I went to the open discussion on transforming patient safety held by the National Patient Safety Foundation Lucian Leape Institute members who are world recognized leaders in healthcare. These interactive conversations were an opportunity to hear what this group of top, patient safety experts are pursing and recommending to create change in patient safety.

Each small group was led by one of the members to help us learn - but they too listened for feedback. Medical students filled the room which, for the first time gave me great hope for the future of patient’s safety.

The first group I sat in on was led by Dennis O’leary MD, President Emeritus of The Joint Commission. He spoke on Reforming Medical Education. Acknowledging the lack of patient safety in medical school education, Dr. O’leary suggested some draft recommendations for medical schools such as patient safety education should start early, and be a required curriculum.

He also suggested that potential medical students should be screened for questionable behavior. Once they become students, they can go on to become problem doctors if there is no screening process. There also needs to be an environment created that shapes skills attitudes and behaviors.

One audience member suggested that medical students need to be asked, following a conversation with a patient to talk about the patient. Not the diagnosis, disease or treatment, but the patient. Recognize if a hospital room has flowers or cards, find out who they are from. Learn about their life and their interests. Patients want more compassionate doctors and this will take education and practice.

The next session was led by Donald Berwick, MD, MPP CEO of Institute for Healthcare Improvement. Dr. Berwick led a discussion on transparency. There are four different levels of transparency in healthcare. 1) Disclosure after a medical error to the patient, family and staff. 2) Learning within a system and sharing the information 3) Sharing information amongst other facilities and 4) Reporting information to the public.

The group discussion was about reporting information to the public. Although only 26 states require mandatory reporting of medical errors to the public, there is still a lot of controversy if states are really reporting, who is watching to see if information is reported and does the public read this information. Or is this information available just for hospitals to compete against each other?

Public reporting of hospital infections or medical injuries is something the public wants to know about but the information must be complete and accurate.

This program was well done and helpful. It’s good to see that this information is being discussed amongst our leaders, but when I leave I wonder why this isn’t all happening already. If the public only knew what is being talked about as a plan, and not presently being done, they too would be shocked at how slow patient safety is moving.