Die of Heart Disease and 574,000 byte of cancer died of cancer. What isnt known and what the function of put the function of the hearing is about and i hope to do my best with the help of fellow senators and members of the panel is to start focusing attention on the third leading cause of death in the United States of america. And that will come as a great surprise to most people and the third leading cause of death in this country has to do with preventable medical errors in hospitals. A recent article published in the journal of Patient Safety estimates that as many as 440,000 people a year may die from preventable medical errors in hospitals. 440,000. That is more than a thousand eight each day. They die from preventable mistakes outside of the hospitals such as misdiagnosis or injury and medication. Nearly 15 years ago the institute of medicine published a report. It is a well publicized report entitled to air is human which found that as many as 98,000 people die in hospitals each year due to preventable medical errors. According to the 2010 report, more recent report, from the department of health and human services, 180,000 medicare patients alone, just medicare patients died from preventable adverse events in hospitals. According to the cdc, one and 25 hospital patients get an infection for being in the hospital and in 2011 b. s hospitals cost 700,000 people to get sick and a 75,000 people to die. Clearly, these errors caused an immense amount of human suffering. But they are also from a financial point of view very, very expensive for the government and for individual families. Medical errors cost the u. S. With your system more than 17 million in 20 08 a. M. But when indirect costs are taken into account such as lost productivity and missed workdays and medical errors may cause to the elite 1 trillion each year. In the midst of this situation that we will be discussing today coming and i think that we agree this is an issue that is taking place all over the world and countries all over the world, Healthcare Systems trying to combat it the good news is that there has been progress made in recent years and we are going to hear from the panelists about the kind of progress that has been made and more importantly, where we have to go. We all understand the tragedy occurs and people die for all kinds of reasons, but the tragedy that we are talking about here on the deaths taking place that should not be taking place and that is what we are going to be focusing on. Some of the advances that we have seen and we will be discussing this morning come from following practices interestingly enough that have been established in other highstakes field like aviation and Nuclear Safety people are dealing with very dangerous situations. For example, through the implementation of checklists have dropped dramatically in advances in technologies such as electronic prescribing and medication and a robotic tools which create smaller incisions during surgery can reduce the risk of infection. Further, there has been increased attention to something that seems pretty obvious they needed to wash hands on a regular basis in hospitals one would assume that would be pretty obvious. This is a problem that hasnt received any of the attention that it deserves and today. Senator warren . I dont have an opening statement. Im eager to get to the testimony and the questions. Senator whitehouse . Think the term and very much for holding this hearing and i want to thank the chairman for allowing us to go forward because this is really an extraordinarily important issue for all of the work and the the fuss and the fighting fast and the fighting that has surrounded the Affordable Care act their remains in very large financial problem in the Health Care System that it costs about 50 more than the most inefficient other industrialized countries with your system in the world. We have an inefficiency premium of about 50 over the Major Economies that we compete with and the end hundreds of thousands of american lives for all the good the Affordable Care act did those two problems remain before us and im delighted and i in particular want to welcome the doctor that weve never met before. But hes the architect. On the quality institute. Keystone principles and applied it in our intensive care units and dramatically reduced the intensive care unit statistically zero. Interestingly it also had the side effect of making the nursing staff in the intensive care unit empowered enough that nursing turnover experienced a considerable drop off that they were so excited about what they were doing. So there are wonderful ways that we can do this and obviously when you are talking about saving peoples lives, saving peoples money it is a secondary concern but here we have a very fortuitous alignment between savings, lives and saving money. This is a very important topic and i applaud you for having brought this Wonderful Group of witnesses together and helping this hearing. Thank you. Thank you senator whitehouse. Lets get to work. Doctor james is the founder and what im going to do is introduce you. He published an article in the Patient Safety which found that somewhere between 2010 and 440,000 americans die each year from preventable medical harm in the hospital. Doctor james retired early in 2014 as the chief toxicologist and received his phd from the university of maryland. Doctor james, thanks very much for being with us. Make sure that its on red. To start the counter . Okay we will start the count. I think the chairman for inviting me to testify about Patient Safety. I speak today on behalf of hundreds of thousands of americans whose voices have been silenced forever by preventable adverse events. The Patient Safety activists occurred in the summer of 2002. My son was 19yearsold and had returned for his junior year at baylor university. While running in the evening of august 20 he collapsed on the University Campus has helped recover that was taken to the local hospital. He was evaluated for four days by cardiologists and underwent electrophysiology test in another hospital. Five days after his discharge he had a followup and they gave him a clean bill of health. In a week he returned. On september 15 at the two weeks after he presumed to running i received a call late in the evening that he had collapsed again while running this time his heart had stopped and he was in an unresponsive coma. He died three days later in the hospital the hospital where he was first taken for evaluation. Once you been able to get his medical records i discovered that my suspicions of the call of death were borne out. During the first hospitalization i had to do to the cardiologist that potassium was low and this might have been the cause of his initial collapse. He discounted the possibility and and decided to see them replacement was never administered. In fact as much leader at least three catastrophic errors were made by his doctors. When they failed to apply a guideline to the National Council on potassium and clinical practice. Number two they failed to diagnose the syndrome and number three committee knew that he should not return to running. They sent his medical records but they never warned him not to run. His only discharge instructions and running were to drive or not to drive for 24 hours. Ive written about the details of this and published in 2007. More have read the book and none have disputed my analysis. In fact an electrophysiology staff to reading my book affirmed to me in an email that she had been frustrated and paid more attention to potassium. Because of the past few years i completed a 25 25 invited reviews of cardiology manuscripts for the cardiology journal. As it unraveled the errors in my sons care and then discovered that his mri was never done properly, i began to realize that medical errors like those were not uncommon. I saw that the institute of medicine estimated up to 98,000 americans die each year from medical errors in hospitals. Other reputable estimates at that kind of size 284,000 deaths. Remarkably if the patient does survive, then with few exceptions the hospital would be paid to fix the harm. How much harm is there . By 2011 i noticed the studies that used the global trigger tool to identify adverse event in medical records. The Peer Reviewed studies and two were from the office of the inspector general. This tool was much more than identify identifying the evidence and unguided decisions. I noted that individual studies gave a remarkably consistent picture of the prevalence of the lethal adverse events. In addition other studies have been published showing that medical records often do not contain evidence that is discoverable of harm when the patient is no they were seriously harmed. In 2013 i published the study in the journal of Patient Safety. The calculation is rather simple. There is no statistic here. There were 33,000 hospitalizations and approximately 9 involved lethal adverse events and approximately 69 on average were judged to be preventable. This is an estimate of 210,000. However, the trigger of the mission has many errors of omission, communication context and diagnosis. It would not have detected any of the catastrophic errors made by my sons doctors. Furthermore no evidence appears in the medical record correcting for these limitations estimate of more than 400,000 lives shortened by preventable adverse events each year. What are the solutions . The senate should establish the standalone committee on the Patient Safety. It should establish a national Patient Safety board. Three committee board. Three committee should have the National Patient bill of rights. No cost for the test and elective procedures before hand. To know when the drugs are prescribed into the warned and to be warned about that lifestyle choice. To have care by teams up officials that build individual and Team Excellence and the performance reviews these are anonymous reviews by patients, supporters, colleagues and readers anonymously. In my opinion it isnt going to improve substantially until the Playing Field between the ill patients and the Healthcare Industry is level by the enforced bill of rights. Despite the high per capita expenditures on Health Care Industry ranked last overall in compared to the systems and other developed countries. That needs to change. Thank you for your attention. Thank you very much. Senator, i think senator, i think you were going to introduce the next panelist. I have the honor of introducing doctor professor of Health Policy and management at the Harvard School of Public Health. Hes also he is also a practicing physician of internal medicine at the boston va. As an undergraduate degree from college and medical degree and masters degree in the masters of Public Health from harvard university. He founded the initiative of the Global Health quality at the Harvard School of Public Health and his research is on the quality and reducing the cost of healthcare in the United States and around the world. In the 2013 he was elected as a member of the institute of medicine. His work has been groundbreaking and it is an honor to have him here today. Thank you very much for being with us. Thank you for that warm introduction. So it has been 50 years since they estimated that about 100,000 americans die each year from preventable medical errors. And when they first came out with that number come it was so staggeringly large that most people wonder could it possibly be right . The evidence 15 years later in hindsight the evidence is in and the evidence is very clear they probably got it wrong. It is an underestimate of the toll of human suffering that goes on from preventable medical errors. Beyond the problem of the senate and exactly how many people are suffering from these injuries, there is a second pressing question that it has been 15 years in a reasonable person might ask how much progress have we made in the last 15 years . Have we done . And you are going to hear from the doctor and others about the various areas we have had progress. But its the mental question as if i walk into an American Hospital today, and i demonstrably safer than i would have been 15 years ago . The unfortunate answer is no we havent moved the needle in any meaningful demonstrably overall. In certain areas been far better and in certain areas that are probably worse that we are not substantially better off than compared to where we were. The last piece of distressing news in my mind is that as you eluded to. What we find is no matter where you look, the size cover scope, the complexity of the problems are remarkably similar and the u. S. When we compare ourselves is right in the middle of the pack. We are better in some areas and worse in others but there is no country i think the point to that i can say theyve really get it right consistently. Beyond all that distressing stuff lets talk about the progress that has been made. That is probably the place weve made the greatest progress and when i talk about that topic i usually point to the two agents but i think have made a central role in reducing infections. One of them is the speaker of two down from me. His work has probably saved tens of thousands of lives if not more and im not going to talk about it because he will do a much better job of explaining it. But the other agent was talking about is the cdc through its surveillance programs. Its surveillance programs around the infections have been i think fundamental to the improvements that we have seen. If you take a step back and ask how is it that we improve and get better at anything in our lives and the key element in my mind is data and the metrics that are valid and credible. If you dont have the data and metrics, you dont know how youre doing, you dont know how you compare to anyone else and you have no way to judge whether the efforts are making a difference or not. Develop it in the tricks of infections and feeding that information back to hospitals. And i think that has been fundamentally important in the kind of improvements that we have seen. So here we are 15 years later and the question we should ask ourselves is how do we avoid another hearing five or ten years down the road where we say we are 25 years after the report. We still have not made much progress or none of us wants to be your. So how do we avoid . How do we begin to make Real Progress and i have three suggestions i think are very doable. First, i think we need to expand the efforts. There is no reason to think what theyve been able to do around the infections they cant do in other areas such as medication they can partner with the fda that cdc has a phenomenal track record and this is a publichealth problem. That cdc is the publichealth agency. I think they have a central role to play. The second is on electronic records. The country is in the midst of digitizing the record system. Weve seen phenomenal progress in the adoption of electronic records and i think it has a lot of potential. But the potential is not going to be realized unless they are focused on improving Patient Safety. The tools themselves wont automatically do it. And i think we need to make that a priority under a very specific thing congress can do in that area and the third is around incentives. We cant continue to have unsafe medical care. We are a regular part of the business and healthcare. And they have a very Important Role to play. Medicare has an Important Role to play. I think that they take important steps in this area that we can do so much more. To finish up, you know, we have a cadre of physicians and nurses in the country who are incredibly welltrained, dedicated and caring individuals who go to work everyday trying to do the best for their patients. We have a system that fails then and that patients who expect and deserve health care that is not only safe, im sorry not only effective but safe and improve their health and not harm it. This time i will introduce doctor gandhi is an associate professor of medicine at Harvard Medical School and she is the president of the national Patient Safety foundation. She received her undergraduate degree from Cornell University and her medical degree and her masters and a publichealth degree from harvard university. Before serving on the national Patient Safety foundation, she was the chief quality and Safety Officer at Partners Healthcare and served as executive director of quality and safety at Brigham Womens hospital. This. Southernmost Common Elements that occur is chillier to follow up on test results. We cannot just tell clinicians to try harder and think better we need better systems to minimize cognitive errors such as computerized algorithms. Better systems are needed to manage the test results to make sure every test ordered is completed the provider receives the results back signifies a patient. Leslies transitions of care. They occur all the time and health care. For example, living hospital to home or to Emergency Department we know transitions are a high risk time when people pieces of information can be lost for after hospital discharge within five days onethird of patients were taking medication differently than prescribed in the hospital. Another study shows 40 p