Patient Experience

Not Yet Free from Harm

March 21, 2017 3:02 pm

Thanks to the collaborative efforts of patient safety organizations and hospital engagement networks that promote innovation and share best practices, as well as other initiatives, the healthcare industry has made great strides in patient safety. But such progress has been fragmented and inconsistent. It also has been much too slow. Research suggests that preventable harm in health care is a leading cause of death, but it also carries significant morbidity and quality-of-life implications.

A Public Health Issue

In January 2016, the National Patient Safety Foundation (NPSF) released Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human , following up on the Institute of Medicine’s seminal report that shed light on the danger of preventable medical errors in hospital settings. The result of a consensus panel of experts, the 2016 NPSF report suggests patient safety is a public health issue not unlike obesity, motor vehicle crashes, and cancer. To accelerate progress, healthcare leaders must move beyond piecemeal projects to a new way of looking at risk and preventing harm.

The report recommends eight steps healthcare organizations can take as they look to lessen their risk.

Establish and sustain a safety culture. This step requires strong leaders who embrace safety as a core value and communicate that value consistently throughout the organization.

Create centralized and coordinated oversight of patient safety. Centralized oversight is needed to set priorities, coordinate efforts, and provide leadership and accountability for patient safety work.

Create a common safety metrics that reflect meaningful outcomes. Despite existing measurement and reporting requirements, specific and meaningful measures related to patient safety are lacking in health care.

Increase funding for research in patient safety and implementation science.We have seen considerable patient safety research, but much more is needed as health care evolves. Furthermore, research needs to address both solutions and consistent implementation of those solutions.

Address safety across the care continuum. Progress in patient safety has been made in hospital settings, but most care is provided outside of hospitals. We need to do much more work around safety issues in ambulatory and long-term care.

Support the healthcare workforce. Burnout, fatigue, and bullying are rampant in health care, yet the emotional, psychological, and physical safety of the healthcare workforce is a precondition to patient safety.

Partner with patients and families. Programs that allow patients and physicians to share information openly have shown that patients who are engaged in their care can help prevent medical errors and enhance safety. In addition, patients and families have a role to play in broader areas such as the design of care processes, the direction of research, and the need for greater transparency.

Ensure that technology is safe and optimized. Technology enhances medicine in numerous ways, but much work needs to be done to achieve greater interoperability and prevent unintended consequences of health IT such as {Can you give a few examples?}.

Pursuing these recommendations can help an organization move toward the goal of total systems safety and a culture in which safety has been embraced as a core value.

Safety First

Pursuing a higher degree of patient safety requires putting safety first in all settings, not just hospitals. It means supporting the health and well-being of the teams that provide care. And it requires cooperation and sharing by healthcare organizations that do not use their safety record to gain competition, but rather to serve as examples from which others can learn.

Although preventable harm during a medical encounter is hardly a certainty, health care will always be a high-risk endeavor. It is time we approach patient safety as we have other public health crises.

Tejal K. Gandhi, MD, MPH, CPPS, is president and CEO of the National Patient Safety Foundation, Boston. She was a featured speaker at HFMA’s ANI 2017. 


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