World Patient Safety Day: Celebrating milestones and charting the course ahead

In 1999, shortly after I finished my internal medicine residency and entered the healthcare workforce, the U.S. Institute of Medicine issued "To Err Is Human: Building a Safer Health System." This groundbreaking report exposed the widespread problem of medical errors. It sparked a national discussion on patient safety and is widely credited for many improvement efforts implemented in the decades that followed. Yet, nearly 25 years later, some in the industry would assert that we haven't made much progress in patient safety at all-that the road to zero harm is just as long and arduous as it's ever been.

I disagree. Yes, the work is far from over. And we must continue to strive every day to reach that ultimate goal. But this World Patient Safety Day, as I reflect on my past 25 years as a safety leader, and in the spirit of Safety II and learning from the positives, we must understand where we've made real progress.

As an industry, we must build upon these learnings, letting our successes to date guide our continued efforts toward zero harm.

The road to safety: From 1999 to the present day

The healthcare safety landscape looked vastly different when I became the first Director of Patient Safety at a large academic medical center in 2000 and worked with a small team to create the strategy for a patient safety program (novel in its day). We lacked many of the sophisticated tools and standardized practices that are now hardcoded into our daily activities. Today, the way we think about and approach safety has progressed substantially. As a result, we've made significant strides in reducing harm and improving patient and workforce safety.

This became clear when, as a coauthor of "Safer Together: A National Action Plan to Advance Patient Safety," released in 2020, we outlined recommendations for safer care and reduced harm. This framework informs current efforts at the national level to advance safety, including the HHS National Action Alliance. It also intentionally reinforces and builds upon the work of the last 25 years-in fact, there is an implementation guide highlighting the important tools and best practices that have been developed during this time frame. It's worth understanding how we have advanced in each of the four foundational areas in the plan, as well as where we need to make continued progress.

The impact of leadership and culture on patient safety

A strong safety culture is the cornerstone of a thriving healthcare system and fosters a safe care experience. When healthcare workers feel safe and confident in leadership's commitment to safety as a core value, employee morale, engagement, and even retention improve.

Progress: Just 25 years ago, we didn't have tools to even measure a culture of safety. Today, we have validated culture surveys (which are showing improvement year over year), as well as detailed blueprints and best practices on how leaders can advance a culture of safety. Leader rounding for safety, also a novel concept 25 years ago, is now a standard practice-as are tiered safety huddles to improve communication around safety concerns and teamwork. An emphasis on transparency, through daily management systems as well as platforms like Care Compare and Leapfrog, has been instrumental in driving improvements. In addition, open conversations about error, coupled with the promotion of safety event reporting and the implementation of fair and just culture algorithms, have been key cultural advancements.

Progress has also come from regulatory and accreditation standards that have driven organizational and leadership commitment-from Joint Commission standards to CMS penalties to the latest CMS patient safety structural measure. I remember being very grateful when the Joint Commission launched its National Patient Safety Goals back in 2003, as it gave me a stronger argument for additional commitment and resources.

Opportunity: Despite progress, nearly 50% of the workforce has a low perception of safety culture. The identified best practices must be reliably implemented: Otherwise, leaders are missing a huge opportunity. When employees feel their organization has a strong safety culture, safety outcomes improve and engagement soars.

Ultimately, a strong safety culture fuels a virtuous cycle that benefits both patients and the workforce.

Workforce safety as a precondition of patient safety

Healthcare has always been a dangerous profession, with high rates of physical injury, burnout, and suicide. Despite these risks, healthcare workers' safety was not prioritized and was often normalized as simply the price of doing business.

Progress: The connection between patient safety and workforce safety hasn't always been recognized. However, back in 2012, the National Patient Safety Foundation (NPSF) Lucian Leape Institute made the bold statement that workforce safety was a precondition to patient safety. When I became NPSF's CEO in 2013, our vision reinforced this: "Creating a world where patients and those who care for them are free from harm."

At that time, the Occupational Safety and Health Administration (OSHA) even called me asking for support. They were struggling to gain traction in healthcare and wanted NPSF to help, given the connection we were making between workforce safety and patient safety. The COVID-19 pandemic reinforced the important fact that our patients are only safe so long as our workforce is safe, physically and emotionally.

As a result, healthcare organizations have expanded their understanding of safety to include the emotional and psychological well-being of the workforce. Many healthcare organizations have been implementing best practices from the Joint Commission, the National Institute for Occupational Safety and Health (NIOSH), OSHA, and others to reduce physical injuries as well as workplace violence, and support emotional health-including increased access to mental health resources. When healthcare leaders prioritize the safety of physicians, nurses, and the rest of the workforce, positive outcomes throughout the organization follow.

Opportunity: While much progress has been made in improving workforce safety, 20% of healthcare employees still don't feel safe at work, and rates of reported violence against caregivers are rising.* Many organizations lack a comprehensive strategy for addressing these issues. They simply don't have the necessary capabilities to measure and understand workforce harm, robust strategies for performing cause analysis, and roadmaps around developing and implementing interventions for improvement. There is a real opportunity to elevate the commitment to workforce safety, just as patient safety was elevated in 1999.

Engaging patients to improve safety

Healthcare organizations have increasingly recognized the importance of engaging patients in all levels of care to improve safety and experience.

Progress: Many organizations have implemented patient and family advisory councils, which give patients a platform to participate in decision-making-while giving providers and leaders a unique perspective into the patient experience as well. PFACs, as they're often called, open the lines of communication between those providing care and those receiving it, resulting in a better mutual understanding and trust.

PFACs empower patients and families to take a more active role in their care. They can also help identify safety risks that might not be apparent.

In the last decade, communication and resolution programs, as well as clear policies and practices around disclosure of harm to patients, have been developed. Believe it or not, 25 years ago the norm was to never disclose errors to patients or really talk about errors at all. But there's been a definite shift toward transparency when errors do occur, with tools like CANDOR to help organizations advance. Disclosing errors to patients and their families is not only the right thing to do, but it also builds trust.

Opportunity: To accurately capture and comprehend the voices of the entire patient population, healthcare organizations must prioritize diversity and representation in their PFACs. This means actively recruiting individuals from different demographic groups-for example, race and ethnicity, age, geographic location, socioeconomic status, gender identity, sexual orientation, and healthcare needs. By ensuring that PFACs are diverse and representative, healthcare organizations can make more informed decisions about safety and quality of care, for all.

Still, patient engagement must go beyond PFACs. Patients must be engaged from the front line all the way to the board room, leveraging a variety of tools to incorporate the patient voice (e.g., digital communities and focus groups, and asking patient safety questions on patient experience surveys). In addition, while best practices for disclosure, communication, and resolution exist, they're still variably implemented. Full transparency has to become the norm.

The learning system

Organizations must implement robust learning systems where they can better identify risks and harms, then take swift actions to prevent them, leveraging safety science.

Progress: We've advanced in so many ways since the early 2000s to create a better learning system to prevent harm. In particular, we've learned how to perform robust cause analysis with a systems and human factors perspective, and drive strong actions. We have electronic reporting systems to help capture, trend, and analyze events. And we now have PSOs to help with cross-industry learning and sharing-which absolutely did not happen before. When organizations come together to share data and best practices, we continuously move the industry forward.

By learning from other high-risk industries over the past 25 years, we have come to understand and implement high reliability principles and practices. Healthcare is, inherently, a high-risk industry. Organizations must adopt rigorous high reliability practices to operate safely, perform consistently, and deliver optimal results-even under hazardous conditions. Organizations that have implemented HRO practices successfully have seen substantial reductions in serious safety events and increased organizational resilience.

Opportunity: Healthcare organizations still have much to do to optimize their learning systems. There are opportunities to improve safety event reporting systems, trend analysis, and risk prediction. Robust cause analysis and strong actions aren't reliably occurring. High reliability principles and practices are variably implemented despite their known benefits. And organizations must incorporate new approaches, such as Safety II (i.e., learning from positives), to enhance resilience, foster proactive learning, and drive continuous improvement.

One last cross-cutting concept that has seen progress, particularly in the past several years, is the understanding that safety and equity are inextricably linked. Equity is embedded in the National Action Plan across all the foundational areas and must be part of all the work we do in safety, because inequities contribute to all kinds of harm-not to mention that inequity is, in and of itself, a form of harm that must be eradicated.

When you listen to patients, you can appreciate how far we've really come

So far, I've been focused on the foundational areas of safety. But there are also many examples of how we've improved specific safety issues.

I was recently at a family function where someone asked me about patient safety-and what it really was. When I explained, they shared some of the things they've noticed during their own care experiences that made them feel safe. Nurses checking their two patient identifiers. Barcoded medications. Computerized physician order entry, vs. the old-school prescription pads. Pre-procedure surgical timeouts. None if these were standard 25 years ago-and we all remember how difficult it was to implement so many of these things. Yet today, it's hard to imagine modern medicine and our work in healthcare without them.

At the end of the day, safety is the bedrock of healthcare-anchoring all patient experiences and outcomes. Safety is our promise to the workforce too: It is our solemn duty to protect those who have dedicated their lives to caring for others, preserving the health and well-being of our communities.

So, every day, we work tirelessly to make healthcare safer for everyone. We refine and enhance safety measures to meet ongoing challenges and new threats. We leverage the latest cutting-edge technologies to narrow the gap between the current state and the ideal state of zero harm.

Yes, the road ahead is long, and there's never time to rest on our laurels. But by looking back upon our accomplishments, we gain insight into our journey, the obstacles we've already overcome, and how best to conquer the yet-unknown challenges ahead. It's a perspective that can inspire us to continue our relentless pursuit of a safer healthcare system, where zero harm is not just an ideal, but reality.

To learn more about the progress and opportunities we have, download our latest report: "Safety in healthcare 2024." If you'd rather discuss these in person, reach out to a member of our safety and high reliability team, and one of our experts will be in touch.

_{* "Safety in healthcare 2024."}

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