I’m Dr. Diane Perez. Every day, families place their trust—and the lives of the people they love—in our healthcare system.While millions of medical professionals provide exceptional care, preventable harm remains one of the greatest challenges.According to the Patient Safety Movement, three million people die each year from preventable harm.Today we'll talk with Dr. Mark Ramsay, CEO of the Patient Safety Movement Foundation, about how accountability, transparency, and knowledge can help save lives.But first, the story of a young boy whose preventable death from undiagnosed, untreated sepsis inspired a crusade to raise awareness and change emergency room care.Ciaran Staunton, Rory’s FatherRory was playing basketball in Skoda Jam. Cut his elbow on the gym floor, teach about a band-aid on it, and that was on Tuesday. And Rory was dead on Sunday at 6 o'clock. How can a young boy go from merely cutting himself on a school gym playing basketball to a morgue in five days? Orlaith Staunton, Rory’s MotherRory's a very gentle kid; he engages a lot with people. Ciaran Staunton, Rory’s FatherHe was a foot bigger than everyone else and a big broad young man. But just when all the new kids came in, he looked after them. Orlaith Staunton, Rory’s MotherI think it became more obvious as he got older that he was becoming a leader. We trusted a lot of people. We trusted that the school would look after him if he fell, that they would clean the cut, they didn't. We trusted our pediatrician would pick up on signs if he was ill, she didn't, the doctor discharged him. The following morning, he was no better, where he began to turn yellow and the tip of his nose started to turn black. We just ran; we ran with him back into the hospital. I got one doctor to come speak with me and he said to me, your son is very ill. And then he was brought up to the intensive care unit. That was on Friday night and he was dead on Sunday evening. I don't even know how to describe losing him. It's, there was a voice in my life that I loved that was gone. Ciaran Staunton, Rory’s FatherWell, we will spend the rest of our days reliving that. We've spent the last four years reliving it, and after the day we die, we'll relive it. Orlaith Staunton, Rory’s MotherThe big thing was, nobody seemed to know the signs of sepsis, and nobody knew that he was septic. Ciaran Staunton, Rory’s FatherWe had never heard of this word called sepsis. But then we find that 50% of Americans have never heard it. Now we know that it's the largest killer of children in the world. When we went online and looking about sepsis, there was nothing. My wife went on to CDC. There was nothing on CDC about sepsis. Yes, it was killing a quarter of a million Americans here. We gave our story to the New York Times and... It was the most shared ever article in the New York Times. And some weeks later, we got an indirect message from a woman in Florida. And she said, I want to thank you for saving our son's life. And she says, my son was in hospital in Florida, the doctors didn't know what was wrong with him, we knew he was very sick. And in frustration, I was talking to my sister and she said well I read a story in the New York times about some boy who died. Could this be sepsis? It was sepsis. And the woman wrote to us; I am sitting here with my boy beside my pool in Florida. My 11-year-old boy, and I owe it to you and your family. And our daughter, Kathleen, said, well, isn't it a pity someone hadn't done that for Rory? Orlaith Staunton, Rory’s MotherI am so thankful for the notes that we get from people, but I so wish that I had known the science and that I wasn't in this situation. Ciaran Staunton, Rory’s FatherRory's death was totally preventable. We came to Washington, knocked on many doors, and we had the first hearing. It was televised live on C-SPAN on Sepsis. We drew up language called Roy's Regulations. Orlaith Staunton, Rory’s MotherEnsures that all hospitals have mandatory sepsis protocols in place. Ciaran Staunton, Rory’s FatherRoy's regulations would save between 5,000 and 8,000 New Yorkers each year. However, that's only in one state. There are 49 other states. Orlaith Staunton, Rory’s Mother It feels very bittersweet because I couldn't save my son's life, but I know we're saving other lives. The frustration is that they had to find out about it from us, that we were their source of information. Ciaran Staunton, Rory’s FatherWe have an empty bed. We sit down at our table in the evening. There are three chairs filled. There's one empty chair.Diane Pérez, MD, MHCMJoining me now is Dr. Mark Ramsay. What a heartbreaking story.Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, Patient Safety Movement FoundationDiane, thank you so much for the invitation. This is such an important subject. Diane Pérez, MD, MHCMDr. Ramsay, in your point of view, what are the most common ways patients experience preventable harm during medical care today? Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, Patient Safety Movement FoundationThe list is very long unfortunately, but some of the common ones are medication errors, diagnostic errors, hospital acquired infections, misdiagnosis, things that we should be able to overcome.But because physicians, nurses, medical staff are usually overburdened with multiple tasks, they don't have a phenomenal memory, they certainly hone in on specific things, but there's so many things going on with patients that they make some errors that they should not make.And we can help prevent them from making those errors because there are systems out there to help do that. Diane Pérez, MD, MHCMAt which point of health care are patients more vulnerable? When it comes to admission, surgery, medication changes, discharges, follow-up?Well, what immediately comes to light, things that have been devastating to patients like wrong site surgery, wrong surgery, wrong medication, hospital-acquired infections.But in fact, it is, as you were just starting to say there, it's right across from preadmission not being admitted because they misdiagnosed sepsis, they don't realize this child being into the emergency room is septic.And sepsis, once you develop sepsis, you're literally talking hours before you get really sick with septicemia and die.And we still, in this day and age, we still see patients being sent home from emergency rooms where sepsis has been misdiagnosed or not diagnosed.Diane Pérez, MD, MHCMWhat would be a message that you would give to parents when their kid falls at school? Has what could appear as a minor scratch. What shall we do with that? And if the kid starts having fever, how can we really raise our voice with the doctor to say, please do something more, this is not normal.I think you have to be able to elevate your concern, and if the physician is not listening to you or is just not seeing it, ask to speak to somebody more senior.Diane Pérez, MD, MHCMIf families want to take one proactive step to reduce the risk of preventable harm, what should that step be, Dr. Ramsay? Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, Patient Safety Movement FoundationWe in the medical profession have to change. We have to come up with solutions and I think the number one is to listen to the patient's voice. You know, you go in to see a clinician and often they're on the computer, they're taking information off the computer or they're writing into the computer of what you're saying and they're not listening to you.And you as a patient, if you go in, you're nervous. You're concerned that you yourself might have something terrible and you're not really listening to the comments from the clinician either.So, there's several things you can do. One, if you’ve got to go in to a hospital because you're concerned or any time you go and bring somebody with you, a trusted friend or relative with you, who can listen to the responses, can remember what the clinician's saying, can articulate for you having talked to you beforehand and emphasize some of the major problems that you're really concerned about, and can be your advocate while you're in the emergency room or while you are visiting the clinician.Diane Pérez, MD, MHCMDr. Ramsey, thank you so much for this interview, and I hope the audience enjoyed it as much as I did.Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, Patient Safety Movement FoundationDiane, thank you so much for the interview..Sign up for our weekly HealthDay newsletter