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from the University of Chicago, and her law degree from Brooklyn Law School. She was co-principal investigator for the Demonstration Mediation and ADR Project, and is principal investigator for the New York City Pilot Mediation Project for Medical Malpractice Claims funded by a grant to Columbia Law School. She is a Lecturer at Columbia Law School and can be reached at CSHyman@aol.com. The project on Medical Liability in Pennsylvania (www.medliabilitypa.org) is a two-year program of research, consultation and communication funded by The Pew Charitable Trusts that seeks to provide decision-makers with objective information about the ways in which medical, legal, and insurance-related issues affect the medical liability system, to broaden participation in the debate to include new constituencies and perspectives, and to focus attention on the relationship between medical liability and the overall health and prosperity of the Commonwealth. The Pew Charitable Trusts (www.pewtrusts.org) serves the public interest by providing information, advancing policy solutions and supporting civic life. Based in Philadelphia, with an office in Washington, D.C., the Trusts will invest $177 million in fiscal year 2005 to provide organizations and citizens with fact-based research and practical solutions for challenging issues. We are all painfully aware of the problem of patient safety in health care. More specifically is the growing number of preventable deaths that occur in our nation’s hospitals at an alarming rate. Some estimate there are over 200,000 preventable deaths. This may be a conservative guess as other studies have put preventable deaths at over 400,000 annually according to James et al.1 This is a 100,000 increase over the past decade. The problem is getting worse, not better. These preventable incidents occur, according to James, in five categories: errors of commission, omission, communication, context, and diagnostic. When looking at this even more closely, however, the causes seem better aligned to: • Failure to diagnose and treat a complication in a timely manner • Medication errors • Overuse of blood transfusions • Infections related to IVs • Overuse of supplemental oxygen to infants • Late or missed diagnosis of congenital heart disease in infants • Hospital-acquired infections • Lack of communication between care providers • Need for a better reporting mechanism for errors and unsafe conditions.2 The Patient Safety Movement is in its second year of existence and has taken this problem head on. Founded by Masimo CEO Joe Kiani, this movement has gathered significant attention and support by the government, The Joint Commission, clinicians, hospital administrators, payers, manufacturers, and most importantly, patients. By getting all interested parties to work together to reduce and eliminate these deaths, the movement is getting credible commitments, and changes are starting to be noticed. Their stated goal is to bring to zero the number of preventable deaths by 2020. Patient safety checklists In January of 2014, a Patient Safety Movement Summit was held. Over 400 invited guests were present to hear some of the best minds in health care talk about how we can help bring these numbers down. One of the presenters was Patrick Dunne, MEd, RRT, FAARC, who shared the two safety initiatives that the AARC developed. They come in the form of checklists and are available for anyone to use and to customize in their own institution.3 There are three checklists. One is an adult risk assessment for patients being discharged from the ICU, and the other two are for patients who are transported within the hospital. The transport checklists were developed after a systematic review of the literature with the intention of finding the most common safety error that related to oxygenation in the hospital. It was patient transports that emerged as the common thread. There may be many reasons for this, but chief among them is that RTs are frequently not present during house transports. RTs prepare the patient for the transport but are not always with them during the transport — instead leaving this role to transporters and nurses. The main components of the transport checklists are categorized into: • Patient readiness for transport • Monitoring equipment: device readiness • Oxygen supply. Preventable Patient Safety Errors by Thomas J. Kallstrom, MBA, RRT, FAARC Thomas J. Kallstrom, MBA, RRT, FAARC, is executive director and chief executive officer of the AARC. about the author… Executive Office Update AARC Times March 2014 25 While these precautions may seem rudimentary to a respiratory therapist, it is essential that all components be assessed and functional by anyone who has anything to do with the transport. These checklists can and should be modified for your own institution as no two hospitals and procedures are ever alike. The other checklist was developed for patients about to be discharged from the intensive care unit. It was developed with a team of physicians, nurses, and respiratory therapists. It allows the RT to use an objective tool that will classify risk pre-discharge. As a long-practicing respiratory therapist and department director myself, I often observed that there were some patients who, due to the need for bed space, were released from the ICU (perhaps prematurely) and were not adequately