Welcome back everybody. In this last review of our report that is important in quality and patient safety, we wanted to take the time to review a more recent report called, Free from Harm: Accelerating Patient Safety Improvement 15 Years After To Err is Human. So this report was published by the National Patient Safety Foundation in 2015. It highlighted how patient safety continues to be a serious public health issue, and that preventable harm 15 years later, remains unacceptably frequent. And I think an important point that was outlined in this report was that preventable harm occurs not just in hospitals. If you recall the, To Err is Human report, talked about preventable harm just in the context of inpatient hospitalization. But this report goes on to say that preventable harm is happening everywhere care is provided. And those include an ambulatory care clinics, in diagnostic centers, in long-term care facilities, in patients homes, when they get home care. And in other locations. It does highlight and reiterate that in 1999 estimates, that preventable harm or medical errors were a significant cause of mortality. So 44000 and 98000 people were dying from medical errors. Again, these are the 1999 estimates. And that was in fact more than the number of deaths caused by car crashes. The number of deaths caused by breast cancer every year, and the number of deaths from AIDS. But we're really to understand the full impact of patient safety, we must not look at just mortality, but we need to also look at morbidity. Because people can have significant morbidity as a result of patient safety errors that don't yet lead to death. And so again, to understand this, they highlight in this report that in fact one in 10 patients develop the healthcare acquired condition such as an infection, a pressure ulcer, a fall, an adverse drug event, during hospitalization. So this begins to quantify the morbidity that patients suffer as a result of preventable harm in healthcare. It also highlights in this report that we need to look beyond hospitals to the full care continuum to really begin to understand the morbidity and mortality associated with preventable harm. So that small orange circle, highlighting 35 million people, were admitted annually to hospitals in the United States. However, that's just a small proportion of the total care that's received across the care continuum. As an example, we're able to highlight that there's roughly 1 billion ambulatory visits that occur in the US every year. And there's preventable harm that's happening there. And so just to focus on that small group of 35 million with hospital admissions, is a gross under estimation of what's really happening in patient safety and quality with across the care continuum. This report does go on to say that by some measures, we have made progress. So as an example, there have been 1.3 million estimated reductions in hospital acquired conditions, as a result of the Federal Partnership for Patients Initiative. And that's highlighting that we are making progress on some hospital acquired conditions. But that's not the progress that's going to be sufficient to tackle this problem across healthcare. So what free from harm does. It says that we need a total system safety approach, that there needs to be advancement in patient safety that requires an overarching shift from reactive piecemeal interventions to a total systems approach to safety. And this report goes on to provide eight recommendations. The first recommendation is that we needed to ensure that leaders establish and sustain a safety culture. Because improving safety requires an organizational culture that enables and prioritizes safety. The importance of culture change, needs to be brought to the forefront, rather than taking a backseat to other safety activities. Really important recommendation here. Safety culture is the building block with which we can build upon, to lead to preventable harm reductions. Recommendation number two, is to create centralized and coordinated oversight of patient safety. That optimization of patient safety efforts require the involvement, coordination, oversight of national governing bodies, and other safety organizations. So this has to be done both nationally, but also locally. Recommendation three, was that we needed to create a common set of safety metrics that reflect meaningful outcomes. Measurement is foundational to advancing improvement. And to advance safety, we need to establish standard metrics across the care continuum and create ways to identify and measure risks and hazards proactively. Recommendation four, was around increasing funding for research in patient safety and implementation science. Because to make substantial advances in patient safety, both safety science and implementation science should be advance to more completely understand safety hazards and the best ways to prevent them. The fifth recommendation was to address safety across the entire care continuum. Because patients deserve safe care in and across every city. Healthcare organizations need better tools, processes, and structures, to deliver care safely, and to evaluate the safety of care in various settings. The sixth recommendation was to support the healthcare workforce. Workforce safety, morale, and wellness, are absolutely necessary to providing safe care. All of these roles need support to fulfill their highest potential as healers in healthcare. The seventh recommendation was around partnering with patients and families to provide the safest care. Because patients and families need to be actively engaged at all levels of healthcare. At its core, patient engagement is about the free flow of information to and from the patient. And then the eighth recommendation, it was to ensure that technology is safe and optimized to improve patient safety, and that we needed to optimize the safety benefits and minimize the unintended consequences of health IT, and then that was a critically important initiative. So in summary, the Free from Harm: Accelerating Patient Safety Improvement 15 years After To Err Is Human took a critical look at the progress we've made, which in some instances was substantial, but also outlined further recommendations to deliver on that promise in crossing the quality chasm that we needed to make care safe and high quality for everybody. Thanks and have a great day.