Shared Responsibility for Patient Safety

By Billy Oglesby, PhD, MBA, FACHE

The National Patient Safety Foundation (NSF) (founded 1997) initiated the annual Patient Safety Awareness Week (PSAW) in 2002 to stimulate discussion - locally and internationally - around ways to optimize patient safety throughout healthcare systems.? The NSF merged with the Institute for Healthcare Improvement (IHI) in May of 2017, working together to improve patient safety.? The NSF/IHI approach recognizes that the medical errors compromising patient safety are not solely attributable to clinicians and medical professionals but rather all aspects of the healthcare system.? PSAW promotes safety for patients as well as their healthcare providers, highlighting the roles each must play to assure safety.??

This year, PSAW takes place from March 10-16.? The public is invited to observe PSAW by joining one or more online lectures and forums,? sharing experiences and expertise on social media platforms, reading and/or sharing relevant articles and, importantly, learning some important facts.?

• Patient safety breach continues to be in the top 10 causes of death and disability globally.
• Up to 80% of patient harm is preventable.?

Patient safety first became a health policy issue in 1999 when a report aptly titled “To Err is Human ” estimated that as many as 98,000 Americans die each year as a direct outcome of medical errors.? ?Medical errors may occur anywhere healthcare is provided: hospitals, clinics, physician offices, nursing care facilities, urgent care facilities.? Although wrong-site procedures often make headlines, under-reported adverse events such as misdiagnoses, faulty medical devices and medication errors can cause serious physical and psychological harm to patients.??

In the wake of this stunning report, public and commercial organizations developed a variety of interventions and programs aimed at improving patient safety in the U.S. healthcare system including:? TeamSTEPPS ?; ?Consumer Assessment of Healthcare Providers and Systems (CAHPS) ?; Healthcare Associated Infections Program ; and Safer Together: A National Action Plan to Advance Patient Safety (IHI). ?

To address patient safety in the nation’s hospitals, the Centers for Medicare & Medicaid Services (CMS) instituted these value-based programs:

• The Hospital Acquired Conditions Reduction Program that encourages hospitals to improve patient safety by implementing best practices to reduce their rates of infections associated with health care.? The program ties hospitals' payments to their performance on measures pertaining to specific conditions (e.g., surgical site infections, hospital-acquired pneumonia).?
• The Hospital Readmissions Reduction Program encourages hospitals to reduce avoidable readmissions by improving communication and care coordination and proactively engaging patients and caregivers in discharge plans. This program also ties payment to hospital performance.?

A recent comprehensive analysis showed that hospital care was getting safer prior to the COVID-19 pandemic.? The retrospective review of 245,000 data about patients in more than 3,100 hospitals showed that adverse events for healthcare-related patient harm fell significantly between 2010 and 2019.? ?The researchers tracked 21 adverse events over the study period and? ?(e.g., adverse medication events, hospital-acquired infections, post-procedure events, postoperative cardiac events).? After adjustment, the relative risk for experiencing adverse events fell by 31-41% for patients with heart attack, heart failure, pneumonia and major surgery.? The decline for patients with all other conditions was 18%.?

This is good news, but most health care occurs outside of the hospital – in physician offices, pharmacies, diagnostic laboratories, clinics, nursing care facilities and patient homes.? Avoidable adverse events that occur in these environments often go unreported.? What more is being done to help ensure patient safety across these settings??

JCPH is privileged to offer a Master of Science degree and certificate in Healthcare Quality & Safety as an educational pathway to improve patient safety. The CAHME accredited MS degree program is designed to strengthen healthcare quality and patient safety leadership skills that will impact the quality of care and improve lives.

Dr. Oglesby is the Humana Dean of the Jefferson College of Population Health.

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