Patient Safety

Linkages to IOM Six Aims

Safe —Creating a culture of safety.

Effective —Focusing on implementing proven safe practices.

Patient Centered —Commitment and constant vigilance in order to do the right thing for the patient every time.

Business Case

Safety is always first in the minds of all health care workers, yet few organizations create safety cultures. Creating systems that provide safe, reliable care is what high reliability organizations strive to achieve. HPOE has identified several HROs and highlights their case studies, along with a list of tools and resources available to all hospitals in their journey to patient safety excellence.

In his 1997 work, "Managing the Risks of Organizational Accidents," James Reason illustrated the key concepts that form the core of the patient safety movement, including the now-famous “swiss cheese model” of errors in high-risk enterprises. Every system, even an ideal one, has holes in it that represent active or latent chances for failure. When the holes in the organization’s defenses align, an accident or injury may occur.

Although error is inherent in human performance, Reason went on to say “We can’t change the human condition, but we can change the conditions under which humans work.”

Then in 1999, the IOM released “To Err is Human: Building a Safer Health System.” It estimated that as many as 98,000 die each year from medical errors. This report laid out a strategy by which government, health care providers, industry and consumers can reduce preventable medical errors.

For the past decade, organizations have focused on improving patient care by building cultures of safety. This requires shifting the way caregivers, medical staff, patients and leadership interact with one another to systematically provide the most effective care in the most efficient manner. Leadership needs to establish a learning organization where data drives the patient safety strategy. Data that is collected from cultural surveys, spontaneous reporting systems, near misses, root cause analyses, executive walkarounds and direct observational assessments can provide insight into the organization’s culture, strengths and weaknesses and guide interventions to ensure the appropriate allocation of resources. [i]

Additionally, organizations are adopting proven safe practices to reduce medical errors. The National Quality Forum has endorsed safe practices that have been demonstrated to reduce the risk of harm resulting from processes, systems and environments of care. These practices include use of critical care-trained physicians in the ICU, computerize physician order-entry systems, ongoing evaluation of patients for pressure ulcers, risk of deep vein thromboses, and malnutrition, use of hand hygiene practices, standardized methods for packaging, labeling, and storing medications, and implementing standardized protocols to avoid wrong-site and wrong-patient surgeries.[ii]  

The Joint Commission has also played a role in advancing safe practices through its National Patient Safety Goals. Updated annually, the goals highlight problematic areas in health care and describe evidence- and expert-based solutions for these problems in hospital, long-term care facilities, and ambulatory settings. The goals address patient safety in several critical domains—patient identification, communication, medication safety, health care associated infection, falls, surgical fires, patient involvement, and pressure ulcer prevention. [iii]

Organizations are on a journey to build a culture that is able to sustain the delivery of safe and reliable care. This requires commitment and constant vigilance in order to do the right thing for the patient every time. [iv]

Health Care Reform/Regulatory/Policy Considerations

Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act ). The Patient Safety Act is intended to encourage voluntary, provider-driven initiatives to improve the safety of health care through the establishment of legal protections to ensure that providers who report patient safety information do not incur new legal liability; to promote rapid learning about the underlying causes of risks and harms in the delivery of health care; and to share those findings widely, thus speeding the pace of improvement. [vi]

HHS issued a final rule for Patient Safety Organizations (PSOs). The rule went into effective on Jan. 19, 2009. It provides final requirements and procedures for PSOs, new entities, with which clinicians and health care providers can work to collect, aggregate and analyze data - within a legally secure environment of privilege and confidentiality protections - to identify and reduce patient care risks and hazards. [vii]

Linkages to Performance Excellence

Creating a high reliability culture—Focusing on systems and processes.

Managing organizational variability—Implementing proven safe practices to reduce the risk of harm resulting from processes, systems, and environments of care.