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followed on the floors post discharge. In fact, once my medical director insisted that because we were seeing an increase in readmissions for respiratory-related problems that it was a problem that the respiratory care department needed to address and solve. This checklist can do this as it takes into consideration the key components of patients’ readiness. Included is: • Level of consciousness • Gag reflex • Ventilator status • Vital signs • Gas exchange. There is also an assessment of known risks that are considered. They include: • Patient was mechanically ventilated • Sleep apnea • Supplemental oxygen over 50% FiO2 • Time in the ICU • Dialysis. Based on these assessments, the patient’s risk classification is determined and scored. From this the clinician can make a reasonable recommendation of egress from the ICU. Additionally, we recommend the use of protocols that the RT can use post discharge. In doing so, the patient will still have a periodic assessment from the respiratory therapist. Get on the team! ICU readmissions are associated with dramatically higher hospital mortality rates, and the best predictor of ICU readmission is the patient’s vital signs.4 I would also add that because respiratory and cardiac conditions are the most common reason for readmission, that it is incumbent on the respiratory therapy team to be part of the solution to this problem. We will be hearing more about the Patient Safety Movement in the years to come. While this is one of many initiatives that have been put in place, I do urge you to learn more about it. Become a front-and-center knowledgeable clinician in your hospital who will be sought after for your expertise in respiratory management and who — with the rest of the team — will help us bring down preventable patient deaths to zero by the year 2020. ■ REFERENCES 1. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J P • 1999: To Err is Human • 44 to 98K deaths • SYSTEM fix • Spurred first wave of changes in healthcare • Science of patient safety is still evolving Preventable Events In Hospitals • Office of Inspector General, reviewed 780 Medicare charts • 27% experienced harm • 13.5% adverse events • 1.5% contributed to deaths (180K /year) • 44% of all harm events were preventable https://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf James JT. J Patient Saf 2013;9: 122-128 Estimates of Errors Vary Wildly: Does it Matter? • NYT: Death by Medical Error: Adding Context to Scary Headlines • Contribute vs cause • Preventability • Complexity • Numbers should not detract from the work that must be done New York Times, August 2016 http://www.nytimes.com/2016/08/16/upshot/death-by-medical-error-adding-context-to-some-scary-numbers.html Medical Errors Defined • Types of ME • Diagnostic • Treatment • Prevention • Communication • Medication • Adverse event: any injury from medical intervention • Errors of comission vs omission • Not always well defined… What Do Patients Think? Using Social Media • Of 1006 tweets, 99% were from patients or their family member • 52% blamed physician, 16% hospital • Most common procedural (26%), medication (23%), diagnostic (23%), surgical (14%) • Examples • “…Hubby went in for what should have been a straight forward procedure. Surgeon screwed up and Brian died in my arms in February” • “Nurse gave me the wrong shot!! OMG what if I died or what if something bad happened I mean I’m already sick #scared” • “Just wanted to tell you all that I am going to be ok. The doctor made a mistake. I do not have cancer. Thank God!” • “Love getting a letter that says my doctor messed up my leg by my lawyer and that we go to court in less than two months.” Nakhasi A. et al. The potential of Twitter as a data source for patient safety. J Patient Saf 2016 No Signifcant Change in Harm Over 7 Year Period Landrigan et al. N Engl J Med 2010; 363:2124-2134 Florida is Making Gains: 2015 FHA Quality Report Florida Hospital Association http://fha.informz.net/FHA/data/images/FHA/2015QualityReport.pdf Medical Errors in the Ambulatory Setting • Less than 10% of studies • Ambulatory malpractice claims account for almost half compared to