Millionaire’s Mission: Joe Kiani Wants Zero Patient Deaths Due to Medical Error

Joe Kiani, founder and CEO of Masimo, is photographed at the company's headquarters in Irvine, California January 27, 2017. Kiani invented non-invasive patient monitoring medical devices. Photo by Kendrick Brinson
Photo by Kendrick Brinson

STAT news reporter USHA LEE MCFARLING recently reported on the work of patient safety advocate Joe Kiani, a millionaire on a mission to solve patient deaths attributed to medical error. I have previously participated in Joe’s annual Patient Safety Summit as a representative of SimGHOSTS, and found the man, the mission, and the organization a powerful voice for improving healthcare. Check out this excerpt of the article by Usha on STAT news:

Joe Kiani likes to point out that the most worn spot on most medical monitoring devices is the mute button. He’s out to change that — and, he hopes, to stop the epidemic of preventable hospital death that kills tens of thousands of Americans each year. It’s not a glamorous cause. And Kiani is not a household name. But he is a multimillionaire with a proven track record of using engineering smarts to fix dogged problems; he made his fortune improving the humble pulse oximeter, which measures oxygen saturation in the blood. Now, he’s pushing a nerdy, but elegant, idea for saving lives: prodding manufacturers of medical devices and electronic records to open their platforms so all the systems can talk to each other.

His tech fix — if widely implemented — could bring order to the cacophony of beeps, buzzes, and blaring alarms that can so overwhelm nurses and doctors that they push “mute” and miss true emergencies. It could make it easier for staff to monitor patients with complex needs. And it could flag, in advance, potentially fatal errors like incorrect dosing and drug allergies. Manufacturers, naturally, aren’t so eager to share their computer code. But Kiani is not one to give up. He stages a glitzy patient safety summit each year, attracting big-name speakers like Bill Clinton and Joe Biden to pound home the need for hospitals to stop killing their patients.

Kiani runs his own medical device company, Masimo, from a building so airy and modern it stood in for Stark Enterprises in the first “Iron Man” movie. “It’s probably better he didn’t become a doctor,” mused Dr. Steven Barker, a professor emeritus of anesthesiology and aeronautical engineer at the University of Arizona who now works as chief science officer for Masimo. “He wouldn’t have saved nearly as many lives.” Soon after graduating, Kiani got a chance to work on pulse oximeters. The geek in him was captivated. “I couldn’t believe you could shine light in your finger and measure oxygen in your blood,” he said. “I just loved the idea.”



When Kiani began to put faces to the statistics, he was shaken. One of those faces belonged to 11-year-old Leah Coufal, who died in December of 2002 at Cedars-Sinai Medical Center in Los Angeles. She’d had routine surgery to correct a mild chest deformity and apparently received a massive dose of fentanyl to control pain — enough to stop her breathing. Her mother, Lenore Alexander, couldn’t talk about Leah’s death for a decade. When she started speaking out, Kiani listened. He was shocked to realize his own daughter — who is fine now — had surgery in the same hospital, with the same surgeon, in the same week as Leah. “That could have been me,” Kiani told the people gathered at his first patient summit in 2013. “It could have been you.”

He was also shocked to find Leah had not been monitored after surgery, not even with a simple pulse oximeter. Another name Kiani couldn’t keep out of his mind at the time was Rory Staunton, a 12-year old from New York who scraped his arm in gym class, then died from a sepsis infection that simple screening tools could have detected.  

How one hospital is beating sepsis and saving lives “He wondered: “Why are people going into hospitals and not coming out?’” said Frederic J. Harris, an electrical engineering professor at San Diego State University who taught Kiani and remains close to him.

He’s working to create the architecture that hospitals could use to network their tens of thousands of devices into what he calls a “truly neutral, two-way plug and play” system. Once those standards are in place, he said, “I’m going to call vendors on their data pledges — very publicly.”

Read the full article on STAT news today


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IHI and NPSF Announce Upcoming Merger During This Patient Safety Week

patient safety week

Official Press Realease from NPSF and IHI

Boston, MA, March 13, 2017 — Recognizing that patient safety is a public health issue in need of fresh, robust approaches and constant focus for health care systems today, the Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) announce plans for a merger, effective May 1.

Derek Feeley, president of IHI, and Tejal Gandhi, MD, MPH, CPPS, president and CEO of NPSF, talk about the merger of their organizations. IHI President and CEO, Derek Feeley, who will lead the combined organization, says now is the perfect time for the two organizations to join forces to help reset and reenergize the patient safety agenda, building on a mutual history of helping health care systems gain the knowledge and skills to implement harm reduction across the entire continuum of care. “Improving patient safety has always been central to IHI’s mission of improving health and health care quality,” said Feeley. “Yet safety now competes for attention and resources with other important issues such as value-driven care and population health. By joining forces, IHI and NPSF will be more effective in helping leaders and frontline clinicians meet all of today’s challenges while ensuring that patient safety remains a priority along the way.” Feeley added, “The entire IHI staff is thrilled about the opportunity to work with the talented staff of NPSF as one, strengthened organization.”

Tejal K. Gandhi, MD, MPH, CPPS, NPSF President and CEO, says she and NPSF staff are equally excited about the merger. She sees it as a game-changing opportunity for the patient safety field. “NPSF and IHI each have a history of raising awareness around patient safety issues and educating the health care workforce about best practices,” Gandhi said. “Our programs are distinct but highly compatible, and we share experience, expertise, and a common goal of accelerating patient safety improvement. NPSF has provided critical thought leadership with the aim of establishing safety as a core value in health care, and IHI has demonstrated an ability to influence large-scale, global change. This merger promises to strengthen our ability to advance progress in patient safety in the coming years.”

The merger involves significant new investment from IHI in patient safety. The merged patient safety teams, to be led by Gandhi, will combine existing NPSF and IHI patient safety programs and reflect an enhanced commitment to achieve patient safety around the world. All NPSF programs, including the NPSF Lucian Leape Institute and the Certified Professional in Patient Safety credentialing program, will continue.

A Call to Action During Patient Safety Week

The merger announcement comes at the start of Patient Safety Awareness Week, a highlight of the NPSF United for Patient Safety campaign. Coupled with news of the merger, and with endorsement of IHI, NPSF is releasing Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response. This document outlines how a public health framework can bring about widespread advances in patient safety and provides specific recommendations for how it can be used to reduce harm to patients and the workforce. The Call to Action was created by the NPSF Board of Advisors and Board of Directors, made up of more than 40 experts in patient safety, patient advocates, industry representatives, and other key constituents.

“We believe that in order to make meaningful and sustained improvement in patient safety, we need to address it within a public health framework,” said Gandhi. “The Call to Action outlines a multipronged, ongoing approach to systematically monitor, measure, and improve patient safety across the continuum of care through partnerships and collaboration among policy makers, health care leaders, professional associations, and others.”

The Call to Action sets forth six broad categories of recommendations, ranging from a call to establish a national steering committee and a national action plan for the prevention of health care-associated harm to a call to expand or develop education, training, and resources for the health care workforce. Read the full press announcement here.

Patient Safety Week

 

The United in Patient Safety campaign culminates each year with Patient Safety Awareness Week, designed to mark a dedicated time and a platform to increase awareness about patient safety among health professionals and the public. This year, patient safety week is taking place now, March 12-18, 2017. The National Patient Safety Foundation works to bring together and engage health care professionals and patients to help spread this important message. There are a number of ways to get involved in Patient Safety Awareness Week.

Find more resources for Patient Safety Week here!

Healthcare IT: Patient Safety, Engagement Relies on Crafting a Culture of Change

patient safety improvements through IT

What role does IT play in the improvement of patient safety? This article from Health IT Analytics helps to spread some light on the culture of change that will be needed to improve healthcare engagement outcomes:

Health IT Analytics Article Excerpt:

“Improving patient safety is primarily a matter of responsibility, says Dr. James Merlino, President and Chief Medical Officer of the Strategic Consulting Division of Press Ganey.  Healthcare organizations must take on the challenge of creating a “culture of care” that encompasses every member of the care team – including patients.

By broadcasting bold patient safety goals, engaging providers, and enacting patient-centric strategies for process improvement, healthcare organizations have the opportunity to make meaningful progress in the fight to reduce preventable patient harm.

“Organizations really need to adapt a strategic objective of patient centricity,” Merlino toldHealthITAnalytics.  “They have to get across to everyone that works in healthcare that they exist for the patient, and that their purpose is to deliver on the promises that they implicitly make with their patients: providing a safe, high-quality, human environment where the patient feels cared for.”

To do this, organizational leaders have to be sure that their staff members are not only educated about patient safety risks, but fully committed to eliminating preventable harm all together. “You must set the goal at zero,” Merlino stated. “Patient safety must be an uncompromisable core value of your organization.” “What I find in some of the organizations that we work with is that they have differing degrees of alignment around the topic.  Obviously, nobody comes to work in healthcare because they think about wanting to harm a patient.”

“But accidents do happen, because we’re human.  We just need to think about how to integrate the best possible processes into the care system, and it has to start with a commitment from leadership to model these practices and create a culture that is deeply patient-centric.”

Read the full article on the Health IT Analytics website!


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CAE Healthcare Shares Patient Safety Foundation Info Graphic

pt safety sim

CAE Healthcare covered the NPSF last week and shared this info graphic of tips to reduce patient harm established by the group:

The National Patient Safety Foundation (NPSF) issued a report which calls for ‘federal agencies to create a portfolio of national standard patient safety processes’ across the care continuum, and ‘to retire invalid measures that are not useful or meaningful.’

Here, above, are the eight recommendations from the National Patient Safety Foundation to achieve this goal. The full report, “Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human” (Boston, MA; 2015) is available online.

CAE Healthcare is a medical simulation/simulation training company with a mission to improve healthcare education and patient safety. The global leader in simulation-based healthcare training, product design and manufacture, CAE Healthcare produces patient manikins / nursing manikins; surgical simulators, ultrasound simulation trainers, and clinical simulation management solutions for customers in more than 60 countries around the world.

Read more about Patient Safety on the CAE Healthcare website

Patient Safety Movement Meets in Washington DC to Plan 2017 Event

psm patient safety congresss mid year

This full-day meeting, co-convened by the Inova Heart and Vascular Institute, will consist of two morning sessions and an afternoon session. The meeting will commence with a general session of lectures and discussions led by patient safety experts.

In the afternoon, each of the twelve Actionable Patient Safety Solution (APSS) workgroups will report on their recent revisions and future plans. The day will end with the annual nomination and selection of new patient safety challenges that will be addressed at the 2017 World Patient Safety, Science & Technology Summit. A networking reception will follow the program so that attendees can connect with one another and share patient safety-related ideas before they go back to their own institutions.

The goal of the meeting is to provide attendees with an opportunity to hear from leading patient safety experts on timely topics, encourage a productive dialogue about proposed updates and revisions to the APSS, and finally, identify patient safety challenges for the 2017 Summit.

Join the Experience Find out what others are seeing and saying about this event, and join the conversation. Use these tags: #2016mpm #0x2020


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Media Covers May BMJ Article: “Medical Error 3rd Leading Cause of Death in U.S.” – Call for New Hashtag #SimToZero!

medical errors and simulation

Earlier this month the BMJ published a study by medical researchers from John Hopkins which provided a deeper analysis into the 2014 Journal of Patient Safety. Check out more about the new article here, and listen to this BMJ Podcast interview about the research:

About the Analysis:

Analyzing medical death rate data over an eight-year period, Johns Hopkins patient safety experts have calculated that more than 250,000 deaths per year are due to medical error in the U.S. Their figure, published May 3 in The BMJ, surpasses the U.S. Centers for Disease Control and Prevention’s third leading cause of death—respiratory disease, which kills close to 150,000 people per year. The Johns Hopkins team says the CDC’s way of collecting national health statistics fails to classify medical errors separately on the death certificate.

The researchers are advocating for updated criteria for classifying deaths on death certificates. “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics,” says Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine and an authority on health reform. “The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.”

This publication really caught a lot of media attention:

  • CBS News – “For the study, Makary and his colleagues evaluated four separate studies that analyzed medical death rate data from 2000 to 2008, including one by the U.S. Department of Health and Human Services’ Office of the Inspector General and the Agency for Healthcare Research and Quality. Based on 2013 data on hospitalization rates, they found that of 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error. They said that adds up to 9.5 percent of all deaths a year in the U.S.”
  • Huffington Post“Unfortunately, this news is not surprising at all. In the medical community, we have seen the consequences of inaccurate diagnoses and medical error for quite some time. While concrete efforts have been made to correct wrong site surgeries and other well publicized issues from the past, not enough has been done to address medical error that results from an incomplete or inaccurate diagnosis. 37% of the cases we review require a change in diagnosis, and over 75% of cases require a change in treatment plan.”
  • CNN – “One reason there’s such a wide range of numbers is because accurate data on these kinds of deaths is surprisingly sparse. That’s in part because death certificates don’t ask for enough data, Makary said. Currently the cause of death listed on the certificate has to line up with an insurance billing code. Those codes do not adequately capture human error or system factors.”
  • Washington Post ““There has just been a higher degree of tolerance for variability in practice than you would see in other industries,” he explained. When passengers get on a plane, there’s a standard way attendants move around, talk to them and prepare them for flight, Sands said, yet such standardization isn’t seen at hospitals. That makes it tricky to figure out where errors are occurring and how to fix them. The government should work with institutions to try to find ways improve on this situation, he said.”

Additional press Coverage spread wide and far…

Unfortunately, many of the articles did NOT cover potential solutions for addressing these avoidable mistakes. As champions of Simulation, we must reach out to these media agencies and remind them that healthcare simulation provides a huge opportunity to better educate and train for improved patient safety outcomes.

With this rare opportunity to maximize such exposure, I encourage you to write in and tweet these media agencies and remind them that simulation is already helping to address many of these problems with the hashtag #SimToZero, highlighting a goal to reduce medical errors to zero through the use of healthcare simulation.

Please join me in this new campaign to create a hashtag supporting
Simulation To Zero Patient Deaths From Medical Error!

2016 Patient Safety Movement Summit Shared Challenges and Solutions for Zero Preventable Deaths by 2020

patient safety movement

At the Patient Safety Movement earlier this year the audience of patient advocates, industry representatives, media, and healthcare professionals met near Laguna Beach to address the issue of preventable medical errors in healthcare. The organization was founded in 2012 by Joe Kiani and medical device manufacturer Masimo. Former President Bill Clinton provided the keynote address inspiring attendees to continue the mission of zero preventable deaths by 2020. As simulation’s end goal is the improvement of learning outcomes and patient safety outcomes, HealthySim will be sharing some of the moments captured during this event over the next month. HealthySim hopes this will highlight the opportunity for the growing global healthcare simulation community to better connect with the Patient Safety Movement to foster excellence and collaborative in healthcare training. Today in this first video a highlight of the 2016 Summit:

The Patient Safety Movement Mission

A disconnected understanding of the patient and appropriate care pathway has a devastating impact in both lives and costs. Saving lives and helping to prevent the more than 200,000 preventable patient deaths each year can largely be addressed by connecting the dots between current processes and procedures and proven solutions that are available today. By bringing the medical technologies and IT infrastructure together with relevant information, intelligent and predictive algorithms, and decision support that facilitate process of care improvements, physicians and patients could be informed of dangerous trends, lives could be saved, and costs could be dramatically reduced. Getting to ZERO will take all of us working together – clinicians, administrators, medical technology companies, payers, government, and patients.

The Patient Safety Movement Foundation was created to aggressively address this problem. The Foundation is breaking down the silos between hospitals, medical technology companies, doctors, engineers, and families of patients who have died needlessly. The mission of the Patient Safety Movement Foundation is to do the following:

  1. Unify the healthcare ecosystem
  2. Identify the challenges that are killing patients to create actionable solutions
  3. Ask hospitals to implement Actionable Patient Safety Solutions
  4. Promote transparency
  5. Ask med tech companies to share the data their devices generate in order to create a Patient Data Super Highway to help identify at-risk patients
  6. Correct misaligned incentives
  7. Promote love and patient dignity
  8. Empower providers, patients, and families through education of medical terminology and medical errors so they may better advocate for their loved ones.

And ultimately get to ZERO preventable deaths by 2020!

2016 World Patient Safety, Science & Technology Summit

The 4th Annual Summit brought together leaders from healthcare organizations, the healthcare industry, the patient advocacy community, and public policy makers to discuss solutions to the leading challenges causing preventable death in hospitals.

This year the event received commitments from organizations representing 1,631 hospitals that have collectively saved 24,643 lives. The group also announced the winners of our first ever Patient Safety Innovation Award competition as well as their annual Humanitarian Awards.

Learn more on the Patient Safety Movement Website today!


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Save the Date May 30th: 2016 National Forum on Simulation for Quality & Safety!

sim one quality and patient safety

On Monday, May 30, 2016, Toronto will welcome the first National Forum on Simulation for Quality & Safety – an exciting knowledge-sharing event on the growing interest in using simulation to improve patient safety and quality of care.

This groundbreaking initiative is a joint launch by SIM-one, IDEAS (Improving & Driving Excellence Across Sectors), Canadian Patient Safety Institute (CPSI), Accreditation Canada, Healthcare Insurance Reciprocal of Canada (HIROC), Health Quality Ontario (HQO), and HealthCareCAN.

The purpose of the Forum is to:

  • Demonstrate ways in which simulation reduces adverse events, costs and financial risks for hospitals;
  • Promote evidence and examples supporting the use of simulation at the point of care delivery;
  • Highlight current Canadian leaders and their knowledge and insights into establishing hospital-based simulation programs; and
  • Motivate decision-makers to pursue the integration of simulation-based patient safety and quality improvement initiatives/education/programs at their organizations.

The event will be co-chaired by:

Dr. Teodor Grantcharov, MD, PhD, FACS
Associate Professor of Surgery, University of Toronto; Canada Research Chair in simulation and surgical safety; creator of the surgical black box

Dr. Adalsteinn (Steini) D. Brown, D.Phil
Director, Institute of Health Policy, Management and Evaluation; co-chair of the IDEAS Quality Improvement (QI) Program.

Attendees should expect a dynamic program that includes an inspiring and informative lineup of presenters from Canadian leaders in simulation in hospitals, and plenty of social and networking opportunities.

Mark your calendars now:

WHAT: 2016 National Forum on Simulation for Quality & Safety
WHO: All hospital and care delivery organizational leaders, administrators, quality and safety leads, hospital-based simulationists and researchers are welcome.
WHEN: Monday, May 30, 2016
WHERE: Sheraton Gateway Hotel Toronto International Airport, Terminal 3 Toronto ON L5P 1C4

For more information, please visit the Sim-One NFSQS Website!

 

Health IT Mistakes Can Hurt Patient Safety

breakdown of medical errors

Over on Health Data Management they recently published a report showing how some Health IT mistakes cause patient safety errors. As simulation touches so much technology and is driven to improve patient safety, I thought this important to consider for those in professional healthcare settings:

Despite the potential for health information technology to improve patient outcomes, adverse events associated with the use of health IT can cause extensive harm and are encountered across all healthcare settings.

That’s the finding of a new analysis of electronic health record-related harm in cases submitted to a large database of malpractice suits and claims maintained by CRICO, an evidence-based risk management group of companies owned by the Harvard medical community.

Researchers identified 248 malpractice cases showing serious unintended consequences from the use of EHRs, representing less than 1 percent of all cases in the database. Of cases with causes related to EHRs, 80 percent involved moderate or severe harm. EHR errors were found to occur more frequently in ambulatory settings than in inpatient settings. Although ambulatory care accounted for more than half of the cases, deaths were more likely to occur in inpatient settings.

Read the full article on Health Data Management’s website!

Professional Learning Series Webcasts from the National Patient Safety Foundation

 

In celebration of our attendance tomorrow at that National Patient Safety Summit today we are sharing about the Professional Learning Series Webcasts from the National Patient Safety Foundation.

The NPSF Professional Learning Series offers the convenience of continuing education and peer-to-peer collaboration in an online learning environment. Members of the American Society of Professionals in Patient Safety (ASPPS) may register for their individual participation in a webcast at the member rate of only $20. Stand Up for Patient Safety member organizations receive complimentary registration for webcasts for their teams. As of January 2016, the cost of attendance for nonmembers has been reduced to $99

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Free from Harm: Accelerating Patient Safety Improvement
Tuesday, January 26, 2016 | 2:00 – 3:00 pm Eastern Time
Complimentary webcast: open to all at no charge

During this webcast, the co-chairs of an expert panel convened by NPSF will discuss the panel’s recommendations for future work in patient safety, recently published in the report Free from Harm: Accelerating Patient Safety Fifteen Years after To Err Is Human.

Featured speakers
Donald M. Berwick, MD, MPP
President Emeritus and Senior Fellow, Institute for Healthcare Improvement
Lecturer, Department of Health Care Policy, Harvard Medical School

Kaveh G. Shojania, MD
Director, Centre for Quality Improvement and Patient Safety, University of Toronto
Editor-in-Chief, BMJ Quality & Safety

Moderator
Tejal K. Gandhi, MD, MPH, CPPS
President and CEO, National Patient Safety Foundation
President and CEO, NPSF Lucian Leape Institute

Registration will open soon. Please check back here.
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Evaluation of Perioperative Medication Errors and Adverse Drug Events
Thursday, February 25, 2016 | 2:00 – 3:00 pm Eastern Time

Featured speaker
Karen C. Nanji, MD, MPH
Anesthesiologist, Massachusetts General Hospital

In this webcast, Dr. Nanji, lead investigator of a recent study on this topic, will discuss her team’s findings. Read the paper published in Anesthesiology.

Registration will open soon. Please check back here.
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Learn more at the NPSF website today!