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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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