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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


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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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