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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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Time to Step on the Accelerator

Posted By Administration, Wednesday, January 11, 2017

With recent gains in patient safety, let’s make sure we maintain focus.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

It snowed heavily in the Boston area this past weekend, resulting in challenging conditions for travelers. I watched one car try to make it up a hill during the worst part of the storm. Of course, driving in snow is hazardous, so we tend to slow down. But as the driver of that car discovered, slowing down can cause you to slip backward. Getting up a hill in difficult conditions requires that we maintain the right amount of momentum.

That’s what we are seeing in the patient safety field as well. As the field marks notable progress, now is the time to accelerate.

In December, the Agency for Healthcare Research and Quality (AHRQ) released the National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015. The agency estimates a 21% decline in hospital-acquired conditions (HACs)—such as pressure ulcers, adverse drug events, falls, and surgical site infections—since 2010. In real numbers, that amounts to 3.1 million fewer HACs than would have occurred had the 2010 rate remained unchanged. Moreover, AHRQ estimates that 125,000 fewer patients died as a result, and some $28 billion in health care costs was saved.

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But most important, the agency acknowledges, as we all must, that we are nowhere near done when it comes to patient safety. AHRQ estimates that in 2015 there were 115 HACs per 1,000 discharges. That is a lot of patients who still experienced preventable harm. Moreover, the definition of harm is broadening now to include both physical and psychological harm, which makes the opportunities for improvement even greater.

 

Furthermore, we must acknowledge how much care is delivered outside of hospitals, and how little we know about ambulatory safety. Improving the safety of care across the continuum is one of the recommendations made in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. It is encouraging that entities like AHRQ and the World Health Organization are turning some attention to primary care. I will be writing more about those efforts in a future column.

The HAC reduction effort detailed in the AHRQ Scorecard was largely fueled by programs and rules made at the federal level, including Medicare payment penalties and the Partnership for Patients initiative introduced as part of the Affordable Care Act. Today, there is much uncertainty about the future of the health care system and the federal government’s role. At NPSF, we remain hopeful that the commitment to better quality and safety will remain, particularly as it has been shown to be fiscally beneficial.

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In writing the preface to Free from Harm, Drs. Don Berwick and Kaveh Shojania, chairs of the expert panel that informed the report, note, “Today we must not let the many competing priorities in health care divert our attention from the important goal of preventing harm to patients. On the contrary—we need to keep our eyes on the road and step on the accelerator.”

As the New Year begins, that is what the National Patient Safety Foundation intends to do. We have a busy year ahead, and I hope you will join us however you are able.

What are your patient safety priorities for 2017? 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:  patient safety 

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Time to Recognize and Honor Patients

Posted By Administration, Thursday, February 18, 2016

Patient Safety Awareness Week aims to engage health consumers in greater understanding of what we mean when we talk about patient safety.

 


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

Anyone working in health care is likely to be aware of some of the many recognition weeks that take place throughout the year. From National CRNA Week (in January) to National Radiologic Technology Week (in November), the health care industry sets aside time to recognize the specialized efforts, skills, and dedication of its workforce.

 

Likewise, disease-specific weeks and months abound, from American Heart Month (February) to Diabetic Eye Disease Month (November), with the goals of informing the public of risks and prevention.

 

Patient Safety Awareness Week, which NPSF has led in March every year since 2002, is a bit different from the rest. It does not honor a specific area of the health care workforce, and it does not target a single issue. Instead, this recognition week challenges all health professionals and workers to put the focus on patients and families and on the need to create the safest health care delivery environment possible.

 

Like the disease-specific weeks and months, however, Patient Safety Awareness Week does aim to engage health consumers in greater understanding of the problem and what we mean when we talk about patient safety.

 

This year, in the wake of the recent NPSF report calling for a public health approach to improve patient safety, NPSF has initiated an ongoing campaign. The United for Patient Safety campaign seeks to highlight and reinforce the fact that everyone has a role to play in keeping patients safe and free from harm. Patient Safety Awareness Week, March 13-19, will be observed as a highlight of the campaign, through the message that “every day is patient safety day.”

 

Among the activities we have planned for the week is a webcast with distinguished speakers from the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and NPSF. We anticipate a thought-provoking discussion about how we can apply the theories and principles of public health to accelerate progress in patient safety.

 

According to the CDC Foundation, “Injury prevention and detection are key components of public health. . . . Overall, public health is concerned with protecting the health of entire populations.” Even the healthiest among us is likely to be a patient one day, meaning the entire population has a stake in the safety of the health care system and the need to prevent harm.

 

Public health practice relies on research into the causes of disease and injury and application of broad programs to address them. Speaking last year about the Future of Public Health, Dr. Tom Frieden, director of the CDC, noted that, “The involvement of many parts of society, including government agencies, health organizations, nongovernmental organizations, clinicians, the private sector, and communities, is increasingly important for success” in public health efforts.

 

The same is true when it comes to patient safety; we need everyone to be involved.

 

What can you do? To begin, visit UnitedforPatientSafety.org where you can honor a loved one affected by medical error, download educational materials, or share your plans for observing Patient Safety Awareness Week in your organization or community.

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Join us March 17 at 1:00 PM Eastern Time for a complimentary webcast, Patient Safety Is a Public Health Issue. Registration is open to all. 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:  patient safety  patients  public health 

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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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