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Is Patient Safety the New Anatomy?

Posted By Administration, Tuesday, February 23, 2016
Updated: Monday, February 22, 2016

In a special webcast moderated by NPSF President and CEO Dr. Tejal Gandhi, Drs. Don Berwick and Kaveh Shojania dove into questions about a new NPSF report and its recommendations for total systems safety and a culture of safety, with a call for leadership education being a key point of the discussion.

by Patricia McTiernan, MS


Should safety science be required learning for health system leaders and trustees? How do we more fully engage leaders in advancing patient safety? How do we get organizations to not just meet benchmarks, but to really work on the process of care?


Those were some of the questions posed to Don Berwick, MD, MPP, and Kaveh Shojania, MD, during a recent open webcast hosted by NPSF and moderated by Tejal Gandhi, MD, MPH, CPPS, president and CEO of NPSF. The session focused on the NPSF report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, and was highlighted by question-and-answer sessions during which Drs. Berwick and Shojania expanded upon the report’s recommendations.


Dr. Berwick, former administrator of the Centers for Medicare and Medicaid Services and president emeritus of the Institute for Healthcare Improvement, and Dr. Shojania, director of the Centre for Quality Improvement and Patient Safety at the University of Toronto and editor-in-chief of BMJ Quality & Safety, served as co-chairs of the expert panel that produced the NPSF report.


The report’s 8 recommendations are:

  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
Tejal Gandhi, Don Berwick, and Kaveh Shojania
Drs. Tejal Gandhi, Don Berwick, and
Kaveh Shojania at the Free from Harm
expert panel meeting

One of the first questions got to the heart of the safety culture conundrum: how can we capture the attention of CEOs and top management when it comes to safety? Acknowledging this as a “hard problem,” Dr. Berwick said that putting patients and families in the room with leaders and trustees is one of the most powerful and effective ways to get them engaged.


Long term, he said, leaders and trustees need training and education in safety, “just as they need to learn to read a balance sheet.” But for an immediate impact, nothing beats putting patients and families who have experienced harm in the same room with leaders and executives. “It’s very, very hard to turn away when that voice is in the room,” Dr. Berwick said.


He emphasized that the leaders need to hear patients and families in an “authentic way,” meaning not in a focus group type session, but in a format where the patients and families get to tell their stories. In answer to a follow-up question, he added that public forums, private executive sessions, and board meetings could all serve as a means of sharing patient stories. “The more the better,” he said.


One listener asked how educational preparation in patient safety has changed since To Err Is Human came out, and what more needs to be done. Dr. Berwick said the changes that have come have not been enough. “This is the new anatomy,” he said. “Safety and quality generally are no longer appropriately dealt with as add-ons to the professional skill set. It’s core; it’s essential.”


Would Dr. Berwick require trustees and executives to take a foundational course in safety science? “I’ll just say it’s really, really smart to do,” he said, stopping short of a requirement, but acknowledging that leaders and trustees have a duty to understand safety science, just as they need to understand financial stewardship of their organizations.


Other areas touched upon include


Reporting: Drs. Berwick and Shojania agreed that there has been an overemphasis on reporting for the sake of reporting, and that there needs to be more focus now on addressing the problems and recognizing which types of events are necessary to report every time. Dr. Shojania said that falls, for example, represent an epidemiologic problem, and there might not be value to reporting each and every one but instead focusing on systematic prevention.


Centralized oversight of patient safety: Dr. Berwick stopped short of calling for a new agency, like the National Transportation Safety Board, to oversee health care errors. He said there is a need for high levels of coordination, but that “a national reporting system may not add the value that some think if might…I’m a very strong fan of national leadership here, but national aggregation of data I think is something we need to approach with some caution.


Patient and family engagement: Dr. Shojania emphasized that many of the methods in use that are supposed to engage patients are superficial. True patient and family engagement needs to be authentic, and health care professionals could do a better job of characterizing what aspects of health care would most benefit from patient and family engagement.


In closing, Dr. Gandhi asked both presenters to pick their top 3 of the 8 recommendations. Both chose recommendations 1, Ensure that leaders establish and sustain a safety culture, and 6, support the health care workforce, among their top 3. Dr. Berwick added engaging patients and families to his list, while Dr. Shojania cited recommendation 8, Ensure that technology is safe and optimized to improve patient safety.


If you were not able to attend the webcast, listen to the replay and download the report here.


Which recommendations would make your top 3? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.


About the Author: Patricia McTiernan, MS is assistant vice president for communications at the National Patient Safety Foundation and editor of the P.S. Blog. Contact her at

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