It's time for patient safety 2.0

The Institute of Medicine report on patient errors sparked the start of patient safety and led hospitals to start thinking about how to improve, said Tejal Ghandhi, MD, president of the National Patient Safety Foundation (NPSF), speaking at the Bipartisan Policy Center’s forum on innovation and patient safety.

In the 2000s, providers became more comfortable talking about errors and those discussions drove improvements, she said. There’s plenty more work to do, she said, citing five key emerging area that require additional focus:

1. Care across the continuum. “The vast majority of work and research on safety has been in hospitals but the vast majority of care is in settings outside of hospitals. We know very little about all the safety issues in those settings.” The top three concerns in primary care, she said, are transitions of care, diagnosis errors and medication safety. From adverse drug events to adherence to tracking medications, “it’s hard to deliver high-quality care if prescriptions are not filled.” Interoperability comes into play with transitions of care because “key pieces of information can fall through the cracks which can lead to quality and safety issues.” Decision support will help clinicians make good decisions as well as ensure all the information is considered to avoid misdiagnoses.
2. Patient engagement. There “really has to be a partnership” between patients and providers at “multiple levels.” Beyond the office setting, hospitals are starting to have patient advisory committees who participate in root cause analyses. And, patient engagement is part of key policy committees to “make sure we’re really hearing that patient voice.”
3. The healthcare workforce “has not gotten as much attention as it ought to,” said Ghandhi. “We feel strongly that worker safety is a precondition to patient safety.” Nurses are five times more likely to be assaulted on the job than a cab driver in New York City. Technology is important because it can make work more meaningful as opposed to more stressful. The NPSF changed its mission statement to say that the organization is working on “creating a world where patients and those who care for them are free from harm.”
4. Transparency is another precondition to safety. This includes clinicians with patients, between clinicians and between organizations. Providers could be learning from each other to prevent problems. “Currently, if an error occurs at a hospital, they do an analysis and make sure it doesn’t happen again. It generally doesn’t leave the walls of that organization so it could happen across the street,” said Ghandhi. Rather than reinventing the wheel for each incident, she noted that patient safety organizations are set up to help with sharing and learning with the public. “We need a lot more work around making sure data is usable and helps the public make good decision. We’ve started down that road but it’s really going to explode.”
5. Health IT. “We know health IT can improve quality and safety and we also know there are unintended consequences that technology can introduce such as alarm fatigue and cut-and-paste documentation. This is a significant part of our work going forward to advance patient safety.”