Urgent call made to improve patient safety

By Christopher Cheney

A group of 27 healthcare sector stakeholders has issued a Declaration to Advance Patient Safety.

Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

Last week at the Institute for Healthcare Improvement Patient Safety Congress in Dallas, the 27 members of the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety. The NSC features healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies such as the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention.

The Declaration to Advance Patient Safety calls on healthcare leaders to embrace three resources developed by the NSC:

NSC members felt compelled to issue the Declaration to Advance Patient Safety, Patricia McGaffigan, RN, vice president of the Institute for Healthcare Improvement and IHI senior sponsor for the NSC, told HealthLeaders.

“We focused on issuing a declaration to call attention to the important work that we felt was necessary because we were concerned that the coronavirus pandemic had been diverting attention away from safety. We also wanted to focus on the ongoing foundational work that is necessary for strong safety performance in healthcare organizations,” she said.

Several specific factors spurred the declaration, McGaffigan said. “Some examples of what prompted the concerns that we had was that family members were often excluded from care settings because of pandemic-related limitations on visitation or accompanying patients to their visits—family members play a key role in supporting safety. Access to care was hampered during the pandemic and there were delays in care. There have been worrisome signals from the workforce around growing fatigue and frustration as well as decline of workforce well-being. In early September, a seminal publication confirmed some of the setbacks in hospital-acquired conditions such as catheter-associated infections and ventilator-associated events. We had begun to accumulate more data on how safety culture scores were declining in many organizations.”

The National Action Plan’s 17 recommendations are organized into four foundational areas. McGaffigan summarized why each of the foundational areas are critical to improving patient safety.

1. Culture, leadership, and governance

The NSC determined that safety is critically dependent on healthcare leaders and governance bodies as well as the positions they take on establishing safety for patients, families, and the healthcare workforce, McGaffigan said. “Safety is a system property, and it is important for us to keep in mind that even if we are focusing on specific projects such as reducing infections, there are many factors that influence whether that work will be successful. Those factors are grounded in the culture and the tone that leaders set in their organization.”

The National Action Plan was built on the premise that focusing on culture, leadership, and governance had to come first because they are essential to attain and maintain safety, she said. “Ultimately, this work is preconditional for getting to safety. We know that leaders who are committed to safety are focused on building the conditions, experiences, and workplace considerations such as culture that encourage trust and transparency, as well as ensuring the physical and psychological safety for everyone who is a part of the organization.”

2. Patient and family engagement

Engaging patients and family members is a vital component of safe care, McGaffigan said. “It is not only safer when individual consumers are more meaningfully engaged in their care, but it is safer in a broad sense when we are able to integrate patients and family members into codesigning our systems and processes for care. They should also be engaged in improvement initiatives overall.”

For example, patient and family engagement can improve diagnosis, she said. “Over the past two years, IHI worked with leaders and experts including patient and family advisors to develop the Safer Dx Checklist. Organizations can use this tool to advance diagnostic excellence. There are 10 recommendations in the checklist and those recommendations reflect the foundational areas in the National Action Plan. One of the items on that checklist that relates to patient and family engagement is whether the healthcare organization is seeking patient and family feedback so they can identify and understand diagnostic safety concerns and address those concerns with patients being actively involved in the codesign.”

3. Workforce safety

Patient and workforce safety are inextricably linked, McGaffigan said. “If we do not have a workforce that is physically and psychologically safe, the workforce will be unable to bring the best effort to their job on any given day. Long before the pandemic and long before the National Action Plan, we had ample data confirming that the incidence of illness and injury in healthcare exceeded that in other industries we would typically consider to be dangerous such as construction and manufacturing.”

In recent years, many healthcare organizations have realized they need to place more emphasis on healthcare workforce safety and well-being, she said. “This has certainly been illuminated during the pandemic, particularly in areas such as workplace violence, burnout, and increases in depression and anxiety among providers and care team members.”

4. Learning systems

Healthcare organizations cannot improve unless they are constantly learning, McGaffigan said. “Because safety is a dynamic property of the system, we cannot say we have reached safety if we sit on our laurels. This is the constant daily work of everyone in healthcare. The work is fostered when we have intentional design and implementation of learning systems that can systematically integrate internal data and experiences with external evidence that we know about any topic we are pursuing.”

Learning systems generate key benefits, she said. “In organizations where we have well-established learning systems, we have patients who get higher quality, safer, and more efficient care. These organizations are better able to deliver on their mission to patients and families, and they are better places to work.”

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.