Report: Improving patient safety will take a total systems approach

The report, 15 years after IOM’s "To Err is Human", tackles patient-safety issues, saying health care is not nearly as safe as it should be


BOSTON — Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response, according to a report released by the National Patient Safety Foundation (NPSF).

The report, "Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after 'To Err Is Human'", calls for the establishment of a total systems approach and a culture of safety.

"The field of patient safety has not achieved enough, despite definite progress having been made," said Tejal K. Gandhi, MD, MPH, CPPS, president and chief executive officer at NPSF. "Health care is still not nearly as safe as it can and should be, and the recommendations of this expert panel set a path for achieving total system safety and making safety a primary focus."

The report proposes eight recommendations for achieving total system safety, and calls for action by government, regulators, health professionals and others to place higher priority on patient safety science and implementation. The eight recommendations are:

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

The new report is the work of a panel of pre-eminent experts brought together by NPSF to assess the state of the patient safety field and set the stage for the next 15 years of work. The panel was led by co-chairs Donald M. Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI) and lecturer in the Department of Health Care Policy at Harvard Medical School, and Kaveh G. Shojania, MD, director of the Centre for Quality Improvement and Patient Safety at the University of Toronto and editor-in-chief of the journal BMJ Quality & Safety.

"Despite some significant successes, we know that far too many people still suffer from avoidable injuries in care," said Berwick. "One of the objectives of this new work was to identify the gaps and outline the actions to save far more lives and avert far more harm."

The report notes that much of the work done in patient safety to date addresses hospital care, whereas most care today is provided outside of hospitals. Moreover, while deaths from medical errors make headlines, morbidity — in the form of lasting effects of harm, additional care or lengthier hospitalizations — also demands attention. The report argues for centralized oversight of patient safety, in part to facilitate sharing best practices and knowledge.

"Fifteen years ago, patient safety represented a new endeavor for health care — focusing on how to prevent avoidable harm while delivering routine care," said Shojania. "Today, interest has shifted toward value, patient-centered care and other domains of quality. These are also important, but we have a long way to go with patient safety. This report provides clear recommendations for what we need to do to achieve the original vision of the IOM report."

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