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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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A Bold Move and a Call to Action

Posted By Administration, Monday, March 13, 2017
Updated: Friday, March 10, 2017

NPSF and the Institute for Healthcare Improvement are joining forces
in an effort to accelerate progress in patient safety.



By Tejal K. Gandhi, MD, MPH, CPPS

 

Tejal K. Gandhi

As many of you know, today marks the first business day of Patient Safety Awareness Week. This important week is a highlight of our United for Patient Safety Campaign and serves as dedicated time for raising awareness about patient safety among health professionals and the public.

With this in mind, today seems especially fitting to share the exciting news that NPSF and the Institute for Healthcare Improvement (IHI), are joining forces in an effort to accelerate progress in patient safety. The merger of our two organizations, which will be effective May 1, reflects a shared belief that patient safety is a public health issue and in need of a fresh and more robust approach. This bold move also reflects a strong commitment on the part of both organizations to making patient and workforce safety a core value in our health care institutions.

NPSF is also pleased to announce that IHI is among more than two dozen organizations that have endorsed the NPSF Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response, which released on our website today.

 

As we know, there is ample evidence to suggest that preventable harm in health care is a leading cause of death in the United States. In the Call to Action, NPSF calls on health care leaders and policymakers to initiate a coordinated public health response to improve patient safety and drive the collective work needed to ensure that patients and those who care for them are free from preventable harm.

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Building on successful efforts to reduce health care associated infections and taking advantage of critical lessons learned, the Call to Action provides a new public health framework to guide collective efforts. The six-part framework, which was developed with significant insight and perspectives from the NPSF Board of Advisors and Board of Directors as well as senior officials at the US Centers for Disease Control and Prevention, identifies effective, replicable interventions that can be implemented across the health care system. It begins with defining the problem and setting national goals and involves improving coordination of activities across sectors and stakeholders.


In our current political climate, leadership at the federal level may be uncertain. But that doesn’t mean others cannot or should not take on a roll in playing a part. As a first step, organizations can demonstrate their commitment to advancing patient safety by supporting the Call to Action.

 

We at NPSF look forward to working more closely with IHI as well as our many other endorsers to advance the components of the Call to Action in the coming year. I hope you will review our framework, share it with your peers, and get involved with us in creating solutions.

Do you believe patient safety is a public health issue? 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:  IHI  public health 

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On More Evidence of the Toll of Medical Errors

Posted By Administration, Tuesday, May 10, 2016
Getting an accurate picture of the problem could help increase research funding for solutions.



By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

 

The patient safety community—and much of the medical field in general—took notice last week at publication of a new study estimating the toll of medical errors. Comparing data from a number of earlier studies, the authors calculated that more than 250,000 deaths per year stem from medical errors, making this category the third leading cause of death, behind heart disease and cancer.

Speaking for the National Patient Safety Foundation, I can say I am not shocked by the numbers suggested by this analysis. Although there have been some criticisms of the new paper’s methodology—mainly that the comparative studies were done on small sample sizes and are just being extrapolated to identify the national numbers—I applaud the authors for increasing public attention on an issue with which health professionals, as well as many patients and families, are all too familiar.

One of the authors’ main arguments is that medical error is not being adequately measured because it is not considered a cause of death on death certificates. They suggest, “…death certificates could contain an extra field asking whether a preventable complication stemming from the patient’s medical care contributed to the death.” If there were an ICD code for medical error, the authors propose, the CDC would be able to track deaths from that cause the way they track mortality from other causes.

While it is absolutely true that medical error is not currently adequately measured, adding “medical error” to death certificates is not as simple as it sounds; often the person completing the death certificate may not know if the death was preventable. Even when error is suspected, it often takes time to investigate and identify underlying causes.

In discussing the new study, Dr. Martin Makary, the lead author, pointed out that the numbers reported by the CDC are important because they help set the national research agenda. This is why NPSF, in our recent report Free From Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, called for federal agencies to create a portfolio of national standard patient safety process and outcome metrics across the care continuum and to retire invalid measures that are not useful or meaningful.

Better measures nationally for all medical errors will help to truly capture the extent of harm. Better measurement will also help identify research needs and increase leadership prioritization of these issues. It is time for us to begin addressing medical errors as we do other serious public health crises—with robust measurement, scientific analysis, and collaborative approaches to solutions that can reduce the toll on patient, families, and the health care workforce.

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:  measurement  public health 

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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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