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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.

 

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Free from Harm? Let’s Take a Giant Step to Improve Patient Safety

Posted By Administration, Tuesday, December 8, 2015
Updated: Thursday, December 3, 2015

In a complex, high-risk environment such as health care, it may be impossible to keep all patients completely free from harm, but that must be our aspiration.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi
  
         
       
         

 

Last week the US Department of Health and Human Services released the latest data from the four-year effort to partner with hospitals to reduce incidents of patient harm. News reports noted that avoidable hospital acquired conditions — such as pressure ulcers, falls, adverse drug events, catheter-associated urinary tract infections, central line-associated bloodstream infections, and surgical site infections — were down by 17% from 2010 to 2014.

 

But amidst that good news was a trend showing that the decline in HACs plateaued between 2013 and 2014. About 10% of hospitalized patients experience a hospital-acquired condition, which all agree is “still too high.”

 

In a way, the news from HHS set the stage for the National Patient Safety Foundation’s release today of a new report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Demonstrating improvement, while acknowledging big challenges still exist, is itself an argument for the approach that the new NPSF report introduces.

 

Our report was informed by an expert panel — led by Drs. Donald Berwick and Kaveh Shojania — convened earlier this year to assess the state of patient safety so many years after the seminal Institute of Medicine report that first brought public attention to medical errors and adverse events. By a wide majority, the experts agreed that patient safety has improved. For one thing, there is greater awareness of medical errors, patient safety, and human failures.

 

But the panel also found wide openings for improvement. The report details eight recommendations for achieving total systems safety and a safety culture:

 

1. Ensure that leaders establish and sustain a safety culture
2. Create centralized and coordinated oversight of patient safety
3. Create a common set of safety metrics that reflect meaningful outcomes
4. Increase funding for research in patient safety and implementation science
5. Address safety across the entire care continuum
6. Support the health care workforce
7. Partner with patients and families for the safest care
8. Ensure that technology is safe and optimized to improve patient safety

 

The patient safety field has made progress via baby steps, and what we need now is a giant step. Total systems safety requires a constant prioritization of safety by leadership, done in a comprehensive rather than piecemeal manner, and taking into account safety culture, systems design, human factors engineering, the inevitability of human failures, and the need for robust error reporting and analysis.

 

This report calls for centralized, coordinated oversight of patient safety efforts and progress, as we have seen with other industries that affect public safety. While the creation of a new agency is unlikely to occur in today’s political climate, we must at least think seriously about expanding the role of an existing organization to serve this purpose. Regional or specialty collaboratives, while valuable, simply cannot achieve the oversight that a national agency can.

 

In addition, with one billion ambulatory visits annually in the US — compared to 35 million hospital admissions — it is well past time to consider safety across the care continuum. And, while deaths from medical errors make headlines, we also need to consider the substantial morbidity that safety failures cause, and include the safety and well-being of the health care workforce as a precondition to patient safety.

 

One of the key arguments this new report makes is that it’s time to acknowledge medical errors and adverse events as a serious public health issue that causes significant mortality, morbidity, and quality-of-life implications. We hope the report will serve as a call to action for all stakeholders to get involved. In a complex, high-risk environment such as health care, it may be impossible to keep all patients completely free from harm, but that must be our aspiration.

 

Download the report at www.npsf.org/free-from-harm.

 

Which of the eight recommendations most resonates with you?  Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.


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Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.


Tags:  IOM  patient safety  To Err Is Human 

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Diagnostic Error in the Spotlight

Posted By Administration, Friday, September 11, 2015

As we anticipate the upcoming Institute of Medicine report on improving diagnosis, NPSF joins with other organizations to think about the next steps. 



By Tejal K. Gandhi, MD, MPH, CPPS

     
  Tejal K. Gandhi    
         

 

Later this month, I will be among the speakers at the Diagnostic Error in Medicine 8th International Conference, hosted by the Society to Improve Diagnosis in Medicine (SIDM). The theme of this year’s meeting — After the IOM Report: What's Next? — gets to the heart of what many of us have been anticipating: release of an Institute of Medicine report on improving diagnosis.

 

While we don’t yet know the report’s findings, early news reports indicate that it will build upon existing research and knowledge about diagnostic error:

  • There are multiple causes and reasons for missed, delayed or wrong diagnosis, from communication breakdowns and inadequate use of information technology to cognitive errors by physicians, such as confirmation bias. In fact, in a study published in 2006, my co-investigators and I found that most cases of diagnostic error involve both systems-related factors and cognitive errors.

  • More research is needed into how diagnostic errors occur and how we can help prevent them. A 2012 paper suggested interventions such as greater patient engagement, better use of information technology, and focused interventions to avoid specific, known pitfalls.

  • Missed, delayed, or wrong diagnoses are a neglected area of patient safety, and no one is really measuring the problem. The approaches we normally use to identify adverse events won’t work for diagnostic errors. Even the Global Trigger Tool, created by the Institute for Healthcare Improvement and widely thought to be the best tool available to identify adverse events in hospitalized patients, captures few cases of diagnostic error, because it is designed to assess treatment flaws.

While most patient safety efforts have been made in the inpatient setting to reduce treatment errors, far more care is delivered in outpatient settings, and studies of malpractice cases show that diagnostic error is the chief claim in ambulatory care. By some estimates, 1 in 20 adults in the US have been or will be affected by diagnostic error.

 

The good news is that the IOM report is sure to bring much needed attention to this area of vulnerability for patients. NPSF recently joined the Coalition to Improve Diagnosis, which is led by SIDM and comprises a number of organizations committed to bringing awareness, attention, and action to the problem of diagnostic error.

 

As we await the IOM report, I encourage you to read Myths and Facts About Diagnostic Error, which NPSF and SIDM prepared jointly for Patient Safety Awareness Week 2014.

 

Have you experienced missed, delayed, or wrong diagnosis, either as a clinician or a patient? Comment on this post below. Note: To comment, you must first register on the website. If you are already registered, you must log in to comment.

 

Tejal K. Gandhi, MD, MPH, CPPS, is president and chief executive officer of the National Patient Safety Foundation and of the NPSF Lucian Leape Institute.



Tags:  diagnosis  diagnostic error  IOM 

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