"Open Letter to the President"

42 CFR 482.51 & Reducing Surgical Errors

July 22, 2009

To: President Obama

From: Helen M. French RN, BSN

Re: One Major Method of Eliminating and /or Reducing Surgical Errors i.e. Save Lives and Limbs, Save Billions of Dollars, and Increase Quality of Healthcare at No Cost: Edit the verbiage in the CMS / COP reg. 482.51 (42 CFR 482.51 (a)(3)2)

The Verbiage Needs to Read: A operating room Registered Nurse called the "Circulator" must be present at all times on each patient's operative / invasive procedure for the entire length of the operative / invasive procedure. Circulating duties cannot be delegated, even under the expanded verbiage of supervision.

The Issue: Many hospitals in the United States DO NOT have a Registered Nurse with each patient in the operating rooms during surgery or even in areas where invasive procedures are being conducted (the OR RN is also called a Circulator or a perioperative nurse). Patients do not realize that because of the CMS verbiage as well as state law verbiage, the patient standard of care is not equal in all hospitals and clinics. Often, LPNs and UAPs (unlicensed assistive personnel) run the rooms and "scrub" without direct supervision of an OR RN in many hospitals. Having an OR RN somewhere "nearby" (whatever that verbiage might mean) fulfils legal "mandates." Surgeons cannot be and are not present at all times to “supervise" in the absence of a Registered Nurse! Incidentally, JCAHO does not "require" an OR RN Circulator per se to be in the operating room where patients are undergoing invasive procedures!

Since this letter is being sent out to people perhaps unfamiliar with operating room verbiage and especially operating room "job roles" I will attempt to explain the critical differences. The bottom line in simple language is, would anyone of you, the "recipients" of this letter, want to go into any operating room and NOT have an RN in charge of YOUR case / procedure? It is the OR RN who coordinates and is responsible for your entire case, mixes drugs, handles the blood, charts, etc. It is the OR RN's critical thinking skills which prevent patient errors! NURSES ARE WHAT DOES NOT HAPPEN TO PATIENTS. There are entire nursing books written on just the different aspects of surgery which the OR RN has to know in order to keep their patient safe. These "aspects" are beyond the "generic nursing education." No matter IF the RN is working with a pediatric or heart or gyn or plastic surgeon etc the fact remains that the OR RN has to deal with a multitude of issues on each case.

So being that Patient Safety Day is being observed on July 25, 2009 (and I do not represent any organization) and because so many nurses are afraid to speak out honestly on "patient errors," I felt compelled to write this letter to you at this time. I apologize for the length of my letter but I am making an attempt to explain a vital issue concerning patient safety to non-healthcare individuals. Questions can be directed to me at anytime.

I just pray that once my mass mailings to individuals go out, that I do not receive the same treatment afforded Dr. Codman. My trials and tribulations with my peers were not as severe as Dr. Codman's, but I am tired and I am in pain. I would like to hand over the "torch," BUT to whom, is the question.

http://www5.aaos.org/oko/ebp/EBP001/suppPDFs/OKO_EBP001_S29.pdf

Dear President Obama,

How are you? I like to introduce myself to you. My name is Helen M. French RN, BSN and I reside in the beautiful Shenandoah Valley in Virginia an area about 45 minutes away from President Jefferson's home.

I have received many honors over the years, one of which was a State of Virginia Resolution #739 for my MERCI Program which I founded and coordinated from 1991-12/2007. MERCI (Medical Equipment Recovery of Clean Inventory) "diverted" over 2,000,000 pounds of clean medical & surgical supplies directly from the hospital / community and/or from networking groups to research labs, to NGOs, to small mission groups, etc. The MERCI concept helps humanity, is environmentally friendly, is an education tool for nursing, medical, and generic students, and involves community volunteers. The MERCI concept, also importantly, could be developed into a useful emergency preparedness tool. MERCI was a 16 year, no-cost program under my direction. I never had an office or staff per se, but directed wonderful "volunteers". My home was my office. Even though I had to retire from nursing in 12/2007, I was recently recognized as a recipient of a 2009 Distinguished Nurse Award.

First of all, I want to let you know that I have you in my prayers every day because what you and Congress do affects not only my husband and I but also my entire wonderful family as well as the rest of our nation and all nations. No one in the world today is a lone ranger. What affects one in a good or bad way WILL eventually affect many others in a good or bad way. My "insider" opinions to you are based on my 33 years of operating room experiences, education, research and 35 years of patient advocacy! My "insider" opinions are best stated in plain, everyday non-legal verbiage. I have been accused of being too candid over the years BUT what is the price of a life? I know the operating room arena, I know the issues, and I know the solutions!

I have alliances with neither persons nor groups, and nothing in my address to you today is said with any malice, only with concern. My motivation is to save patients' lives. I am proud to say that I as a staff nurse never had a patient error occur in any of my operating rooms in which I worked daily for 33 years! My steadfast fastidiousness to all details and my reluctance to lower my work ethics, kept my patients safe!

Secondly, I want and need to point out that there are over 2.9 million Registered Nurses in the United States. My own national association has only about 40,000 members. The ANA (American Nurses Association) has only about 157,000 members. I want to make it very CLEAR that neither of these associations speak for me! I get very upset when I hear someone say, ALL nurses are for this or ALL nurses are for that! Until someone "contacts" all the 2.9 million RNs in the US, no one should be using these general terms! One will find in all walks of life that there are many who talk the talk but don't walk the walk and some who speak sincerely and mislead and others who fraudulently mislead!

Again, I ask, "What is the price of a life?" There can be no middle ground! The "Emperor's New Clothes" mentality for whatever reason exists, i.e. money, power, cronyism, secure job, etc. cannot be an excuse for any nurse to renege on their ethical and legal nursing responsibility to "Do No Harm."

There are successful operations done everywhere BUT official studies, now being collected and shared, are confirming what I have seen, read, researched or that which other nurses have shared that patient injuries needlessly occur! Many reports are out of date! For example, the IOM report, which stated that 44,000 - 98,000 people die from medical errors every year, was done in 1998. NEW data indicate that those numbers are the "tip of the iceberg." If people would research the real numbers of lawsuits as I have done after I sustained "RISKS" of surgery in 2007, they will learn that only 6% of all doctors are responsible for 60% of all medical negligence. I thought that the National Practitioners Data Bank was to be a monitor!

One more issue about TORTs is the fact that even though lawsuits have decreased, the insurance companies still have been raising their rates, so it is NOT the number of lawsuits driving up rates for doctors, it is the amounts of the settlements. Patients should never have their legal rights of recourse taken away! Attorneys of course like the open and shut cases! Important is the fact that most injured patients don't have $30-50,000 to pay an attorney to pursue their case.

Allow me to share with you some "real" operating room stories in abbreviated and simple verbiage. I have hundreds of other stories as well.

As my own:

1. Obese woman who underwent a long vaginal hysterectomy i.e. legs in stirrups, had to have both of her legs amputated. Her heavy thighs, while in OR stirrups, compressed i.e. closed off, her femoral arteries for hours. She died that year. I know the EASY solutions to this sad issue. This was not my case, BUT ever since that day early in my career up to the day I had to retire from nursing in 2007, I mentally pre-op dissected all "MY" cases as to what could happen, always thinking, "how can I prevent any harm from coming to my patients?"

2. Go on the web and read the recent case of an OR staff person from Colorado who was stealing narcotics from "vials," yes, they were caught, BUT not before "infecting" over perhaps 5000 patients with their Hep C virus! This solution is so simple that even a "fifth grader" can probably tell you what should have or not have been done. If you said that "someone" should have followed "regulations" and per regs had not left the narcotic unattended so the vial of narcotics would not have been tampered with and then the 5000 patients would not have to have sleepless nights worrying about the fact that they might end up being HEP C+, you would be correct! Some patients have already converted to positive AND THEN, having been a patient in 2007, I thought to myself OH MY GOSH, the SALINE that was placed into the "vials" to replace the narcotic would not have alleviated any patients' post op pain!

3. A shared story of an OR staff who consistently will not label their medicine cups, BUT this person always keeps the labels just in case "someone important” would walk in! I bet a "fifth grader" could tell you what is wrong with this scenario! IF I ran this OR, this staff person would be FIRED STAT!

4. I have hundreds and hundreds of stories BUT here is another one, why is a hospital attendant assisting on C-Sections? How can a UAP, any UAP, (unlicensed assistive personnel) be able to REALLY assist the surgeon safely. Are they educated enough to know IF the ureter is about to be cut by mistake ? Do they know what to do if during an emergency C-section the uterine artery is accidentally cut and hemorrhage occurs. It is difficult to operate on any normal c-section let alone when blood covers everything causing zero visibility! Surgeons are real people and surgeons, as do pilots, need and deserve educated / licensed "co-pilots." I ask, "who is holding your heart," "who is removing your saphenous so it can be used to replace your old blocked artery on your heart? "Who is cutting out the "valves" in the saphenous vein before giving it to the surgeon, i.e. the valves must be removed before the graft is placed on someone’s heart?

I know the issues, I know the solutions!

5. How about the retained sponge issue? Especially the big sponge that is called the lap sponge! One person ended up with a lap retained in their belly. Because of the massive infection the lap sponge caused, they had to have a colon resection. Later, sadly, they also had to have a trach tube inserted into their windpipe. The solution is easy: COUNT before the case, COUNT the appropriate times per the standards, and COUNT at the end with the surgeon still present in the room! A no brainer. No matter who might complain that counts take too long, counts must be done and done properly. Many staff still argue as to when and how many times to count. I ask "who the heck is in charge here?" There was at one time a "staff" member who hid "sponges" between the OR table and his belly while RNs crawled all the floors looking for the missing sponges when count time began.

6. IMPORTANT CAUTION: The definition of delegation is, in effect, the assignment of authority and responsibility to another person. However in nursing and in medicine, one really can only delegate "authority.” One cannot nor should not delegate responsibility. "Responsibility" in nursing and medicine would mean that the "person" to whom you are delegating responsibility is on the same educational / training plane as one self!

Solution: No one should legally or ethically work or practice outside of their "role" or "job description!" I could be assigned to assist in the harvesting of a kidney BUT this assignment of assisting COULD NOT / SHOULD NOT include the delegated function of preparing the kidney for implantation. Just because ONE thinks they can perform certain tasks / procedures, does not mean they should! Since patients are paying for a surgeon to do a job, then the surgeon needs to be doing that job. Otherwise, let us just get rid of all Medical Schools and Residency programs! Heck, maybe we can teach "these" skills in high schools. The system is already being asked to “automatically" allow corpsman to become LPN / RN without going through a formal nursing program. Corpsman are important in the military arena which has its own guidelines, etc. but in the private sector, anyone wanting to become a nurse, I feel, needs to go through a formal, accredited nursing program.

7. IMPORTANT CAUTION: The definition of supervision is often interpreted as "being near" to someone being supervised. However the word "supervision" is often used as "supervising" even from many buildings away, from another office, even across oceans, via the phone and video conferencing. The correct definition needs to be "direct supervision!”

Solution: One cannot supervise what is or is not going on in MULTIPLE operating rooms, no one is that good! Besides, this practice is against national nursing recommendations.

I decided to "attempt" to get this letter to you on surgical errors via someone else because being a realist, I know my correspondence sent directly to you, probably would not reach your desk, let alone your eyes.

The issue of surgical errors, as it relates to the absence of an OR RN Circulators in hospitals is one of paramount importance because it concerns the Public Safety of patients in all states. The main issue i.e. having no OR RN Circulator, in my opinion, affects not only patients but also their families, "physically, mentally, spiritually and financially". Also, the coffers of the United States of America can no longer sustain shoddy and substandard practices of any type of "operating room / invasive procedure room," be it in a clinic, ambulatory center, private or teaching hospital, or even in doctors' offices.

Please also keep in mind, that when anyone travels throughout our glorious USA since there are so many variations of policies at state level and especially because the CMS REG 482.5 allowed too much latitude in interpretation as to who can or cannot circulate that anyone can be confronted at any time with an emergency for which they might need surgical / invasive treatment, somewhere!
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How will you know who is "following standards and regs" because many staff are doing what they want? How do you know who is "pushing" the scope during your colonoscopy? Colons have been ruptured. How do you know who is really putting you to sleep and monitoring your BP and oxygen levels, and even intubating you if things go wrong? A sedative called Versed, which is often used on short procedures, causes "amnesia," BUT I always wondered if just because you don't consciously remember the pain during procedures IF your brain does? Propofol goes in IV push. I wonder if Michael Jackson knew who was or was not monitoring him?

The "issue" is the massive number of "surgical errors" occurring throughout all states! The "issue" has always been tracked in some small research, but not well publicized. The turning point, for the procurement of more accurate stats, has been the mandate in some states for "mandatory reporting of near misses."

See an interesting report from the State of Pennsylvania: www.Patientsafetyauthority/documents/annual_report_2008.pdf
PA passed a law in 2002 / enacted in 2004, that hospitals had to report "near misses." Pennsylvania was so overwhelmed with the massive amount of "reports" per month i.e. "15,000 per month," per a gentleman I spoke with, that the state outsourced its "data crunching / request for solutions" to ECRI in PA. Can you imagine 15,000 reports a month?

There are now many sites tracking "error issues" and one an interesting site is AHRQ.

As an FYI, some will call the OR RN Circulator a perioperative nurse. I detest the term "perioperative nurse." I believe that it is in the best interest of the public to know the OR RN as just that, an OR RN nurse. The public knows the RNs that work in the emergency room as ER nurses. The public knows the RNs that work with children as Pediatric nurses and etc. There is no shame in having a simple and clear "title." RN's are usually highly regarded just for being RNs! The issue in the operating rooms began years ago when Medicare / Medicaid (now CMS) stated that in ALL operating rooms, the Circulator needs to be a Registered Nurse, one RN in the OR is supposed to be the usual staffing ratio IF THAT! However, verbiage was tacked on stating that IF a state allowed, that a LPN or surgical tech could also circulate IF the RN was in the "operating suite," whatever that means! The SUITE could be an office 100 yards away! Unlicensed staff, i.e. techs, should not be administering drugs, blood, and etc!! JCAHO does not care WHO is in the OR! They have no standard that states that the circulator needs to be a RN! Why would any patient want to enter any OR room if they realized that there was no RN in the room coordinating their entire case, mixing drugs, charting, and enforcing "standards." All patients expect a RN in the ICUs, in the ER, in all units of a hospital! What makes some people feel that anyone can take the place of an OR RN Circulator? While we are letting everyone and their uncle do whatever they want in the OR behind closed doors, let’s just allow the first year medical students perform a heart transplant!

As far as the verbiage goes, AORN "supports" the surgical technologist role. First of all, the term "surgical technologist" designates one who went through a two year associate degree program in "surgical technology." There are TECHs scrubbing in the OR working as techs who have only a high school education and have learned to scrub on the job! Then there is a CST, i.e. a certified surgical technician, whose total course time might be 6 months to 18 months. And there are other such issues. Read for yourself on: www.AST.org. TECHs are not nurses.

So, out of our 50 states, some laws state firmly that the OR Circulator must be an OR RN and even then the verbiage is weak!! Over half of the other states really have no law regarding staffing requirements in the operating room. SCARY! Beware, when a friend of mine who lives in Tennessee, a state which has no law mandating a OR RN in the operating room, went for a D&C because of retained placenta. My advice was "meet the OR RN Circulator," not just the RN who checks you in, and ask to have a spinal block to stay awake. No Versed (that causes amnesia). No Propofol (it knocks you out). Stay awake! You never know who is and who is not going to be with you in the operating room behind the closed doors! Again I say, I have 35 years of stories and not just mine!

Therefore, in my humble but expert opinion, the solution lies not only with each individual operating room in each state but also lies at the CMS (Centers for Medical Services) level with the COP (Condition of Participation) 482.51 regulation which has been expanded, muddied, and twisted at each state level so much that it has caused confusion and non-conformance and non-adherence to any type of "recommendations / standards" made by anyone. Visits and mandates by various accreditation organizations cannot stem the tide of "patient errors/injuries/deaths," because announced visits which allow the ORs to "stage" do not force a permanent culture change! Reform starts and ends in each operating room! Each OR KNOWS what is going on or is not going on in their ORs.

I, therefore, am begging you and the others copied on this email to initiate "investigative journalism" of the issue off operating room and invasive procedures injuries and deaths. Demand the names of "those" who are circulating or scrubbing on each case as well as their qualifications and education, certifications etc. And have the findings submitted to "you," Mr. President. There will be "misrepresentations" by many and I will probably be shunned again BUT I have the evidence to what has and is "occurring" in many ORs, BUT I have the solutions. 99% of all the “solutions" are no cost! If no one wants to bother with "my solutions" then I have to suggest that when an issue occurs in any OR that injures, kills, or affects people adversely, then criminal charges should be filed on all involved! It is time to get tough because otherwise the CMS "NEVER EVENTS" will keep on occurring!

However, the CMS 482.51 regulation above ALL needs to be changed.

AGAIN, I can substantiate everything I am sharing with you because I have kept notes / correspondence on "nursing and/or hospital patient issues" for the last 35 years. PLEASE remind me to tell you about a 2003 incident! This was a time in my life that I sadly realized that not all nurses are "truly" worried about patients. However, "preventing an injury to a patient or preventing the needless death of a patient" is still the number one priority in my professional nursing career. I almost have all the facts as to what occurred to me on April 03, 2007 while I was undergoing surgery! Very important, because our system makes it very difficult for patients to sue their doctors. The injured patient, and rightfully so, burdens the healthcare system.

As for me, my "risks" of surgery as someone called them, although verified by outside surgeons and tests over the next many months, were never written up, i.e. no incident report was filed. My story is invisible and will never show up in any mandated reports! My "risks" of surgery never occurred!

Watching and listening to you on TV as you visited Ghana, I honed in to the "words" on a wall at one of the castles from which African slaves were deported. The writing on the wall said, "Door of No Return!" My own Ukrainian born father, as did other cultures, all had a "Door of No Return." No man from any country in the world has had a monopoly on freedom. We all have to fight for it.

As you and your wife's ancestors fought for freedom then, so it is still with many people. I was almost five when we arrived at Ellis Island, but I still remember neighbors telling my father to go "home." What home? His own parents were deported to "collective farms" a fancy name for a Russian concentration camp, while, except for one, all his other brothers all suffered / died because of the war. The sign, "Door of No Return" made me cry! One of these days I have decided to write a book for my "patients" entitled "Doors of No Return," because if one dies in the operating room, there is no Door of Return!

Please view my website, and please make sure your audio is on. Some nurses wrote me telling me my site is horrible, but I don't care what they think! During my surgery I didn't die BUT there were many days that I wish I had because my pain was very intense after surgery and for so many months afterwards! Now I have to deal with daily chronic pain and the knowledge that I have to have redo surgery! Only the thoughts of my children and grand children kept me from committing suicide after surgery. Now, I eat a lot of yogurt and just keep smiling when I am around people but in the inside most of the time I am enduring pain, especially at night. There is no excuse for what happened to me.

www.operatingroomrnwatchingoveryou.com

Since it has taken me a few days to compose this letter, I have to share with you another comment made by an OR nurse to me this evening! The nurse accused me of "collaborating with attorneys to detect errors?" Even with my site, my opinions based on my education, expertise, experiences, and my research, to this day, I have never "collaborated with attorneys to detect errors." But now, Mr. President, put yourself in my shoes for a few minutes. This is what happened to me:

What would you think if when you woke up from neck surgery completed at two levels for herniated discs i.e. HNP, and you felt as if you were being stabbed constantly in both arms and as a result screamed for three days?

What would you do IF the pains post-op then settled in your thumbs, your wrists, and the length of your arms and even your shoulders, with the stabbing pains relentlessly waking you up all night, every night even after you got home, and you cried like hell?

What would you think if you couldn't open up your eyes for days because you were so weak and you wondered what caused you to have a sudden high blood ammonia? And why did some stupid non-thinking staff had the gall to tell you to be "happy, and to open up your eyes."

I wonder if they were the same staff that did not answer my call bell when I desperately needed assistance to go to the bathroom, golly, my siderails were in the up position, a little hard to climb over them especially since I was so weak. How humiliating for me when I had to urinate in my bed several times. Belittling!

What would you think if when you were given food and pills later in the week with "gagging" resulting each time? Gagging / choking when you eat or drink and still occurring after two years and always leaving you with lingering fear of aspiration! Would you like to feel the presence of a chicken bone in your throat at all times? I am petrified to have the needed redo surgery!

What would you do when subsequent tests performed at two other hospitals showed that the top of the metal plate is protruding into your throat and that one of the six screws has always been partially OUT i.e. not flush with the metal plate and is actually covered by your esophagus, hmm, could erosion occur at this screw site. Hmm, if a cabinet maker did shoddy work on the hinges of your kitchen cupboards, would you pay him? Screwing down a screw is not rocket science. It took many tests and months of driving back and forth to surgeons to "discover" what was wrong with me! Subsequently, all my "complaints" were validated by TESTS!

What would you do if you had a burn on your left hand, after surgery and the issue was never addressed?

What would you do if you found out from tests that you now have a full left shoulder tear and a partial right shoulder tear called rotator cuff tears? I DO! Could it be from the way your arms were pulled down and then tied to the OR table in order to 'separate" your neck vertebrae?

Another reason to scream after surgery, you would now experience pain even just playing ball with your beautiful daughters!

All activities of daily living (ADL) will be painful! MINE ARE!

What would you do when you are told you need "corrective surgery" to remove the metal implant and six screws as well as 'decompress the second level which was not "completely fixed?" Would you not be scared? I am scared to death. Scared for the first time of post op pain and lingering pain, and scared of ending up in a wheelchair with a feeding tube down my esophagus and perhaps living in a nursing home till I die! I still remember my mother's nursing home situation!

I apologize for my lengthy letter. I had to vent and I'm in pain! Lastly, and excuse my redundancy, EACH FACILITY KNOWS THEIR ISSUES!

All issues which often are not necessarily seen by the higher powers are being tracked daily by staff doing "quality reports." This is where the reform must ORIGINATE AND END if issues occur then the manager should be fired! Managers have to have the guts to correct issues as well as be given the power to correct the issues! In the end everyone will be a winner!

Shoddy care in some facilities coupled with the lack of an OR RN Circulator in the OR etc. is costing the healthcare system billions of dollars. Not my "figures."

Studies show that 30% of all patients released from a hospital return within 30 days!

Let us not allow a patient's medical number become a number of death. Let us not allow the medical number become a symbol of a GULAG ARCHIPELAGO! The COP reg. 482.51 (42 CFRs, 482.51 (a)(3)2) has to be defined clearly.

Also, individual state manipulation of the verbiage cannot be allowed, as patients' life and limb and quality of life depend on it!

My opinions and most importantly, I will always be MY PATIENTS' ADVOCATE!

Respectfully,
Helen French RN, BSN
Fulltime Operating Room Nurse 1974 - 12 / 2007
Founder and Coordinator of the UVA MERCI Program 1991 - 12 / 2007
(Medical Equipment Recovery of Clean Inventory)
Most recently a recipient of a 2009 Sigma Theta Tau International Chapter Distinguished Nurse Award
My last Virginia State evaluation was "exceeds all expectations"
Resume provided upon request

July 25th: Patient Safety Day

I was given permission to share the following info / site with you:

PATIENT SAFETY DAY
National, World, Global Patient Safety Day

JULY 25th - CANDLELIGHT MOMENT OF SILENCE AND HOPE

Remembering patients and families who have lost their life (or quality of life) due to medical errors - and in tribute to those who work to improve the safety and quality of healthcare for future patients.

"Together, lighting the path to safe healthcare - today and everyday: safe, high quality healthcare is neither accidental nor static."
Time: Moment of Silence at Noon and 6 p.m. your time zone
2009 Inaugural Florence Nightingale and Dr. E. Codman Patient Safety Day
Award recipient is Dr. Lucian Leape.

PATIENT SAFETY DAY
NATIONAL, WORLD, GLOBAL
Mission: Offer hope, healing and advocacy for safe healthcare - today, everyday, everywhere.
Vision: Saving lives and reducing healthcare costs through elimination of preventable medical errors.
Since 2001, many of you have joined with others throughout the world in the annual Patient Safety Day observance on July 25th. Upon last count, patients, families, providers and consumer groups from at least 40 states and several countries have participated in the Patient Safety Day moment of silence and candlelight vigil; in tribute to those who work to improve the quality and safety of healthcare for future patients - in memory of patients and families who have lost their life or quality of life due to medical errors. Wherever you are on July 25th, in your home, at work or a group Patient Safety Day event within your community, light a candle (or turn on your headlights if in your car) or simply take a moment to pause at noon and 6 p.m. your time zone for a moment of silence that will connect you with others across the world on Patient Safety Day.

Patient Safety Day is a time to embrace life, loss, change and hope in your own way; a day that gives everyone a moment of silence to reflect and join in a shared vision of safer healthcare and a shared moment to honor the lives of all patients and families harmed by medical errors.

P.U.L.S.E., Voice4Patients, Patient Safety Cleveland, Association of Dialysis Advocates, Mothers Against Medical Error, 1stDoNoHarm, Luna'sLight, Colorado Citizens for Accountability, Floridians For Patient Protection, Pennsylvania Patient Safety Authority and Consumers Union are some of the groups who have joined in support of Patient Safety Day on July 25th in the past. Everyone is welcome: please join hands or hearts, connecting again this year with individuals and families across the United States, Canada, United Kingdom, Mexico, Korea, Germany, France and throughout the world. We are pleased to announce that the Inaugural Florence Nightingale and Dr. E. Codman Patient Safety Day Award recipient is Dr. Lucian Leape. Below is one article that references the values and achievement of both Florence Nightingale (briefly) and Dr. E. Codman – two selfless pioneers. Florence Nightingale, a nurse, was the first epidemiologist, statistician, evidence-based practice and patient safety pioneer who focused on outcomes in health care. Dr. Codman followed with his stellar surgical career and hospital evidence-based "end results" theory and practice. Nightingale and Codman represented the values, character and pioneering evidence-based translational practice that placed patient safety and quality outcomes above all else. Dr. Lucian Leape follows in and broadens the "patient safety first" footpath of Florence Nightingale and Dr. E. Codman.

http://www5.aaos.org/oko/ebp/EBP001/suppPDFs/OKO_EBP001_S29.pdf

Patient Safety Day Committee
Patti O'Regan, ARNP, Committee Chairperson
Ilene Corina, Award Committee Member
Jennifer Dingman, Award Committee Member
Becky Martins, Award Committee Member
John McCormack, Award Committee Member
Roberta Mikles, RN, Award Committee Member

Contacts:
Patient Safety Day Committee
Patti O'Regan, ARNP, Chairperson (727) 845-4250, pattioregan@gmail.com
Becky Martins, Awards Committee Secretary (207) 975-3475
voice4patients@aol.com

FOR IMMEDIATE RELEASE - JULY 15, 2009
LUCIAN LEAPE, M.D. RECEIVES 1st NIGHTINGALE & CODMAN PATIENT SAFETY DAY AWARD LUCIAN LEAPE, M.D., Adjunct Professor of Health Policy, Harvard School of Public Health and pediatric surgeon has been selected as the recipient of the inaugural Florence Nightingale and Dr. E. Codman Patient Safety Day Award. The award is being given in conjunction with this year's 9th annual Patient Safety Day and the 10th year anniversary of the Institute of Medicine's groundbreaking patient safety in America report to Congress.

Florence Nightingale was one of the first epidemiologists, statisticians, evidence-based practice and patient safety pioneers in nursing and healthcare. Dr. Codman followed with his stellar surgical career and hospital evidence-based "end results" theory and practice.

Nightingale and Codman represented the values, character and pioneering evidence-based translational practice that placed patient safety and quality outcomes above all else. In recognition of his pioneering research in patient safety and quality of care, Dr. Leape has been selected as the 2009 recipient of the award which honors those who represent the values and furtherance of the patient safety work of Nightingale and Codman.

Like Nightingale and Codman, Dr. Leape has devoted his professional career to learning about and understanding medical error epidemiology; how they occur and what must be done to improve patient safety. Dr. Leape is known to patient safety advocates as the father of the modern patient safety movement. He was a lead investigator of the Harvard Medical Practice Study (1991) and a member of the Institute of Medicine's Quality of Care in America Committee, which published the landmark 1999 "To Err is Human: Building a Safer Health System" report that indicated up to 98,000 hospital patients die annually from medical errors. He published one of the first studies showing the application of systems theory to the prevention of medication errors. He is an outspoken advocate of full disclosure, transparency, and prompt apology when patients have been harmed by errors. Dr. Leape's patient safety service includes being a founding member of the National Patient Safety Foundation, the Massachusetts Coalition for the Prevention of Medical Error, the Harvard Kennedy School Executive Session on Medical Error and the Lucian Leape Institute, a think tank, founded in 2007.

Patient Safety Day is held on July 25th annually. Patients, families, healthcare providers and consumer groups join together in a moment of silence and candlelight vigil at noon and 6:00 PM; at home, work or wherever you are - in memory of patients and families who have lost their life or quality of life due to medical errors - and in tribute to those who work to improve the quality and safety of healthcare for future patients. The event now draws participants from more than 40 states and numerous countries.

For additional detail on the 9th annual Patient Safety Day, please visit
www.patientsafetyday.com

Helen M. French RN, BSN