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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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The Year in Review

Posted By Administration, Thursday, December 11, 2014
Updated: Thursday, December 11, 2014

“At NPSF and in the field of patient safety, there has been much progress this year, but there remains much work to be done. We continue to pursue our vision of creating a world where patients and those who care for them are free from harm.”


By Tejal K. Gandhi, MD, MPH, CPPS


  Tejal K. Gandhi

NPSF began 2014 with a new vision statement, as well as a revitalized mission and goals. With only weeks remaining in the year, it is a good time to reflect on the progress we have made.


The Foundation’s three-year strategic plan focuses on four areas: 1) engage with patients, families, and communities to identify and create strategies and disseminate tools to improve patient safety; (2) engage the health care community through education, shared learning, and professional advancement; (3) partner with key stakeholders to identify and evaluate safety issues requiring best practices, solutions, or business innovation; and (4) guide health care leaders and policy makers to advance patient safety in the evolving market.


For Patient Safety Awareness Week in March, we forged new alliances that allowed us to broaden the reach of this annual campaign. With a focus on diagnostic error, NPSF worked with the Society to Improve Diagnosis in Medicine (SIDM) and other partners to create and disseminate educational resources for hospitals, health professional, and health consumers. Thanks to the generosity of the Cautious Patient Foundation, NPSF and SIDM developed a webcast series free to all, including one session devoted to the patient’s perspective. We also shared patient narratives and published a series of blog posts written by members of the Partnership for Patients Patient and Family Engagement Network.


Also in March, the NPSF Lucian Leape Institute issued a report identifying specific action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health care. NPSF held a webcast about the report, and we partnered with other entities (IHI, the Partnership for Patients) on programs focused on report’s content. If you missed these programs, you can find the replays on our website.


Patient and family engagement continued to be a major issue at the 16th Annual NPSF Patient Safety Congress in May with a full-day session and a breakout track devoted to exploring what works and how patients and families can partner with the clinicians on their team. Also at Congress, Standard Register Healthcare, in partnership with the NPSF Lucian Leape Institute, conferred the inaugural John Q. Sherman Awards for Excellence in Patient Engagement. Four keynote sessions covered a diverse range of topics, from artist-turned-advocate, to the top research papers of the past year, to burnout among health care workers and how to avoid it, and the prickly issue of accountability. If you have not had a chance to view the video of the Bob Wachter-Gregg Meyer debate, I hope you can make some time to do so. The overwhelming majority of Congress attendees polled at the event favored some level of personal accountability for repeated or careless violations of patient safety practices.


The NPSF Congress also addressed our goal 4, with a day-long session for leaders and policy makers on the issue of keeping quality and safety front and center in an environment where so much emphasis is being placed on the costs of care. Download the Executive Summary of this session to learn more about the proceedings.


In the realm of professional advancement, NPSF enlisted a number of experts to help develop a review course for professionals planning to take the Certified Professional in Patient Safety (CPPS) examination. The course, offered on site at the 2014 NPSF Congress, was such a success, the content was offered as a webinar in October. Another review course is planned to be held on site at the 2015 Congress in Austin. More than 600 professionals have achieved certification since it was introduced in 2012, with roughly 250 this year alone thus far.


In July, NPSF began a new affiliation with BMJ Quality & Safety, recognizing the international, peer-reviewed journal as an official publication of NPSF. Members of the American Society of Professionals in Patient Safety (ASPPS) receive complimentary online access to the journal as a benefit of membership, while organizational members of the NPSF Stand Up for Patient Safety program may subscribe to the journal at a reduced rate. I am pleased to report that NPSF membership continues to grow; nearly 1,000 individuals joined ASPPS this year, joining a community of health care professionals, students, and patient advocates.


The highlight of the Foundation’s fall activities was the 7th annual NPSF Lucian Leape Institute Forum & Gala. The afternoon program featured an interactive session followed by breakouts on patient engagement, workforce safety, and the future of patient safety. Dr. Bob Wachter gave a revelatory talk about the hazards of health IT, the subject of his forthcoming book. If you were not able to attend this year, you can view the keynote address on our website.


NPSF also unveiled its new website in October, allowing for improved communications with members and greater functionality. I hope you’ve had a chance to explore the content and participate in the online forums.


In the policy realm, I was honored to be among the witnesses invited to testify before the Senate Committee on Health, Education, Labor & Pensions, Subcommittee on Primary Care and Aging, which held a hearing on medical error in July. Led by Sen. Bernard Sanders of Vermont, the subcommittee heard from a panel of patient safety leaders and advocates who made recommendations for how the federal government can contribute to advancing health care safety. You can watch a replay of the hearing or download the testimony of each witness on the subcommittee’s website.


NPSF has also had a seat at the table on the important issue of health information technology (HIT), participating on the ONC’s Health IT Policy Committee Safety Task Force, ONC’s HIT Implementation, Usability and Safety Workgroup,  and the AMIA EHR 2020 task force, all of which are working to reduce safety risks and optimize the benefits of electronic health records. In addition, beginning this month, I am representing NPSF on the NQF Prioritization and Identification of Health IT Patient Safety Measures Expert Panel that is working to improve measurement of HIT-related safety events.


Looking forward, the NPSF Lucian Leape Institute will soon publish a report on transparency in health care as a catalyst to improving safety. Led by Drs. Bob Wachter and Gary Kaplan, this project brought together two expert roundtables to develop recommendations for making transparency a reality in health care. Stay tuned to the NPSF website for news of this report’s release and a related webinar being planned. And of course, we are busy planning a great program for the NPSF Patient Safety Congress in Austin, Texas, April 29-May 1, 2015.


At NPSF and in the field of patient safety, there has been much progress this year, but there remains much work to be done. I hope you will stay in touch with NPSF as we continue to pursue our vision of creating a world where patients and those who care for them are free from harm.


Best wishes for the New Year.

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To Improve Patient Safety, Commit to Worker Safety

Posted By Administration, Tuesday, November 18, 2014
Updated: Monday, November 17, 2014

“Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.”


By Tejal K. Gandhi, MD, MPH, CPPS


  Tejal K. Gandhi

As the Ebola crisis continues in West Africa, and the US health care system works to address potential risks to workers here, it is worth noting that long before this year’s events, health care was known to be among the most dangerous sectors of the US workforce. According to the Occupational Safety and Health Administration, US hospitals reported 253,700 work-related injuries and illnesses in 2011. That amounts to 6.8 illnesses or injuries per 100 full-time employees (OSHA 2013). And that’s just hospitals; many more injuries occur in other health settings, such as long-term care facilities and ambulatory centers. More work days are lost in health care each year than in such industries as mining, machinery manufacturing, and construction (OSHA 2013).


These numbers represent muscle strains and musculoskeletal injuries, exposure to blood-borne pathogens, trips or falls, and other physical harms. Moreover, the health care sector experiences a significant toll of psychological injury as a result of bullying, stress, and burnout. One survey of health professionals found that 77% reported witnessing disruptive behavior by a physician, and 65% reported witnessing such behavior from a nurse, with the overwhelming majority saying that such behavior resulted in stress, loss of concentration, and reduced communication, and other hazards (Rosenstein and O’Daniel 2008).


NPSF has long supported the precept that health care workforce safety is a precondition to patient safety. In 2013, the NPSF Lucian Leape Institute examined this issue in a report compiled from the proceedings of two expert roundtable meetings and other research. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care states that “workplace safety is inextricably linked to patient safety. Unless caregivers are given the protection, respect, and support they need, they are more likely to make errors, fail to follow safe practices, and not work well in teams.”


The report cites root causes for the slow progress in improving workforce safety in health care. For one, many organizations do not have systems in place to support learning and improvement about worker safety. There is little awareness that by keeping workers safe, we help keep patients safe. Unnecessary risk to workers is largely driven by “rigid organizational structures and hierarchical models that are deficient in respect, teamwork, and transparency.”


Progress in workforce safety has been slower than many would like, yet there are health care organizations that are making great improvements. The Institute’s report outlines a number of recommendations to advance worker safety, among them:

  1. Develop and embody shared core values of mutual respect and civility; transparency and truth telling; safety of all workers and patients; and alignment and accountability from the boardroom to the front lines of care.
  2. Adopt the explicit aim to eliminate harm to the workforce and to patients.
  3. Create a learning and improvement system using evidence-based management skills for reliability.
  4. Create and track metrics for physical and psychological harm
  5. Support research to study issues and conditions in health care that are harming the workforce and, by extension, patients.

The National Patient Safety Foundation’s vision is: “Creating a world where patients and those who care for them are free from harm.” While addressing the current Ebola concerns is paramount, we must not lose sight of the long-term transformation required to make the health care sector a much safer place for workers and patients alike.

How does your organization monitor and respond to worker injury? Comment on this post below.



Occupational Safety & Health Administration (OSHA). 2013. Caring for our caregivers: Facts about hospital worker safety. Washington, DC: US Department of Labor. Available at:


Rosenstein AH, O’Daniel M. 2008. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 34(8):464-471.



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Health Literacy Month: A Great Time for Learning and Improving

Posted By Administration, Thursday, October 16, 2014
Updated: Tuesday, November 4, 2014

In order to advance patient safety, it is critical to optimize tools to help address health literacy challenges.


By Tejal K. Gandhi, MD, MPH, CPPS


  Tejal K. Gandhi

Earlier this year, the National Patient Safety Foundation’s Lucian Leape Institute issued a report about how patient and family engagement is critical for patient safety, citing health literacy problems as one of the barriers to effective patient partnerships. With Health Literacy Month in progress, there is no better time to learn more about this topic and to work to improve communication. 


The Institute of Medicine defines health literacy as “the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions” (Nielsen-Bohlman 2004). That involves more than just the ability to understand word meanings. It requires listening skills, communicating thoughts, facility with numbers, and judgment. By some estimates, only 12% of English-speaking adults in the United States are proficient in these skills (National Action Plan 2010). 


Patients with poor health literacy skills, “receive less preventive care, have less knowledge about chronic conditions, perform more poorly at self-care, use health care services at a higher rate, and have worse outcomes on a variety of measures than do patients with better literacy.” (NPSF Leape Institute 2014; Johnson et al. 2008). 


Clinicians and consumers alike need help in the form of training and tools that can facilitate communication—and ultimately lead to more meaningful and productive engagement and partnership. Health professionals who provide information and services need training on clear communication principles and skills to ensure that patients fully understand their health status and care plans. 


The US Department of Health and Human Services, the CDC, The Joint Commission, and others (Weiss 2007; Roter 2011) have recommended relatively simple tactics that health professionals can use to improve communication with patients: 

  • Slow down your speech
  • Limit, and repeat, information at every visit
  • Avoid medical jargon (See Words to Watch)
  • Use illustrations to explain important concepts
  • Use easy-to-read written materials
  • Make visits interactive by encouraging questions
  • Use “teach-back” to gauge comprehension 

To really step up on health literacy, organizations should test their patient information and education materials with a sampling of their audience—patients—to gauge comprehension and ease of use (HRSA 2010). 


Another thing that health professionals can do right now is to explore some of the resources that are currently available to help. 

  • The Centers for Disease Control and Prevention has a vast array of resources available, including background research, help in developing materials, and information about activities at the state level.
  • The Health Literacy Universal Precautions Toolkit, provided by the Agency for Healthcare Research and Quality, offers guidelines for all levels of staff.
  • The National Network of Libraries of Medicine is a good source of background research, bibliographies, and resources.
  • The US Department of Health and Human Services Office of Disease Prevention and Health Promotion offers the online Quick Guide to Health Literacy, a good starting point for the basics of how to improve the usability of the information you are giving to patients.
  • Medline Plus, produced by the National Library of Medicine, offers materials for both patients and clinicians. It has a health literacy section, and much of the content is available in Spanish as well as English.
  • Health Literacy San Diego offers information about tests that you can use to measure the reading level of your content.
  • Last but not least, the National Patient Safety Foundation offers the Ask Me 3 program, which includes materials designed to encourage patients to ask questions and be more involved in their care, particularly when they don’t immediately understand something.

What are you doing to improve health literacy in your organization? Comment on this post below. 




CDC (Centers for Disease Control and Prevention). Health Literacy—A Public Health Priority. In: Health Literacy for Public Health Professionals. 


DeWalt DA et al. 2010. Health Literacy Universal Precautions Toolkit. (Prepared by North Carolina Network Consortium, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, under Contract No. HHSA290200710014.) AHRQ Publication No. 10-0046-EF) Rockville, MD. Agency for Healthcare Research and Quality. 


The Joint Commission. 2007. "What Did the Doctor Say?" Improving Health Literacy to Protect Patient Safety. A Health Care at the Crossroads Report. 


HRSA (U.S. Department of Health and Human Services: Office of Disease Prevention and Health Promotion. 2010. National Action Plan to Improve Health Literacy. Washington, DC.


HRSA (U.S. Department of Health and Human Services, Health Resources and Services Administration). Effective Health Care Communications Course.


Johnson B, et al. 2008. Partnering with Patients and Families to Design a Patient- and Family-Centered Health Care System. Bethesda, MD: Institute for Patient- and Family-Centered Care.


National Patient Safety Foundation Lucian Leape Institute. 2014. Safety Is Personal: Partnering with Patients and Families for the Safest Care. Boston, MA: National Patient Safety Foundation. 


Nielsen-Bohlman L, Panzer AM, Hamlin B, Kindig DA, Eds. (2004). Health Literacy: A Prescription to End Confusion. Institute of Medicine. Washington, DC: National Academies Press. 


Roter D. 2011. Oral literacy demand of health care communication: challenges and solutions. Nursing Outlook. 59(2):79–84. 


Weiss B. 2007. Health Literacy and Patient Safety: Help Patients Understand: A Manual for Clinicians. Chicago: AMA Foundation.



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Accentuating the Positive

Posted By Administration, Wednesday, September 10, 2014
Updated: Friday, October 24, 2014

By Tejal K. Gandhi, MD, MPH, CPPS 


  Tejal K. Gandhi

A highlight of the NPSF Patient Safety Congress last May was a lively debate about accountability for patient safety. Two noted safety experts—Gregg Meyer, MD, MSc, and Bob Wachter, MD—each took a position on the question of whether punitive measures (fines, suspensions) should be applied when health care workers fail to consistently follow established safety procedures. Dr. Meyer argued we would make more progress if we did not solely focus on poor performers, but also celebrated those who were performing at the highest levels. “We need to laud them in front of their colleagues. We need to get people excited about trying to emulate them,” he said.

In an article in the July issue of BMJ Quality & Safety, Rebecca Lawton and colleagues make a similar argument, suggesting that focusing on positive deviance is a tactic well worth trying in health care. “Patient safety management…can feel like a relentlessly negative treadmill,” they write. “Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic.”

The authors note that, in health care, poor or unexpected outcomes are commonly investigated so that the root cause can be identified and avoided in future. It is the worst outcomes that bring the most attention—including the focus of external agencies such as regulatory bodies or the media. This relentless pursuit of the “negatively deviant” could certainly wear on the energy and enthusiasm of even the most committed clinicians and patient safety officers, which is a critical issue as we try to combat burnout in health care.

Yet, consistently good outcomes are seen at the unit or provider level in many organizations, and they receive relatively little notice. Lawton and colleagues offer suggestions for ways to identify the positive deviants in our midst and to support the adoption of their methods within the wider community.

I recently visited a hospital that was beginning to do RCAs on cases that went extremely well—to try to learn why they went well and share and learn from those lessons. I was really excited by this innovative concept—what a great way to learn and to celebrate the positives!


Do you think there is a role for positive deviance in your organization? Comment on this post below.



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Staying Current on Patient Safety Research

Posted By Administration, Thursday, August 7, 2014
Updated: Tuesday, September 2, 2014
By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi
At the NPSF Patient Safety Congress in May, Dr. Kaveh Shojania, editor-in-chief of BMJ Quality & Safety, provided an overview of key studies in patient safety research over the prior year. I have heard from many attendees that they really learned a lot from his presentation. To fully understand the implications of research, nothing beats having an expert summarize the finer points of an important study.


Dr. Shojania said that this year some of the most interesting studies focused on “ideas and themes…that are important for people on the front lines.” These included the Canadian study of the WHO surgical safety checklists (Urbach et al. 2014); a paper derived from the RN4CAST study of the impact of nurse staffing on outcomes (Aiken et al. 2014); and a study that revealed startlingly high rates of missed diagnoses (Singh et al 2013). We are excited that Dr. Shojania will be providing a new version of his talk on the latest studies from the upcoming year at the 2015 NPSF Annual Congress in Austin, Texas.


Unfortunately, most of us don’t have an expert available at all times to collect the most notable studies and interpret the findings in simple terms that we can apply to our work. In health care as in all industries, many of us struggle to manage the massive flow of information that comes at us every day. And yet, it’s vital to keep up with new developments in patient safety science. Think, for example, of how researchers have shown us the nuances involved in implementing checklists or the potential hazards of electronic medical records. Even the best safety ideas need refinement and adaptation, largely because they are implemented by human beings working in less-than-perfect systems.


So, how do we keep current? Most of us rely on some combination of subscriptions, news digests, conferences and meetings, and networking to learn what we need to know. We also rely on news sources (newspaper articles, social media), but more reliably, we turn to resources like AHRQ’s PS Net or the National Patient Safety Foundation’s Current Awareness Literature Alert (available to members) to learn about new studies. When we surveyed members of the American Society of Professionals in Patient Safety at NPSF (ASPPS) about what they need to help them in their work, one of the areas they were most interested in was access to research in patient safety. Partly in response to this, NPSF established an agreement with BMJ Quality & Safety, recognizing it as an official journal of the Foundation. (Read more about the agreement here.) We also include links to news items on our website and in our monthly e-news, and we are adding to the Links and Further Reading section of our website to help point health care professionals to useful resources.


Part of the NPSF mission is to disseminate strategies and best practices to advance patient and workforce safety, including sharing research findings. I hope you’ll let us know how we are doing in this regard.


Where do you get your latest research news? Comment on this post below. Read the President’s Corner archive.


Tejal K. Gandhi, MD, MPH, CPPS, is president of the National Patient Safety Foundation and president of the NPSF Lucian Leape Institute.



Aiken LH, Sloane DM, Bruyneel L, et al. 2014. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet. 38(9931);1824 -30. 24 May. doi:10.1016/S0140-6736(13)62631-8. [show in context]


Singh H, Davis Giardina T, Meyer AND, Forjuoh SN, Reis, MD, Thomas EJ. 2013. Types and origins of diagnostic errors in primary care settings. JAMA Intern Med. 173(6):418-425. doi:10.1001/jamainternmed.2013.2777. Available at:


Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. 2014. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med. 370:1029-1038. March 13. doi: 10.1056/NEJMsa1308261.

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