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Into the Future with IHI, Together for Safer Care

Posted By Administration, Tuesday, April 25, 2017
Updated: Monday, April 24, 2017

As NPSF celebrates its 20th anniversary, we prepare for the next chapter of advances in patient safety
with the Institute for Healthcare Improvement.

By Tejal K. Gandhi, MD, MPH, CPPS


Tejal K. Gandhi

NPSF was founded in 1997, so this year marks our 20th as a leading voice for patient safety. It is not unusual while observing such a milestone to take time to reflect on where we’ve been and where we are headed.

Health care, and the patient safety field, have changed considerably over the past 20 years. At the beginning, NPSF was all about raising awareness, because people were not talking about preventable harm in health care back then. The first NPSF Patient Safety Congress was held in 2001 with the theme being, appropriately, “Let’s Talk.”

Since then, we have kept talking—and working—with many individuals and organizations committed to making health care safer. Among them have been government agencies, private foundations, professional societies, researchers, patients and patient advocates, industry, health care leaders, and frontline staff. NPSF has long held the position that everyone has a role to play in making health care safer. When we ask people about the Foundation’s place in the patient safety field, it is not unusual to hear the words “big tent,” an indication that NPSF has always been keen to invite those with diverse experiences and perspectives to share them in the interest of advancing our shared mission.


A notable change over the years has been a broadening of the definitions we use for patient safety. Initially, medical errors got the most attention and they were closely defined as adverse events or errors of omission or commission. More recently, patient safety has become the operative ambition for broad, organizational culture change and “systems of safety” that can prevent a wide range of harms, including those that are born of disrespect, poor communication, and insensitivity.

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We’ve also seen wide acceptance of the fact that faulty systems, not bad people, are the cause of preventable harm in health care. Improving systems is an ongoing effort, because new therapies and technologies are introduced every day. Vigilance is required to avoid unintended consequences of any new tool.


Another advance has been the growing emphasis on the importance of joy, meaning, and workforce safety as a precondition to patient safety. We can never truly ensure the safety of patients if those who are caring for them are at risk of injury or emotional or psychological harm from disrespect or bullying.

Perhaps most significant, patient safety is now recognized as a unique discipline in health care, with more than 1600 health professionals recognized as Certified Professionals in Patient Safety.

Topping the agenda for our 20th year has been a push to address patient safety as a public health issue and to focus on culture and leadership as the foundation for safe care. These are challenging efforts, and we are living in challenging times for health care. Continued progress requires bold moves, innovation, and collaboration.

This is why, in this year of celebration, NPSF and the Institute for Healthcare Improvement (IHI) have chosen to merge. NPSF has provided critical thought leadership with the aim of establishing safety as a core value in health care, and IHI has demonstrated an ability to influence large-scale, global change.

Together, officially as of May 1, we believe our combined knowledge, skills, and resources will be more effective in helping leaders and frontline clinicians meet all of today’s challenges and, together, we intend to develop some fresh approaches to focus and energize the patient safety agenda.

We want to ensure that safety is a central part of every organization’s improvement strategy today, and that the safety of patients and the health care workforce becomes a core value of health care systems around the world.

I will have the privilege of leading the safety programs at IHI, and I hope you will stay engaged with us as we move the mission forward.

What do you think has been the biggest advance in patient safety over the past 20 years? What advances do you hope to see in the near future? 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.

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Susan Gidding says...
Posted Wednesday, April 26, 2017
I believe the biggest advance in patient safety over the past 20 years is transparency and the sharing of data (quality and patient safety indicator results). I would also like to see a commitment to a Just Culture for all healthcare systems and the utilization of Learning Teams for patient safety incidents.
In addition, more analysis on Work as Imagined (WOI) vs. Work as Done (WOD). Identifying causes for the gap.

Susan Gidding
Director Quality Management
Life Flight Network
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