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The President’s Corner is a monthly column presenting the insights and reflections of the president and chief executive officer of the National Patient Safety Foundation. Readers wishing to post comments need to register and sign in to the website before posting a comment.


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Swinging the Patient Safety Pendulum to Primary Care

Posted By Administration, Friday, February 10, 2017

Patient safety efforts in outpatient settings have been quietly advancing.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


This week, NPSF announced a project we are undertaking in collaboration with CRICO, the Risk Management Foundation of the Harvard Medical Institutions, to identify best practices for managing referrals using electronic health records (EHRs).


Breakdowns in referral management are common and can result in missed or delayed diagnoses and other lapses in patient safety. Closing the loop on referrals is vitally important to achieving correct and timely diagnosis and treatment, and research suggests that EHRs have the potential to close these loops. Through this collaboration, we hope to outline best practices.

I mention this project as an example of how patient safety in outpatient settings has been quietly advancing. As noted in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, we need more research, tools, processes, and structures specifically for ambulatory settings, where most health care is delivered.

Take primary care, for example. A recent review of studies published from 1980 to 2014 finds that patient safety incidents are relatively common in primary care, with roughly 2 to 3 incidents per 100 consultations. Of these, an estimated 4% result in harm, with the most severe cases of harm commonly associated with diagnostic or prescribing errors.

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Although considerable research is still needed into the causes of safety lapses in outpatient settings, we are also beginning to see resources developed that can help health care providers improve. In December, the Agency for Healthcare Research and Quality (AHRQ) began releasing resources as part of the Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. This project is modeled on a similar guide for the hospital setting. Led by MedStar Health Research Institute, the guide for the primary care setting provides resources in four main areas:

  1. Teach-Back: a technique for clearly communicating medical information to patients and families.
  2. Be Prepared to Be Engaged: a toolkit for patients and families to use that helps them get ready for medical encounters.
  3. Medication Management: a toolkit to help engage patients and caregivers in helping maintain accurate medication lists.
  4. Warm Handoff: a practice wherein transfer of care from one clinician to another is done with the participation of the patient and family.

As AHRQ notes, patient engagement has been shown to contribute to improved safety and quality. NPSF has long advocated that patient and family engagement at all levels of the health care system is a vital component of safe care. What works best in a hospital setting can be very different than what works in primary care, however, and the challenges are different. These new materials from AHRQ are a terrific resource for those working in primary care, and they can help frame an incremental approach to improvement.

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Another development comes from the World Health Organization (WHO). I had the privilege of serving as a reviewer last year on the WHO Technical Series on Safer Primary Care. Consisting of nine separate monographs on topics such as patient engagement, human factors, and transitions of care, this series delves into the scope and nature of harm in primary care settings.

Among its goals, the WHO project seeks to raise awareness among health professionals about the potential for safety lapses in primary care and to provide information about how to design and deliver safer care in that setting.

Raising awareness is a necessary first step in any improvement journey. The availability of these new resources is an encouraging sign that the patient safety pendulum is at last swinging to outpatient care.

What are your thoughts about improving the safety of primary care? 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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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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Five Notable Developments in Patient Safety in 2016

Posted By Administration, Tuesday, December 20, 2016

Progess was made in 2016, but there is much work to do in the patient safety field.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Just about a year ago, the National Patient Safety Foundation released Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, a report offering eight recommendations for elevating national focus on patient safety. These recommendations continued to reverberate within the field in 2016, and guided my picks for five notable developments in patient safety this year.

  1. Developing a culture of safety (Recommendation 1): One of the chief messages of the Free from Harm report is that without a culture of safety, it is difficult for any organization to advance patient safety and sustain improvements. The report defines a culture of safety as one in which “health care professionals and leaders are held accountable for unprofessional conduct yet not punished for human mistakes; errors are identified and mitigated before they harm patients; and strong feedback loops enable frontline staff to learn from previous errors and alter care processes to prevent recurrences.”

    NPSF is currently collaborating with the American College of Healthcare Executives on a resource to help leaders create a culture of safety in their organizations. But perhaps most notable this year is the number of other organizations also working on this issue. The American Nurses Association addressed safety culture and leadership in monthly installments of resources this year, and a culture of safety was the theme of National Nurses Week. Meanwhile, the number of research studies and articles addressing the importance of culture is on the rise.

  2. Recognizing the need for improved safety metrics (Recommendation 3): In May, BMJ published a paper suggesting that medical errors are the third-leading cause of death in the U.S. The paper received wide attention, including some counter-arguments that the methodology was flawed. Ultimately, however, this article should spark broad agreement that there is a great need for improvements in the way we measure patient safety. Right now, too many of our methods are retrospective, reporting is inconsistent, and metrics are not uniformly used and analyzed. This year we began to see that the true toll of preventable harm in health care will only be known once we establish consistent and robust metrics in all settings.

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  3. Adding to our knowledge about ambulatory safety (Recommendation 5): Free from Harm points out that, while most of the patient safety work done thus far has been done in acute care hospitals, the vast amount of health care delivered in the U.S. happens in the outpatient arena. For example, the Office of the Inspector General released a report this year estimating that 29 percent of Medicare recipients experience an adverse event or temporary harm while in a rehabilitation setting, with almost half of them deemed preventable.

       Some of Dr. Gandhi's picks for notable developments
    in patient safety this year reflect recommendations of
    the NPSF report, Free from Harm.
    We have so much to learn about risks and strategies to prevent harm in ambulatory or other settings. One notable development this year has been increased research in this topic. Most recently, AHRQ issued a technical brief that combined interviews with key informants as well as a literature review. The brief identifies medication safety, diagnosis, transitions, referrals, and testing as important ambulatory care safety topics. Communications, health IT, teaming, patient engagement, organizational approaches, and safety culture are flagged as the most important areas in which to seek improvement.

    This is not just a U.S. concern, however, and it is encouraging to see the World Health Organization convene experts to develop ways to “bridge knowledge gaps” in primary care.

  4. Increasing emphasis on workforce safety (Recommendation 6): NPSF considers the physical, psychological, and emotional safety of clinicians and staff to be a precondition to patient safety. This year we have seen growing recognition that burnout is a huge issue for the health care workforce, with more than half of physicians reporting at least one symptom of burnout. This has a direct impact on patient safety, as we know that clinicians experiencing burnout are not only more likely to make an error, but also less likely to take the steps necessary to engage patients, families, and the health care team.

    In encouraging signs, the American Medical Association, the National Academy of Medicine, and other entities are beginning to take a hard look at solutions. There is now wide acknowledgment that we need to look beyond the toll on individuals and begin addressing burnout as a system-wide issue and even as a quality measure.

    Related to this, fatigue can be a significant contributor to burnout. This year, the Accreditation Council for Graduate Medical Education has been exploring changes to duty hour limits, despite the evidence that fatigued residents are more likely to make errors that harm patients or themselves. NPSF and others are opposed to any change and, instead, argue for improving handoffs and communication.

  5. Partnering with patients and families (Recommendation 7): Communication and resolution programs (CRPs) promote open communication after an adverse event is discovered, comprehensive analysis of the event, implementation of improvement initiatives, emotional support for patients and providers, and appropriate resolution. In 2016, we saw progress in the number of organizations putting CRPs into practice.

    In April, NPSF offered a complimentary webinar on this topic in partnership with the Collaborative for Accountability and Improvement. The following month, the NPSF Patient Safety Congress featured an all-day immersion workshop on implementing CRPs.

    Also this year, the Agency for Healthcare Research and Quality released the CANDOR Toolkit, designed to help expand use of an AHRQ-developed process called Communication and Optimal Resolution, or CANDOR. This program gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

If you have not had a chance to read the Free from Harm report, I encourage you to do so. These developments show that the issues discussed in the report remain vital to patient safety and are sure to be important as we move in to 2017.

What are your thoughts on the top developments in patient safety this year? 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:  culture  Health IT  leadership  workforce safety 

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The Many Roads to Medication Adherence

Posted By Administration, Tuesday, November 15, 2016

Medication adherence is a major challenge, particularly in outpatient settings.
We need a multipronged approach to improvement.

By Tejal K. Gandhi, MD, MPH, CPPS


Tejal K. Gandhi

Last month in this column I wrote about the importance of addressing patient safety across the continuum of care. As an example of how challenging this is, let’s take a look at one aspect of outpatient safety: medication adherence.

Medication adherence problems are not simply a matter of patients accidentally missing a dose. Primary nonadherence occurs when patients do not take the step of filling or picking up a prescription. But nonadherence also includes taking a lower or higher dose than prescribed; stopping a prescription early; taking an old medication for a new problem without consulting a doctor; taking medication prescribed for someone else; and forgetting whether a medication has been taken.

These are major problems in the ambulatory arena, where patients or their family members serve the vital role of administering medication.

Most health professionals recognize the challenges involved when patients do not take medications as directed—or at all—whether intentionally or unintentionally. In one study of 195,000 newly prescribed e-prescriptions, only 72% were filled. Nonadherence was common for medications for chronic conditions such as hypertension, diabetes, and hyperlipidemia.


When medication is not taken as prescribed, health problems may worsen, requiring more intervention. Nonadherence not only poses risks to patients’ health, it also costs our health care system an estimated $100 billion annually in avoidable hospitalizations.

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Medication Adherence in Practice

The issue of not taking medications—and how to improve it—is linked to several major themes in patient safety:

  1. Patient and family engagement. As noted in the NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, most definitions of patient engagement include ideas such as partnership, communication, information exchange, and respect. Health care practitioners can help improve adherence by making sure patients understand why the medication has been prescribed and how to take it properly, and by answering questions and addressing concerns.

  2. Health literacy. More than one-third of US adults have below basic or basic health literacy skills. Health literacy involves the ability to not only read and follow instructions, but also work with numbers and understand what to do if something goes wrong, if a dose is missed, or if an adverse event occurs.

  3. Transitions in care. Patients recently discharged face challenges in adhering to medication regimens that may have changed since they entered the hospital. In one study, 29% of patients were not taking a medication on their discharge list, were taking a different does or frequency, or taking an additional medication.

There is no easy solution and, in fact, a multipronged approach is likely needed to improve medication adherence. Zullig and colleagues note that greater research and evaluation of strategies, similar to the drug development process, is needed to encourage adherence. Furthermore, they note that the success of each strategy may differ between patient populations and settings, and that efforts are needed for wide dissemination and adoption of proven interventions.


Other interventions are currently being tested:

  • Mobilizing pharmacists to answer patients’ questions and be sure they know how to take medication properly.
  • Encouraging the use of patient portals by patients to become familiar with their medications, order refills, or ask questions.
  • Exploring pill monitoring technology, such as electronic pill caps and “smart” blister packaging.
  • Using innovative options such as electronic monitors (for example, biometric monitors or activity monitors) and mobile health strategies (such as text messaging and smartphone apps) to alert health practitioners about medication adherence and remind patients to take their medication. One of the eight recommendations of the NPSF Free from Harm report is to ensure that technology is safe and optimized to improve patient safety. There is much promise in the drive to use technology to improve medication adherence.

We still have work to do to determine the best strategies to improve this area of patient safety, and we need to match interventions to each patient’s individual needs. But we are at a point where innovations in technology, coupled with increased education among providers about the issue, may converge to help improve medication adherence across the continuum of care.

What strategies do you think will encourage medication adherence? 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:  ambulatory  medication  patient engagement 

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Patients, Patients—Everywhere

Posted By Administration, Friday, October 14, 2016

Why we must improve patient safety in all settings.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


According to publicly reported data, about half of all adults in the U.S. have a chronic illness, 60% take at least one prescription medication, and more than 1 billion health care encounters take place each year in ambulatory settings such as doctor’s offices, emergency departments, and hospital-based outpatient clinics. By comparison, there are roughly 35 million hospital admissions in the U.S. each year.


Despite the much greater utilization of outpatient health services, patient safety research and advances have largely taken place in hospitals. Today, when only the very sickest patients are hospitalized, and many patients with chronic illnesses are treated in ambulatory care or even in the home, it is past time to focus research dollars and efforts toward the epidemiology of medical errors, lapses, and near misses in other settings, and in finding solutions to effectively prevent them.

What do we know about medical errors in outpatient care? A 2011 study that looked at paid medical malpractice claims found that 43% of the events took place in ambulatory settings, and another 9% involved both inpatient and outpatient settings. The most common reason for a paid claim in outpatient care was for misdiagnosis, and the most common outcomes in either setting were “major injury” and “death.”

Outcomes associated with malpractice claims may be the most shocking, but they are far from the only instances of safety lapses. A systematic review of patient safety incidents in primary care published earlier this year found that errors occur fairly frequently, although most do not result in serious harm. Medication errors and diagnostic errors were found to be most common, but the authors note that lack of a “standardized taxonomy for classifying incidents and harm” make it difficult to compare results across settings and over time.

About 9 million people in the U.S. receive home health care or care in nursing homes, rehabilitation centers, and other residential care facilities. The lack of care coordination between these settings and the risk of miscommunication or lack of communication between providers is another gaping opportunity for error. A 2014 analysis by the Department of Health & Human Services Office of the Inspector General (OIG) reviewed records of Medicare patients who transitioned from acute care hospitals to skilled nursing facilities. According to the OIG report, 22% of the patients sampled experienced an adverse event with serious harm, and another 11% experienced temporary harm. Physician reviewers determined that 59% of the events and harms were “clearly or likely preventable.”

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Safety in home care is another largely unexplored territory. According to the Family Caregiver Alliance, in 2015, some 43 million people provided care to an adult or child in the U.S. Unlike a hospital or physician’s office, a patient’s home is an uncontrolled environment with unique hazards that can potentially harm both the patient and the home health care worker or family caregiver.

We are only at the very beginning stages of grasping how to address patient safety under these circumstances, and the need for improvement grows in proportion to our aging population.

Addressing safety across the care continuum is among the key recommendations of an NPSF report released late last year. In order to advance safety in all settings we need to better understand the epidemiology of medical errors and safety lapses in those settings, which will require more funding for research and creation of better metrics for tracking and improvement.

In addition, while most hospitals today have patient safety officers, departments, or committees, many outpatient and residential care facilities lack the infrastructure and expertise so necessary to make improvements. The NPSF report recommends expanding safety expertise, reporting mechanisms, collaboratives for sharing experiences and insights, and other methods of identifying and implementing best practices for all settings across the care continuum.

Of course, this is easier said than done. I have written here recently about the importance of federal funding for the Agency for Healthcare Research and Quality, which does so much to support patient safety research. But we also need health care leaders to recognize the importance of safety issues in all settings and prioritize developing the safety science and expertise to drive improvement.

What are your ideas for improving patient safety across the continuum of care? 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:  ambulatory 

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