Seventeen years after the National Patient Safety Foundation's landmark "To Err Is Human: Building a Safer Health System" report and new research that finds medical errors are the nation's third-leading cause of death, patient safety stands at a crossroads, according to a commentary published in JAMA.
Healthcare needs a safety culture that emphasizes accountability over punishment, write Tejal K. Gandhi, M.D., of the National Patient Safety Foundation; former Centers for Medicare & Medicaid Services Administrator Donald Berwick, M.D.,; and Kaveh G. Shojania, M.D., of Canada's Centre for Quality Improvement and Patient Safety.
For such a culture to function, they write, there must be a reasonable assumption that hospitals will report near-misses and errors and act on such reports.This means healthcare leaders must play a key role in developing a culture of safety within their organizations, they write.
"A safety culture encourages honesty, fosters learning and balances individual and organizational accountability, and leadership is essential to creating and sustaining such a culture," the authors write. "Leaders of healthcare organizations--as well as board members--have extraordinary power to influence the behaviors, beliefs and practices within organizations. Yet most have not yet found a roadmap to follow that leads to safety."
Such a roadmap, the commentary states, must include education. Hospitals' boards, leaders, regulators and managers must all possess foundational education in patient safety science, with the education based on evidence-based best practices. Rather than simply discussing patient safety, leaders must zero in on specific strategies they can apply across the healthcare system.
The process of creating a safety culture must also involve practical day-to-day strategies, from formal agreements about roles and responsibilities to safety huddles to the use of patient stories in board meetings.
To learn more:
- read the commentary (subscription may be required)