of their work.


However, there's still much work that needs to be done if we're going to eliminate all preventable patient deaths and harm in the next 3 years. Everyone in the healthcare ecosystem, including hospital administrators, physicians, nurses, pharmacists, respiratory therapists, engineers, technologists, patient advocates, and policy makers, needs to commit to zero if we're going to plan for zero instead of just hoping for it.


What needs to happen to reach zero?


* Every person in the healthcare ecosystem needs to commit and lead his or her institution to make safety the number one priority.


* Hospitals need to implement proven processes that address every identified challenge and create a policy of zero tolerance toward continued practices that are proven to be inadequate.


* Hospitals need to be transparent. Every 3 months, each hospital should report the number and type of preventable patient harms and deaths that have occurred in the institution.


* Hospitals need to implement the free CANDOR online toolkit. CANDOR provides healthcare organizations with a framework for communicating accurately and openly with patients and their families in the event of a medical error, and promotes a culture of safety that focuses on organizational accountability and learning from every mistake.


Hospitals are proving that zero is possible

We're already seeing hospitals getting to zero deaths in certain areas such as hospital-acquired infections. For example, Tri-City Medical Center in San Diego, Calif., recently celebrated 7 years of zero central line-associated bloodstream infections in its neonatal ICU. Intermountain Healthcare System based in Salt Lake City, Utah, hasn't seen a single catheter-associated urinary tract infection in its 160-bed LDS hospital in 6 months. The common thread that these and other hospitals achieving remarkable patient safety outcomes share is that they're putting systems in place to deter anyone from breaking patient safety processes while creating a culture focused on what's best for the patient. Participation is mandatory, not optional.


What life in a hospital with zero looks like

Zero is possible today and it doesn't require limitless resources. In fact, processes that avoid preventable deaths reduce costs. We've seen it done in both large hospitals and small ones. It does require fostering a culture of safety from top to bottom and bottom to top. It also requires diligently implementing new proven processes. Once you implement the APSS and start reducing preventable patient deaths in the areas most hospitals find challenging, it will spread to every clinician and area. Success will inspire more to participate. And the best part is that your team will function with the confidence and peace of mind of knowing they're doing everything in their power to protect their patients' well-being.


Clinicians, pharmacists, administrators, patients, and families will benefit from open lines of communication, and any mishaps will be addressed quickly, effectively, and with full transparency. With a goal of zero, every incident of harm will be analyzed for a root cause. Hospitals will experience fewer medical liability claims and improved patient satisfaction scores by engaging patients and families throughout the process.


The role of nurses in creating a culture of safety

Tami Minnier, a colleague of mine from UPMC, once asked me, "Why do you think patients go to the hospital?" As I fumbled with my answer, Tami said, "Because of nursing care!" Nurses are on the frontlines of healthcare and vital to great outcomes for patients and zero preventable deaths. Many nurses have taken a leadership role in their hospitals' patient safety programs. As the physician's partner in patient care, they must not be afraid to speak up. As patient advocates, they need to embrace and facilitate a culture of transparency, patient and caregiver dignity, and safety. Patients rely on them.


The 13 Actionable Patient Safety Solutions

Challenge 1: Creating a culture of safety


Challenge 2: Healthcare-associated infections


Challenge 3: Medications


Challenge 4: Failure to rescue: monitoring for opioid-induced respiratory depression


Challenge 5: Anemia and transfusion: a patient safety concern


Challenge 6: Handoff communication


Challenge 7: Neonatal safety


Challenge 8: Airway safety


Challenge 9: Early detection and treatment of sepsis


Challenge 10: Optimal resuscitation


Challenge 11: Optimizing obstetric safety


Challenge 12: Venous thromboembolism


Challenge 13: Mental health: access to acutepsychiatric beds



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