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Reflections on Safety
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Reflections on Safety is a monthly column presenting the insights of Tejal K. Gandhi, MD, MPH, CPPS, Chief Clinical and Safety Officer, Institute for Healthcare Improvement (IHI). Dr. Gandhi was president and CEO of the National Patient Safety Foundation prior to its merger with IHI in May 2017.

 

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Top tags: leadership  culture  diagnostic error  patient safety  patients  public health  transparency  AHRQ  ambulatory  Health IT  IOM  workforce safety  2016 NPSF Congress  2017 Patient Safety Congress  board certification  collaboration  communication  communication and resolution  CRP  diagnosis  education  emotional harm  families  flu  health communication  health literacy  IHI  measurement  medical education  medication 

Time to Recognize and Honor Patients

Posted By Administration, Thursday, February 18, 2016

Patient Safety Awareness Week aims to engage health consumers in greater understanding of what we mean when we talk about patient safety.

 


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

Anyone working in health care is likely to be aware of some of the many recognition weeks that take place throughout the year. From National CRNA Week (in January) to National Radiologic Technology Week (in November), the health care industry sets aside time to recognize the specialized efforts, skills, and dedication of its workforce.

 

Likewise, disease-specific weeks and months abound, from American Heart Month (February) to Diabetic Eye Disease Month (November), with the goals of informing the public of risks and prevention.

 

Patient Safety Awareness Week, which NPSF has led in March every year since 2002, is a bit different from the rest. It does not honor a specific area of the health care workforce, and it does not target a single issue. Instead, this recognition week challenges all health professionals and workers to put the focus on patients and families and on the need to create the safest health care delivery environment possible.

 

Like the disease-specific weeks and months, however, Patient Safety Awareness Week does aim to engage health consumers in greater understanding of the problem and what we mean when we talk about patient safety.

 

This year, in the wake of the recent NPSF report calling for a public health approach to improve patient safety, NPSF has initiated an ongoing campaign. The United for Patient Safety campaign seeks to highlight and reinforce the fact that everyone has a role to play in keeping patients safe and free from harm. Patient Safety Awareness Week, March 13-19, will be observed as a highlight of the campaign, through the message that “every day is patient safety day.”

 

Among the activities we have planned for the week is a webcast with distinguished speakers from the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services, and NPSF. We anticipate a thought-provoking discussion about how we can apply the theories and principles of public health to accelerate progress in patient safety.

 

According to the CDC Foundation, “Injury prevention and detection are key components of public health. . . . Overall, public health is concerned with protecting the health of entire populations.” Even the healthiest among us is likely to be a patient one day, meaning the entire population has a stake in the safety of the health care system and the need to prevent harm.

 

Public health practice relies on research into the causes of disease and injury and application of broad programs to address them. Speaking last year about the Future of Public Health, Dr. Tom Frieden, director of the CDC, noted that, “The involvement of many parts of society, including government agencies, health organizations, nongovernmental organizations, clinicians, the private sector, and communities, is increasingly important for success” in public health efforts.

 

The same is true when it comes to patient safety; we need everyone to be involved.

 

What can you do? To begin, visit UnitedforPatientSafety.org where you can honor a loved one affected by medical error, download educational materials, or share your plans for observing Patient Safety Awareness Week in your organization or community.

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Join us March 17 at 1:00 PM Eastern Time for a complimentary webcast, Patient Safety Is a Public Health Issue. Registration is open to all. 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  patients  public health 

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Getting into the Game on Safety Culture

Posted By Administration, Friday, January 22, 2016

Leaders need practical tools to work toward a culture of safety in their organization, and board members need to be more than cheerleaders — they need to be in the game.

 


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

A search of the words “culture of safety” in Google brings more than 9 million results. Not all of these relate to health care, of course; theories about a culture of safety started in other industries. Yet, the abundance of material about a culture of safety is reason enough to wonder why such a culture is so difficult to achieve and sustain in health care organizations.

 

To understand why, we must first define what we mean. In the new NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, we use a definition of safety culture that is widely used in health care, which states in part:

 

Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures (Health and Safety Commission 1993).

 

A culture of safety provides the means for robust reporting of errors and near misses, as well as the feedback loop to inform staff of what was done to prevent recurrence. It is a learning environment, where adverse events do not get hushed up, but instead are shared throughout the organization to educate all. It is a culture that does not punish human error, but that does address unprofessional and disruptive behavior that can undermine safety. It is a culture where everyone is preoccupied with the possibility of failures and how to prevent them and mitigate harm.

 

The expert panel members who contributed to the NPSF report cited culture change as the biggest struggle around effecting improvement in patient safety. As others agree, it’s difficult to imagine making long-term progress in patient safety if our culture remains dysfunctional.

 

In making culture the focus of our number one recommendation, we tied it to leadership, because the leaders and board members of health care organizations hold extraordinary power to impact the culture.

 

But knowing that, even accepting it, in theory alone is not enough. We need to give our leaders practical tools to use to improve their organization’s culture. And board members need to be more than cheerleaders for this work. They need to be in the game.

 

Where to begin? Sadly, I would wager that every hospital in the country has an adverse event or near-miss story to tell at least once a month. Why not open every board meeting with a patient story, so board members get a sense of the real people they are serving by being in the room? Why not demand that safety data be reported at every board meeting?

 

We also call for all board members and leaders of health care organizations to receive education about the fundamentals of patient safety science, just culture principles, and systems thinking. This is really an essential first step toward “shared perceptions of the importance of safety.”

 

I’ve said many times in recent talks and interviews that we cannot simply tell people: “Go change your culture.” It’s hard work that is never really done. Leaders must prioritize the importance of safety culture and learn strategies to effectively create it.


What tactics are implemented in your organization to encourage a culture of safety? 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  leadership 

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Five Notable Developments in Patient Safety in 2015

Posted By Administration, Monday, December 28, 2015
Updated: Sunday, December 27, 2015

As the year comes to a close, it's time to reflect on some of 2015's most important
patient safety stories.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

It’s hard to believe that the final days of 2015 are upon us. It’s been an incredibly busy and productive year for NPSF and for the broad patient safety community. As the year winds down, here in no particular order is a look at some of the most notable developments in patient safety this year.

  1. Reductions in patient harm. Earlier this month, the Agency for Healthcare Research and Quality (AHRQ), reported a 17% reduction in patient harm in hospitals over three years. The report quantified the efforts of the Partnership for Patients and as well as Medicare payment incentives, estimating that 1.3 million fewer patient harms and 50,000 fewer deaths occurred between 2010 and 2013 than would have been expected had hospital-acquired conditions continued at the 2010 rate. While this is good news, the report also noted that incidents of harm are still too high, with 1 in 10 hospitalized patients experiencing a hospital-acquired condition.

  2. A new focus on diagnostic error. In September, the Institute of Medicine released a consensus report pointing out the depth of the problem presented by diagnostic errors. By some estimates, diagnostic error affects 1 in 20 patients, or approximately 12 million people in the U.S. each year. The IOM report’s recommendations include enhancing culture and teamwork, improving health care professional education and training in the diagnostic process, ensuring health IT supports the diagnostic process, and increasing research into identifying and learning from diagnostic errors. The report launched an important conversation about a serious patient safety issue with broad impact across the continuum of care.

  3. Public interest in measurement and transparency. Over the summer, ProPublica, a nonprofit news agency, issued the Surgeon Scorecard, which calculated complication rates for eight relatively low-risk surgeries at the hospital and surgeon level. While some may argue about the accuracy of the risk-adjusting and the use of claims data to assess outcomes, the ProPublica reporters did an admirable job of trying to be fair and measured in their approach. Love it or hate it, the Surgeon Scorecard makes my list simply for the discussion it sparked around the need for greater transparency about outcomes in health care. Was it perfect? No. Was it a step in the right direction? Absolutely.

  4. A growing appreciation that harm is not just physical. Over the past few years, NPSF has focused a lot on disrespect within the health care workforce and the emotional and psychological harm it breeds. But the truth is, even patients—those who are at their most vulnerable state—can be the victims of emotional and psychological harm during care. A recent viewpoint article calls emotional harm the “neglected preventable harm.” We need to continue discussing, learning about, and preventing emotional harm to patients and families.

  5. Recommendation for total systems safety. My final pick is one close to my heart: the new NPSF report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. While we’ve seen pockets of improvement in patient safety, it’s time for a new approach. Our report provides eight recommendations for achieving total systems safety and a culture of safety. I urge you to download the report and share it with your leaders and teams. We’ll be focusing on many of these themes as we embark on 2016.

It is gratifying to see movement and achievement in patient safety, but there is still much work to be done. Whether you are a patient, a clinician, an executive, or a consumer who will someday be a patient, it’s your business to be engaged and involved as part of the solution. Let’s accelerate progress in 2016. 

 

What would you choose as the most notable development 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:  diagnostic error  emotional harm  transparency 

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Free from Harm? Let’s Take a Giant Step to Improve Patient Safety

Posted By Administration, Tuesday, December 8, 2015
Updated: Thursday, December 3, 2015

In a complex, high-risk environment such as health care, it may be impossible to keep all patients completely free from harm, but that must be our aspiration.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi
  
         
       
         

 

Last week the US Department of Health and Human Services released the latest data from the four-year effort to partner with hospitals to reduce incidents of patient harm. News reports noted that avoidable hospital acquired conditions — such as pressure ulcers, falls, adverse drug events, catheter-associated urinary tract infections, central line-associated bloodstream infections, and surgical site infections — were down by 17% from 2010 to 2014.

 

But amidst that good news was a trend showing that the decline in HACs plateaued between 2013 and 2014. About 10% of hospitalized patients experience a hospital-acquired condition, which all agree is “still too high.”

 

In a way, the news from HHS set the stage for the National Patient Safety Foundation’s release today of a new report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. Demonstrating improvement, while acknowledging big challenges still exist, is itself an argument for the approach that the new NPSF report introduces.

 

Our report was informed by an expert panel — led by Drs. Donald Berwick and Kaveh Shojania — convened earlier this year to assess the state of patient safety so many years after the seminal Institute of Medicine report that first brought public attention to medical errors and adverse events. By a wide majority, the experts agreed that patient safety has improved. For one thing, there is greater awareness of medical errors, patient safety, and human failures.

 

But the panel also found wide openings for improvement. The report details eight recommendations for achieving total systems safety and a safety culture:

 

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

 

The patient safety field has made progress via baby steps, and what we need now is a giant step. Total systems safety requires a constant prioritization of safety by leadership, done in a comprehensive rather than piecemeal manner, and taking into account safety culture, systems design, human factors engineering, the inevitability of human failures, and the need for robust error reporting and analysis.

 

This report calls for centralized, coordinated oversight of patient safety efforts and progress, as we have seen with other industries that affect public safety. While the creation of a new agency is unlikely to occur in today’s political climate, we must at least think seriously about expanding the role of an existing organization to serve this purpose. Regional or specialty collaboratives, while valuable, simply cannot achieve the oversight that a national agency can.

 

In addition, with one billion ambulatory visits annually in the US — compared to 35 million hospital admissions — it is well past time to consider safety across the care continuum. And, while deaths from medical errors make headlines, we also need to consider the substantial morbidity that safety failures cause, and include the safety and well-being of the health care workforce as a precondition to patient safety.

 

One of the key arguments this new report makes is that it’s time to acknowledge medical errors and adverse events as a serious public health issue that causes significant mortality, morbidity, and quality-of-life implications. We hope the report will serve as a call to action for all stakeholders to get involved. In a complex, high-risk environment such as health care, it may be impossible to keep all patients completely free from harm, but that must be our aspiration.

 

Download the report at www.npsf.org/free-from-harm.

 

Which of the eight recommendations most resonates with you?  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:  IOM  patient safety  To Err Is Human 

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A “Must Do” to Avoid Flu

Posted By Administration, Thursday, November 12, 2015

In advance of National Influenza Vaccination Week, it's time to get on board with universal influenza vaccinations for health care workers.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

The National Patient Safety Foundation this week re-issued an important policy statement initially issued in 2009: Support for mandatory influenza vaccination of health care workers. We took this stance six years ago in light of evidence that supports the ability of vaccination to prevent the flu in health care workers, which in turn can reduce the rate of infection among patients.

 

According to the Society for Healthcare Epidemiology of America (SHEA), flu vaccination by health care workers serves multiple purposes, including preventing transmission to patients; reducing the risk of influenza infection in the vaccinated health care workers; creating “herd immunity” that protects both health professionals and patients who are unable to receive the vaccine or unlikely to develop an immune response; reducing the impact of workforce absences due to illness during flu season; and modeling how important vaccination is for everyone. (See Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel.)

 

Earlier this year, writing for the NPSF Lucian Leape Institute, Dr. Bob Wachter argued in a Health Affairs blog post that influenza vaccination (along with hand hygiene) should be a “must do” practice among health care workers. The Institute chose these practices because they meet five specific criteria: the patient safety problem they address is important; the practice is recognized as being effective; the impact of compliance is significant in terms of the harm that would be prevented; universal compliance is feasible; and the practice has been accepted by professional societies and by professional consensus.

 

If you’ve checked the Centers for Disease Control and Prevention’s flu website, you’ll know that there is good news and less good news about vaccination among health care workers. Pharmacists win the title of highest percentage vaccinated last season, and hospitals rank highest among all settings for staff vaccination. But there is still a lot of opportunity for improvement, particularly in long-term care settings, where vaccination rates are among the lowest.

 

National Influenza Vaccination Week is observed next month, December 6-12, 2015. But you don’t need to wait until then to get your flu shot. Do it today.

 

Have you gotten your flu shot yet? 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:  flu  vaccination 

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