When discussing process improvement, it's important to understand the concept of reliability. Reliability is defined as the number of actions that achieve their intended result, divided by the total number of actions. Now with this concept of reliability in mind, let's look at the administration and medications in the hospital. Let us assume that the system I work in, UF Shands Health Hospital, has achieved a 99.9% reliability. Sounds highly reliable, doesn't it? But let's calculate what this does look like. 99.9% reliability means that out of every 1,000 medications administered, there is one mistake. Now, patients at UF and Shands on average receive, 13 medications per day, and they receive these medications 3 times per day. On average they stay in hospital for six days. That means that the average patient receives 234 medication administrations during their hospitalization. Now how do we calculate the reliability? We multiply 0.999 by itself 234 times. And that translates to a reliability of 0.79 or 79% reliability. That means there is a 21% chance during any one patient's hospitalization of a medication, Error. Now there are 800 beds that are filled each day at UF Shands Hospital. So let's multiply 800 times 0.21 and that's 168 medication errors occur over six days. That means, if we divide this by six there are 28 medication errors, Per day. Now, what does that mean from the standpoint of patient safety? This is the tip of the iceberg so to speak. 4% of medication errors cause serious harm. Multiplying 0.04 by 28 means that 1.12 patients per day suffer a medication error that causes serious harm. One out of every 100 patients seriously harmed dies or if the reliability is 99.9%, there'll be one death every 89 days due to medication error a at Shands UF. When it comes to medication safety 99.9% reliability Is not good enough. But in some hospitals, conditions are far worse. We know that hospitals that use hand-written rather than electronic medication orders have a much lower reliability. Problems with reading handwriting and other issues result in only a 92% reliability. In other words, patients have an 8% chance of a medication error, with one medication order. If they receive 13 medications 3 times per day, that would be 39 medications administered, and they would be expected to experience nearly one error every day. If you were working or being cared for in a hospital without an electronic ordering system, beware. You should strongly consider finding another hospital. Reports suggest that in most hospitals, patients do experience one medication error per day. And in an 800 bed hospital, this would translate to 1 death every 3 days. I worry, as should you, that patient deaths caused by medication errors are being underreported. How can we improve medication errors? Whenever possible, simplify. Both the number of steps, and the medications count. The fewer, the better. Let's look at a very simple example, one that anyone who travels by airline knows all too well. When I have a very important meeting, I often book a direct flight. This requires me to drive to a larger airport Orlando or Jacksonville rather than used the local Gainesville Airport. Why do I accept the inconvenience of two hour drive to Orlando or Jacksonville? Let's calculate the likelihood of me being on time to my meeting. Many flights have an on time percentage of 80%. Therefore if I take a direct flight from Orlando or Jacksonville, I have a 20% chance of being late. Not great, but what happens if I book a connecting flight, each with an 80% on time record? Reliability is now 0.8 times 0.8 or 0.64. Therefore the chance of being late nearly doubles increasing to 36%. The other danger of course is if the plane is late I could miss my connection. Now we understand why the fewer steps the better. When it comes to medication safety, it's even more complicated than I originally described. There are on average 25 to 30 steps required between ordering, dispensing, transporting, storing, and administering. If each of these steps is 99.9% reliable, you can see the reliability run turns out to be even worse. Remember every step increases the risk of an error. Given the number of medications administered combined with the number of steps required to deliver the medications to patients' bedsides, it is very clear that 99.9% is not good enough. We in healthcare need to aspire to six sigma. What is this? That is a reliability of 3.4 mistakes per million actions or 99.99966%. And when it comes to fatal airline crashes the airline industry has achieved this goal. You can see that the number of fatal airline crashes, the blue line, has dropped to nearly zero despite a marked increase in the number of flights per year, the red line. In the next session, we will discuss some of the ways that our hospital system and others are trying to improve reliability. Shouldn't every hospital be trying to improve reliability? As you've seen so clearly with medication reliability, patients' lives are at stake. Thank you.