David B. Mayer of the Patient Safety Movement Foundation: “We must stop blaming people for system and process weaknesses”

Mandate hospitals to be open and honest when medical errors lead to patient harm and death. If we don’t embrace transparency, we can’t learn how to improve our systems and processes. As a part of my interview series with leaders in healthcare, I had the pleasure to interview David B. Mayer, MD, CEO of the […]

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Mandate hospitals to be open and honest when medical errors lead to patient harm and death. If we don’t embrace transparency, we can’t learn how to improve our systems and processes.


As a part of my interview series with leaders in healthcare, I had the pleasure to interview David B. Mayer, MD, CEO of the Patient Safety Movement Foundation

Dr. Mayer joined the Patient Safety Movement Foundation as its CEO in January 2019 bringing decades of experience in both the public and private sector. Passionate about eliminating preventable medical harm and deaths, he is focused on helping the Patient Safety Movement Foundation ensure safety across three key priority areas: process and system improvements, enhanced communication and resolution after preventable harm, and continued education for future generations of healthcare workers. As a lifelong advocate of patient safety, when COVID-19 hit he realized more needed to be done and kicked off Dave’s Virtual Walk Across America for Healthcare Safety in February 2020 to raise awareness of the importance of healthcare worker and patient safety during the pandemic and to honor those on the front lines.


Can you share the most interesting story that happened to you since you began leading your company?

Every year in the U.S., more than 200,000 people die in hospitals from what are considered preventable medical deaths. I joined the Patient Safety Movement Foundation as CEO in 2019 to help achieve the goal of zero preventable patient deaths by 2030. One of the biggest hurdles to achieving this goal has been a lack of public awareness and after watching the movie “Forrest Gump” again last February, I decided to do a virtual walk across the U.S. to raise awareness of preventable medical errors, which were the third leading cause of death in the U.S. behind cancer and heart disease, before COVID-19. I started my journey in San Diego and 2,460 miles and 350 days later I arrived in Jacksonville Beach, Fla. My original goal was to hit all 30 major league baseball stadiums, however, due to the pandemic’s quarantine and travel restrictions I was only able to visit 20 MLB stadiums, 12 spring training ballparks, three minor league stadiums and seven NFL stadiums. During these portions of the walk, I was joined by families who lost loved ones due to preventable harm. While this leg of the journey is complete, I plan to continue walking to the remaining stadiums and raising awareness for this cause along the way.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

Most of my funniest moments and biggest learning curves have been trying to keep up with younger staff members who are all so tech savvy. All the new ways to share documents, conduct group chats, etc. I also learned there was something called social media and used Twitter and Instagram to share my walk across America progress and those I walked in memory of along the way. My biggest takeaway from these moments is that I will never figure out every new technology and need to share with the team when I can’t access something.

What do you think makes your company stand out? Can you share a story?

The Patient Safety Movement Foundation’s mission is to urgently unify people and collectively improve patient safety around the globe. This sets us apart from other organizations in two ways:

First, urgency: I have worked with many healthcare societies and foundations throughout my career and they did great work, but did we really move the needle on lives saved? I am not sure. With the PSMF there is a real sense of urgency and this drives us every day, as we must have it if we are going to really help save lives. Second, we work side-by-side with patients, family members and safety advocates. They lead our committees and our programs and truly make us a stronger and better organization.

What advice would you give to other healthcare leaders to help their team to thrive?

Hire passionate people who are committed to your mission, mentor them when needed, get them the support they require and then get out of their way. They do amazing things.

Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?

From my experience, there are two reasons the U.S. healthcare system ranks poorly. First, we still focus far too much on illness rather than prevention and wellness. Second, the U.S. healthcare system rewards the quantity and volume of care versus the quality and outcomes of care. I believe if these two areas were addressed, we could drastically improve the U.S. health system.

You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

Unfortunately, patients and healthcare workers are affected by preventable medical errors. But here are five ways I think that we can work together to improve the healthcare system and help us achieve our goal of zero preventable patient harm and death.

Align payments and incentives to quality, safety and outcomes of care instead of the volume and quantity of procedures/care completed.

Create a national patient and caregiver safety authority similar to the National Transportation Safety Board.

Mandate hospitals to be open and honest when medical errors lead to patient harm and death. If we don’t embrace transparency, we can’t learn how to improve our systems and processes.

Adopt CANDOR (Communication and Optimal Resolution) programs that have been shown to reduce preventable harm events as well as save money.

Train all personnel on the importance of high reliability, resilience science and human factor approaches to safety. We must stop blaming people for system and process weaknesses.

During my time as the executive director of quality for the MedStar Institute for Quality and Safety, we were able to implement and appreciate the power of these five system improvements. For example, MedStar was committed to doing the right thing, when harm was done to Jack Gentry, a patient who was seriously injured as a result of a medical error during an elective surgery to repair two bulging discs in his neck. MedStar’s open and honest communication and ongoing support for the family could not reverse the harm done but did demonstrate how healthcare providers can respond to unintended medical harm. Additionally, through Annie’s story where a machine failure led to patient harm, we saw how healthcare organizations seeking high reliability embrace a just culture in all they do versus the old approach focused on blame and shame when analyzing near misses and harm events.

Ok, its very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

It is very tough to create change of the existing culture– especially in large hospital and healthcare systems. Oftentimes, too many stakeholders love the status quo and don’t want changes to occur as it would impact them financially. As a whole, we need to embrace resilience science, become more highly reliable and more similar to the aviation industry, where thousands upon thousands of annual deaths would never be tolerated, but rather investigated and swiftly addressed. We can no longer stand for these preventable patient deaths to continue. We can achieve change through continued education, making resources available free of charge and also holding health systems accountable when preventable harm occurs.

I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this?

I am not an expert here so would leave this discussion to others more knowledgeable on this topic. However, the conversation about mental health is not discussed enough in regard to physicians, nurses and other healthcare workers. Depression, burnout and suicide rates have been extremely high and the pandemic has dramatically increased those rates. If the pandemic taught us anything, it is that we can’t have patient safety without healthcare worker safety — and that includes their mental health and well-being.

How would you define an “excellent healthcare provider”?

The definition is different for different patients. Everybody needs to find the provider that meets their personal needs. I personally believe healthcare providers should be knowledgeable, empathetic, compassionate and most importantly good listeners. In addition, I think it is important that they understand that they are a visitor in their patient’s life, the patient is not a visitor in their life. As my friend Carole Hemmelgarn says, “The patient needs to be first, last and everything in between.”

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” Margaret Mead’s quote has stuck with me through the years and has played a role in my decision to be part of a small but impactful team at the Patient Safety Movement Foundation.

Are you working on any exciting new projects now? How do you think that will help people?

This last year, the Patient Safety Movement Foundation announced its new mission to achieve zero preventable patient harm and death by 2030. Preventable medical harm can include medication errors, healthcare associated infections, wrong diagnosis, etc. These have been a little-acknowledged issue among the public; but the COVID-19 pandemic has increased public awareness of the systemic industry issues hindering the safe delivery of care. Not only has COVID shed light on the precarious foundations upon which healthcare organizations operate, but it has also shown that there can’t be patient safety without health worker safety. We must do better. I am also writing a book about my Walk Across America, those who walked with me and their loved ones who died from preventable medical harm and my experiences at all the different major league ballparks during my year-long trek.

What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?

I always enjoy a good sportsbook and watching West Wing episodes — Jed Bartlett was an amazing president. The sports books and West Wing episodes help me check out and relax.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂

I am fortunate to already be part of something great: The Patient Safety Movement Foundation. This global organization is already starting to do great things. Just recently, we called for a Patient Safety Moonshot and won’t stop our efforts until we reach zero.

How can our readers follow you online?

They can follow me on Twitter and Instagram at #WalkForPtSafety.

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