100,000 patients die annually as a consequence of preventable medical errors, and over 1 million patients suffer life-changing injuries. Despite the calls to action medical errors continue at the rate of 1 out of 10 patients. How can those of us who help to deliver care and those of us that receive care help to prevent harm? There are 5 fundamental areas each of us needs to understand and use to fix healthcare delivery: 1. Apply the principles of high performing manufacturers and athletic teams to continually improve our processes. 2.We all need to learn how lead and be part of multidisciplinary teams that include patients and coordinate the care they receive. 3.The human brain continually makes errors. Certain conditions increase the likelihood of errors, and these need to be avoided. Systems can be designed that force the right behavior, and second checks can help caregivers provide the right care at the right time and in the right place. 4.We all need to become effective leaders. Most importantly we must practice adaptive leadership, that is, leadership that promotes a true change in the way things are done. 5.Finally we all can utilize the campaign methods of successful politicians and advocacy groups to change the attitudes of our fellow caregivers and patients, and thereby change the culture of our healthcare systems. During this 8-module course you will be provided with the tools to accomplish all 5 of these goals, and as an individual you can truly make a difference. Why do we need to understand about systems? How do we evaluate a system and as a patient or provider what characteristics do you think are important? How does quality relate to safety? These are important questions that we all need to have answers to as we learn how to improve how we deliver and receive healthcare. The personal consequences of distracted physicians and defective systems are illustrated in Mary's frightening hospital experience.

In this module we will be discussing the manufacturing principles of the Toyota Production System. The concept of value stream or work flow diagrams will be introduced. The well known 80/20 rule in manufacturing will be applied to patient care. The 8 ways waste can be reduced in health care will be explored, and finally the problem of push medicine and how patients can guard against this all too common problem will be covered.

Teamwork is critical in modern healthcare. We will explore the state of healthcare teamwork in most healthcare systems. The 5 resources required for effective teams will be reviewed, and we will discuss how athletic principles can be used to encourage teamwork, improve efficiency and increase the quality of patient care. We will review how to launch and coach a team, and how to manage the complex dynamics of teams. Finally we will discuss how to create a self-improving team.

This module will be discussing the consequences of medical errors, and you will learn from Sorrel King's loss of her daughter, Josie, and from my personal experience that preventable injuries not only cause death but also can lead to permanent life changing injuries. Sitting around and doing nothing is not an option. However we all need to understand and use three key tools to determine the causes of medical errors and to fix them, Root cause analysis, Driver Diagrams, and PDSA cycles. Finally we will discuss the issue of small errors and our tendency to ignore and workaround them. Unfortunately this approach to small problems is one of leading causes for the continued high rate of preventable injuries and deaths in our hospitals and clinics. It is time to fix the little things.