With the introduction of the Patient Protection and Affordable Act and Partnership for Patients, a collaboration between the U.S. Department of Health and Human Services, hospitals, employers, health plans, physicians, nurses and patient advocates, the focus on patient safety has grown considerably. Healthcare leaders across the country are searching for ways to reduce readmissions, hospital-acquired infections and preventable errors. The following individuals have been and continue to be influential in efforts to improve patient safety in healthcare settings. These patient safety advocates have been chosen through careful research and consults with other patient safety advocates. Individuals were chosen using several criteria, including leadership positions in patient safety-related organizations, research and other writing that have shaped the field, success in raising awareness of key issues, awards for patient safety and implementation of initiatives that have improved the quality and safety of care.
Note: Names are listed in alphabetical order.
James Bagian, MD, PE. Dr. Bagian, a former NASA astronaut, is a professor in the departments of industrial engineering and anesthesia and director of the Center for Health Engineering and Patient Safety at the University of Michigan. From 1999-2010 he served as the first director of the VA National Center for Patient Safety and the first chief patient safety officer for the Department of Veterans Affairs, where he developed several patient safety tools and programs.
He is a member of the Institute of Medicine and the board of governors of the National Patient Safety Foundation and is a fellow of the Aerospace Medical Association. He is one of the authors of "Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety" and has written multiple other publications. Under his leadership, the VA National Center for Patient Safety received the John M. Eisenberg Patient Safety Award for System Innovation in 2002.
David W. Bates, MD, MSc. Dr. Bates is chief of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital in Boston, a professor of medicine at Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health, where he co-directs the Program in Clinical Effectiveness. He is also editor of the Journal of Clinical Outcomes Management and associate editor of the Journal of Patient Safety. Dr. Bates serves as medical director of Clinical and Quality Analysis for Partners Healthcare System, executive director of the Center for Patient Safety Research and Practice and external program lead for research in the World Health Organization's Global Alliance for Patient Safety. He has been elected to the Institute of Medicine, American Society for Clinical Investigation and Association of American Physicians.
Dr. Bates has received several awards, including the 2002 John M. Eisenberg Patient Safety Research Award, the 2006 Board of Directors Honor Award of Excellence in Medication-Use Safety and the 2010 Don Eugene Detmer Award for Health Policy Contributions in Informatics. He has published over 400 articles related to patient safety, including a seminal study on the epidemiology of drug-related injuries and research on information systems' impact on patient safety.
Donald M. Berwick, MD, MPP. Dr. Berwick is the administrator for the Centers for Medicare and Medicaid Services, through which he has helped initiate patient safety initiatives such as Partnership for Patients and patient safety incentives in health reform legislation. He is also adjunct staff in the Department of Medicine at Boston's Children Hospital and a consultant in pediatrics at Massachusetts General Hospital. In the past he served as president and CEO of Institute for Healthcare Improvement, chair of the National Advisory Council for the Agency for Healthcare Research and Quality and a member of IOM's governing council. He was previously a clinical professor of pediatrics and healthcare policy at Harvard Medical School and a professor of health policy and management at Harvard School of Public Health. In 1997 and 1998 he was appointed by President Clinton to serve on the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.
Dr. Berwick has won several awards, including the 1999 Ernest A. Codman Award, the 2006 John M. Eisenberg Patient Safety Award and the 2007 William B. Graham Prize for Health Services Research.
Rick Boothman, JD. Mr. Boothman is chief risk officer at Ann Arbor-based University of Michigan Health System. He participated in the Agency for Healthcare Research and Quality's National Advisory Committee Subcommittee for Patient Safety and Medical Liability Reform. He serves on the board of governors of the National Patient Safety Foundation and on the board of directors of the Michigan Hospital Association Patient Safety Organization.
At the University of Michigan Mr. Boothman led an approach to unanticipated patient outcomes that responds with honesty and transparency. He co-authored an article that showed the program decreased the number of claims for compensation against UMHS. In addition to reducing claims, the program has changed the organization's culture around patient safety, promoting a more accountable, proactive reaction to errors.
Mark R. Chassin, MD, FACP, MPP, MPH. Dr. Chassin is president of The Joint Commission and of the Joint Commission Center for Transforming Healthcare, which he created in 2009 to address quality and safety problems in healthcare. He previously served as the Edmond A. Guggenheim Professor of Health Policy and founding chairman of the department of health policy at Mount Sinai School of Medicine and executive vice president for excellence in patient care at Mount Sinai Medical Center in New York City. At Mount Sinai he formed a quality improvement program that focused on safety, clinical outcomes, patient and family experiences and the caregiver working environment.
Dr. Chassin was also Commissioner of the New York State Department of Health. In addition, he practiced emergency medicine for 12 years and conducted research on healthcare quality measures and health policy. He was also part of the Institute of Medicine committee that published "To Err is Human" and "Crossing the Quality Chasm." Dr. Chassin is a member of IOM and a lifetime member of the National Associates of the National Academies. He received the Founders' Award of the American College of Medical Quality and the Ellwood Individual Award of the Foundation for Accountability.
Charles R. Denham, MD. Dr. Denham is editor-in-chief of Journal of Patient Safety. He is also founder and chairman of the medical research organization Texas Medical Institute of Technology. Dr. Denham serves as chairman of The Leapfrog Group Safe Practices Program, funded by TMIT, co-chairman of the National Quality Forum Safe Practices Consensus Standards Maintenance Committee, faculty member for technology assessment and adoption at IHI and member of the International Steering Committee for the World Health Organization Collaborating Centre on Patient Safety Solutions.
Dr. Denham was an associate professor of biomedical engineering at the University of Texas in Austin for 20 years, a fellow of the Harvard University Advanced Leadership Initiative in 2009 and a senior fellow of the same program for 2010. He invented software-based innovation design and development decision support systems and was the executive producer of the film Chasing Zero: Winning the War on Healthcare Harm.
Atul Gawande, MD, MPH. Dr. Gawande is a surgeon at Boston's Brigham and Women's Hospital and the Dana Farber Cancer Institute as well as a writer for The New Yorker. He has written several books, the latest of which is The Checklist Manifesto. He is a professor at Harvard Medical School and at Harvard School of Public Health, and program lead of the World Health Organization's Safe Surgery Saves Lives initiative, through which he helped develop a surgical checklist that has improved patient safety. Dr. Gawande is currently working with WHO to develop a safe childbirth checklist and is researching the effective and ineffective use of the WHO Safe Surgery Checklist.
He is also director of the Risk Management Foundation/Harvard Surgical Chiefs Patient Safety Collaborative and executive director of Lifebox, a company created by the Global Pulse Oximetry Project of the World Federation of Societies of Anaesthesiologists. He was named a MacArthur Fellow for his research and writing in 2006 and won the National Magazine Award for Public Interest writing in 2010. From 1992-1993, Dr. Gawande served as a senior health policy advisor in the Clinton presidential campaign and White House.
Helen Haskell. Ms. Haskell is founder and president of Mothers Against Medical Error, an organization dedicated to promoting patient safety and providing support to those affected by medical errors. She is also co-founder and co-leader of The Empowered Patient Coalition, which provides resources and education to the public. In addition, Ms. Haskell serves on the board of Consumers Advancing Patient Safety. In 2005 in South Carolina, she helped pass the Lewis Blackman Patient Safety Act, named after her son who died from medical errors. This legislation was followed by the creation of the Lewis Blackman Chair of Patient Safety and Clinical Effectiveness, an endowed professorship at the Medical University of South Carolina. Ms. Haskell also shares her experience with medical error in "The Story of Lewis Blackman," part of an educational video series called "The Faces of Medical Error…From Tears to Transparency."
Gary S. Kaplan, MD, FACP, FACMPE, FACPE. Dr. Kaplan is chairman and CEO of Seattle-based Virginia Mason Health System, where he has implemented the Virginia Mason Production System, based on the Toyota Production System, to reduce costs and improve quality, safety and efficiency. Under Dr. Kaplan's leadership, Virginia Mason was named a Distinguished Hospital for Clinical Excellence by HealthGrades in 2011, a Top Hospital by The Leapfrog Group for five consecutive years and was one of two hospitals named a Leapfrog Top Hospital of the Decade for patient safety and quality. Dr. Kaplan is also a clinical professor at the University of Washington, secretary-treasurer of IHI and chair of the National Patient Safety Foundation's board of directors. He serves on the board of Washington Healthcare Forum and is a founding member of Health CEOs for Health Reform. In 2009, Dr. Kaplan won the John M. Eisenberg Award for patient safety and received a Harry J. Harwick Lifetime Achievement Award from the Medical Group Management Association.
Sorrel King. Ms. King is co-founder and president of the Josie King Foundation, an organization that supports innovative patient safety programs. She is an active public speaker on patient safety issues. In 2001, she delivered a speech to attendees of the Institute for Healthcare Improvement conference on the medical errors that led to the death of her daughter, Josie, The DVD of her speech is used by many hospitals and health systems to promote a culture of patient safety. Ms. King has also written a book on her experience: "Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safer," which was named one of the best health books by the Wall Street Journal in 2009. In addition, she was featured in a 2006 documentary, "Remaking American Medicine."
Lucian L. Leape, MD. Dr. Leape is a professor at Harvard School of Public Health and former chief of pediatric surgery at Boston's Tufts University School of Medicine and Tufts Medical Center (formerly Tufts-New England Medical Center). He co-founded the National Patient Safety Foundation, Massachusetts Coalition for the Prevention of Medical Error and Harvard Kennedy School Executive Session on Medical Error. He was also a member of the Institute of Medicine's Quality of Care in America Committee. Dr. Leape chairs the Lucian Leape Institute at the National Patient Safety Foundation, created in 2007 as a patient-safety think tank. In 1994 he published an influential article, "Error in Medicine" in the Journal of the American Medical Association and was a member of the IOM's committee that published "To Err is Human" in 1999 and "Crossing the Quality Chasm" in 2001. He has won several awards, including a Robert Wood Johnson Foundation Investigators Award in Health Policy Research in 1998, the Lifetime Achievement Award from the Institute for Safe Medication Practices in 2001 and the John M. Eisenberg Patient Safety Award in 2004.
Peter J. Pronovost, MD, PhD, FCCM. Dr. Pronovost is a practicing anesthesiologist, professor and researcher. He is a professor at the Johns Hopkins University School of Medicine, the Bloomberg School of Public Health and the Johns Hopkins University School of Nursing. He created and directs the Quality and Safety Research Group at Johns Hopkins University School of Medicine and directs the Center for Innovation in Quality Patient Care at Johns Hopkins Medicine in Baltimore. He chairs the ICU Advisory Panel for Quality Measures of The Joint Commission and the ICU Physician Staffing Committee for The Leapfrog Group. He also serves on the Quality Measures Work Group of the National Quality Forum and leads patient safety monitoring and evaluation efforts at the World Health Organization. He has written a book, Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out as well as over 200 articles and chapters on patient safety. He won the 2004 John M. Eisenberg Patient Safety Research Award and was named a MacArthur Fellow in 2008.
One of Dr. Pronovost's greatest contributions to patient safety is his checklist of basic safety practices, such as hand washing, that has been shown to greatly reduce catheter-related bloodstream infections. It is estimated that his program, which was first tested in Michigan, saves 2,000 lives and $200 million annually. So far 44 states have implemented Dr. Pronovost's checklist.
Robert M. Wachter, MD. Dr. Wachter is a professor and associate chairman of the Department of Medicine at the University of California, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also chief of the Division of Hospital Medicine and chief of the Medical Service at UCSF Medical Center. He is editor of the patient safety journal Agency for Healthcare Research and Quality WebM&M and the patient safety portal AHRQ Patient Safety network. He serves on the board of the American Board of Internal Medicine and has served on the healthcare advisory board of Google, among other companies. He was the first to coin the term "hospitalist" in a 1996 New England Journal of Medicine article, and is a past president of the Society of Hospital Medicine. In 2004 he was one of the winners of the John M. Eisenberg award for innovation in patient safety and quality. He has published 200 articles and six books on quality, safety and health policy, and created a popular healthcare blog, Wachter's World.
Note: Names are listed in alphabetical order.
James Bagian, MD, PE. Dr. Bagian, a former NASA astronaut, is a professor in the departments of industrial engineering and anesthesia and director of the Center for Health Engineering and Patient Safety at the University of Michigan. From 1999-2010 he served as the first director of the VA National Center for Patient Safety and the first chief patient safety officer for the Department of Veterans Affairs, where he developed several patient safety tools and programs.
He is a member of the Institute of Medicine and the board of governors of the National Patient Safety Foundation and is a fellow of the Aerospace Medical Association. He is one of the authors of "Counterheroism, Common Knowledge, and Ergonomics: Concepts from Aviation That Could Improve Patient Safety" and has written multiple other publications. Under his leadership, the VA National Center for Patient Safety received the John M. Eisenberg Patient Safety Award for System Innovation in 2002.
David W. Bates, MD, MSc. Dr. Bates is chief of the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital in Boston, a professor of medicine at Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health, where he co-directs the Program in Clinical Effectiveness. He is also editor of the Journal of Clinical Outcomes Management and associate editor of the Journal of Patient Safety. Dr. Bates serves as medical director of Clinical and Quality Analysis for Partners Healthcare System, executive director of the Center for Patient Safety Research and Practice and external program lead for research in the World Health Organization's Global Alliance for Patient Safety. He has been elected to the Institute of Medicine, American Society for Clinical Investigation and Association of American Physicians.
Dr. Bates has received several awards, including the 2002 John M. Eisenberg Patient Safety Research Award, the 2006 Board of Directors Honor Award of Excellence in Medication-Use Safety and the 2010 Don Eugene Detmer Award for Health Policy Contributions in Informatics. He has published over 400 articles related to patient safety, including a seminal study on the epidemiology of drug-related injuries and research on information systems' impact on patient safety.
Donald M. Berwick, MD, MPP. Dr. Berwick is the administrator for the Centers for Medicare and Medicaid Services, through which he has helped initiate patient safety initiatives such as Partnership for Patients and patient safety incentives in health reform legislation. He is also adjunct staff in the Department of Medicine at Boston's Children Hospital and a consultant in pediatrics at Massachusetts General Hospital. In the past he served as president and CEO of Institute for Healthcare Improvement, chair of the National Advisory Council for the Agency for Healthcare Research and Quality and a member of IOM's governing council. He was previously a clinical professor of pediatrics and healthcare policy at Harvard Medical School and a professor of health policy and management at Harvard School of Public Health. In 1997 and 1998 he was appointed by President Clinton to serve on the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.
Dr. Berwick has won several awards, including the 1999 Ernest A. Codman Award, the 2006 John M. Eisenberg Patient Safety Award and the 2007 William B. Graham Prize for Health Services Research.
Rick Boothman, JD. Mr. Boothman is chief risk officer at Ann Arbor-based University of Michigan Health System. He participated in the Agency for Healthcare Research and Quality's National Advisory Committee Subcommittee for Patient Safety and Medical Liability Reform. He serves on the board of governors of the National Patient Safety Foundation and on the board of directors of the Michigan Hospital Association Patient Safety Organization.
At the University of Michigan Mr. Boothman led an approach to unanticipated patient outcomes that responds with honesty and transparency. He co-authored an article that showed the program decreased the number of claims for compensation against UMHS. In addition to reducing claims, the program has changed the organization's culture around patient safety, promoting a more accountable, proactive reaction to errors.
Mark R. Chassin, MD, FACP, MPP, MPH. Dr. Chassin is president of The Joint Commission and of the Joint Commission Center for Transforming Healthcare, which he created in 2009 to address quality and safety problems in healthcare. He previously served as the Edmond A. Guggenheim Professor of Health Policy and founding chairman of the department of health policy at Mount Sinai School of Medicine and executive vice president for excellence in patient care at Mount Sinai Medical Center in New York City. At Mount Sinai he formed a quality improvement program that focused on safety, clinical outcomes, patient and family experiences and the caregiver working environment.
Dr. Chassin was also Commissioner of the New York State Department of Health. In addition, he practiced emergency medicine for 12 years and conducted research on healthcare quality measures and health policy. He was also part of the Institute of Medicine committee that published "To Err is Human" and "Crossing the Quality Chasm." Dr. Chassin is a member of IOM and a lifetime member of the National Associates of the National Academies. He received the Founders' Award of the American College of Medical Quality and the Ellwood Individual Award of the Foundation for Accountability.
Charles R. Denham, MD. Dr. Denham is editor-in-chief of Journal of Patient Safety. He is also founder and chairman of the medical research organization Texas Medical Institute of Technology. Dr. Denham serves as chairman of The Leapfrog Group Safe Practices Program, funded by TMIT, co-chairman of the National Quality Forum Safe Practices Consensus Standards Maintenance Committee, faculty member for technology assessment and adoption at IHI and member of the International Steering Committee for the World Health Organization Collaborating Centre on Patient Safety Solutions.
Dr. Denham was an associate professor of biomedical engineering at the University of Texas in Austin for 20 years, a fellow of the Harvard University Advanced Leadership Initiative in 2009 and a senior fellow of the same program for 2010. He invented software-based innovation design and development decision support systems and was the executive producer of the film Chasing Zero: Winning the War on Healthcare Harm.
Atul Gawande, MD, MPH. Dr. Gawande is a surgeon at Boston's Brigham and Women's Hospital and the Dana Farber Cancer Institute as well as a writer for The New Yorker. He has written several books, the latest of which is The Checklist Manifesto. He is a professor at Harvard Medical School and at Harvard School of Public Health, and program lead of the World Health Organization's Safe Surgery Saves Lives initiative, through which he helped develop a surgical checklist that has improved patient safety. Dr. Gawande is currently working with WHO to develop a safe childbirth checklist and is researching the effective and ineffective use of the WHO Safe Surgery Checklist.
He is also director of the Risk Management Foundation/Harvard Surgical Chiefs Patient Safety Collaborative and executive director of Lifebox, a company created by the Global Pulse Oximetry Project of the World Federation of Societies of Anaesthesiologists. He was named a MacArthur Fellow for his research and writing in 2006 and won the National Magazine Award for Public Interest writing in 2010. From 1992-1993, Dr. Gawande served as a senior health policy advisor in the Clinton presidential campaign and White House.
Helen Haskell. Ms. Haskell is founder and president of Mothers Against Medical Error, an organization dedicated to promoting patient safety and providing support to those affected by medical errors. She is also co-founder and co-leader of The Empowered Patient Coalition, which provides resources and education to the public. In addition, Ms. Haskell serves on the board of Consumers Advancing Patient Safety. In 2005 in South Carolina, she helped pass the Lewis Blackman Patient Safety Act, named after her son who died from medical errors. This legislation was followed by the creation of the Lewis Blackman Chair of Patient Safety and Clinical Effectiveness, an endowed professorship at the Medical University of South Carolina. Ms. Haskell also shares her experience with medical error in "The Story of Lewis Blackman," part of an educational video series called "The Faces of Medical Error…From Tears to Transparency."
Gary S. Kaplan, MD, FACP, FACMPE, FACPE. Dr. Kaplan is chairman and CEO of Seattle-based Virginia Mason Health System, where he has implemented the Virginia Mason Production System, based on the Toyota Production System, to reduce costs and improve quality, safety and efficiency. Under Dr. Kaplan's leadership, Virginia Mason was named a Distinguished Hospital for Clinical Excellence by HealthGrades in 2011, a Top Hospital by The Leapfrog Group for five consecutive years and was one of two hospitals named a Leapfrog Top Hospital of the Decade for patient safety and quality. Dr. Kaplan is also a clinical professor at the University of Washington, secretary-treasurer of IHI and chair of the National Patient Safety Foundation's board of directors. He serves on the board of Washington Healthcare Forum and is a founding member of Health CEOs for Health Reform. In 2009, Dr. Kaplan won the John M. Eisenberg Award for patient safety and received a Harry J. Harwick Lifetime Achievement Award from the Medical Group Management Association.
Sorrel King. Ms. King is co-founder and president of the Josie King Foundation, an organization that supports innovative patient safety programs. She is an active public speaker on patient safety issues. In 2001, she delivered a speech to attendees of the Institute for Healthcare Improvement conference on the medical errors that led to the death of her daughter, Josie, The DVD of her speech is used by many hospitals and health systems to promote a culture of patient safety. Ms. King has also written a book on her experience: "Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safer," which was named one of the best health books by the Wall Street Journal in 2009. In addition, she was featured in a 2006 documentary, "Remaking American Medicine."
Lucian L. Leape, MD. Dr. Leape is a professor at Harvard School of Public Health and former chief of pediatric surgery at Boston's Tufts University School of Medicine and Tufts Medical Center (formerly Tufts-New England Medical Center). He co-founded the National Patient Safety Foundation, Massachusetts Coalition for the Prevention of Medical Error and Harvard Kennedy School Executive Session on Medical Error. He was also a member of the Institute of Medicine's Quality of Care in America Committee. Dr. Leape chairs the Lucian Leape Institute at the National Patient Safety Foundation, created in 2007 as a patient-safety think tank. In 1994 he published an influential article, "Error in Medicine" in the Journal of the American Medical Association and was a member of the IOM's committee that published "To Err is Human" in 1999 and "Crossing the Quality Chasm" in 2001. He has won several awards, including a Robert Wood Johnson Foundation Investigators Award in Health Policy Research in 1998, the Lifetime Achievement Award from the Institute for Safe Medication Practices in 2001 and the John M. Eisenberg Patient Safety Award in 2004.
Peter J. Pronovost, MD, PhD, FCCM. Dr. Pronovost is a practicing anesthesiologist, professor and researcher. He is a professor at the Johns Hopkins University School of Medicine, the Bloomberg School of Public Health and the Johns Hopkins University School of Nursing. He created and directs the Quality and Safety Research Group at Johns Hopkins University School of Medicine and directs the Center for Innovation in Quality Patient Care at Johns Hopkins Medicine in Baltimore. He chairs the ICU Advisory Panel for Quality Measures of The Joint Commission and the ICU Physician Staffing Committee for The Leapfrog Group. He also serves on the Quality Measures Work Group of the National Quality Forum and leads patient safety monitoring and evaluation efforts at the World Health Organization. He has written a book, Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out as well as over 200 articles and chapters on patient safety. He won the 2004 John M. Eisenberg Patient Safety Research Award and was named a MacArthur Fellow in 2008.
One of Dr. Pronovost's greatest contributions to patient safety is his checklist of basic safety practices, such as hand washing, that has been shown to greatly reduce catheter-related bloodstream infections. It is estimated that his program, which was first tested in Michigan, saves 2,000 lives and $200 million annually. So far 44 states have implemented Dr. Pronovost's checklist.
Robert M. Wachter, MD. Dr. Wachter is a professor and associate chairman of the Department of Medicine at the University of California, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also chief of the Division of Hospital Medicine and chief of the Medical Service at UCSF Medical Center. He is editor of the patient safety journal Agency for Healthcare Research and Quality WebM&M and the patient safety portal AHRQ Patient Safety network. He serves on the board of the American Board of Internal Medicine and has served on the healthcare advisory board of Google, among other companies. He was the first to coin the term "hospitalist" in a 1996 New England Journal of Medicine article, and is a past president of the Society of Hospital Medicine. In 2004 he was one of the winners of the John M. Eisenberg award for innovation in patient safety and quality. He has published 200 articles and six books on quality, safety and health policy, and created a popular healthcare blog, Wachter's World.