8 recommendations for a culture of patient safety

A total system approach and a culture of safety are necessary to combat medical errors and adverse events, according to a new report issued by the National Patient Safety Foundation (NPSF).

The report is a follow-up to the 1999 landmark report, "To Err is Human: Building a Safer Health System," which first brought public attention to patient safety issues within healthcare organizations. Although the industry has made progress, the latest report, entitled, "Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err is Human," finds that organization must take a more pervasive response to patient safety.

NPSF convened a panel of patient safety experts earlier this year to assess the state of the patient safety field and set the stage for the next 15 years of work, according to the report announcement. The panel was led by Donald M. Berwick, M.D., president emeritus and senior fellow at the Institute for Healthcare Improvement, and Kaveh G. Shojania, M.D., director of the Centre for Quality Improvement and Patient Safety at the University of Toronto and editor-in-chief of the journal BMJ Quality & Safety. The panel's report identifies gaps in patient safety and outlines actions organizations can take to save more lives, according to Berwick.

"The field of patient safety has not achieved enough, despite definite progress having been made," Tejal K. Gandhi, M.D., president and chief executive officer, NPSF, said in the announcement. "Healthcare is still not nearly as safe as it can and should be, and the recommendations of this expert panel set a path for achieving total system safety and making safety a primary focus."

The report proposes eight recommendations for stakeholders and organizations to achieve a total system of safety:

Ensure that leaders establish and sustain a safety culture: Culture change can't take a backseat to other safety activities, according to the report. 

Create centralized and coordinated oversight of patient safety: This requires the involvement, coordination, and oversight of national governing bodies and other safety organizations.

Create a common set of safety metrics that reflect meaningful outcomes: Standardized measures are necessary across the care continuum and needed to identify and measure risks and hazards proactively

Increase funding for research in patient safety and implementation in order to fully understand safety hazards and the best way to prevent them.

Address safety across the entire care continuum: Healthcare organizations need better tools, processes, and structures to deliver care safely and to evaluate the safety of care in various settings, the report noted.

Support the healthcare workforce: Leaders must address workforce safety, morale, and wellness so that healthcare workers can provide safe care to patients.

Partner with patients and families for the safest care: At its core, the report said, patient engagement is about the free flow of information to and from the patient.

Ensure that technology is safe and optimized to improve patient safety: Leaders must take actions to minimize the unintended consequences of health IT, the report said.

But success of these actions requires active involvement of every player in the healthcare system, authors said in an executive summary. Those players include boards and governing bodies, leadership, government agencies, public-private partnerships, health care organizations, ambulatory practices and settings, researchers, educators, the healthcare workforce, and patients and their families.

"Our hope is that these recommendations and the accompanying specific tactics for implementation will spur broad action and prompt substantial movement towards a safer healthcare system. Patients deserve nothing less," the authors said. 

The panel noted that much of the progress in patient safety has been led by hospitals. But the majority of patient care now occurs outside the hospital walls. The report calls for a centralized oversight of patient safety, in part to facilitate sharing best practices and knowledge.

"Fifteen years ago, patient safety represented a new endeavor for healthcare--focusing on how to prevent avoidable harm while delivering routine care," Shojania said. "Today, interest has shifted toward value, patient-centered care and other domains of quality. These are also important, but we have a long way to go with patient safety. This report provides clear recommendations for what we need to do to achieve the original vision of the IOM report."

To learn more:
- read the announcement
- here's the executive summary (.pdf)
- download the report

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