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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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Five Notable Developments in Patient Safety in 2016

Posted By Administration, Tuesday, December 20, 2016

Progess was made in 2016, but there is much work to do in the patient safety field.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Just about a year ago, the National Patient Safety Foundation released Free from Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human, a report offering eight recommendations for elevating national focus on patient safety. These recommendations continued to reverberate within the field in 2016, and guided my picks for five notable developments in patient safety this year.

  1. Developing a culture of safety (Recommendation 1): One of the chief messages of the Free from Harm report is that without a culture of safety, it is difficult for any organization to advance patient safety and sustain improvements. The report defines a culture of safety as one in which “health care professionals and leaders are held accountable for unprofessional conduct yet not punished for human mistakes; errors are identified and mitigated before they harm patients; and strong feedback loops enable frontline staff to learn from previous errors and alter care processes to prevent recurrences.”

    NPSF is currently collaborating with the American College of Healthcare Executives on a resource to help leaders create a culture of safety in their organizations. But perhaps most notable this year is the number of other organizations also working on this issue. The American Nurses Association addressed safety culture and leadership in monthly installments of resources this year, and a culture of safety was the theme of National Nurses Week. Meanwhile, the number of research studies and articles addressing the importance of culture is on the rise.

  2. Recognizing the need for improved safety metrics (Recommendation 3): In May, BMJ published a paper suggesting that medical errors are the third-leading cause of death in the U.S. The paper received wide attention, including some counter-arguments that the methodology was flawed. Ultimately, however, this article should spark broad agreement that there is a great need for improvements in the way we measure patient safety. Right now, too many of our methods are retrospective, reporting is inconsistent, and metrics are not uniformly used and analyzed. This year we began to see that the true toll of preventable harm in health care will only be known once we establish consistent and robust metrics in all settings.

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  3. Adding to our knowledge about ambulatory safety (Recommendation 5): Free from Harm points out that, while most of the patient safety work done thus far has been done in acute care hospitals, the vast amount of health care delivered in the U.S. happens in the outpatient arena. For example, the Office of the Inspector General released a report this year estimating that 29 percent of Medicare recipients experience an adverse event or temporary harm while in a rehabilitation setting, with almost half of them deemed preventable.

       Some of Dr. Gandhi's picks for notable developments
    in patient safety this year reflect recommendations of
    the NPSF report, Free from Harm.
    We have so much to learn about risks and strategies to prevent harm in ambulatory or other settings. One notable development this year has been increased research in this topic. Most recently, AHRQ issued a technical brief that combined interviews with key informants as well as a literature review. The brief identifies medication safety, diagnosis, transitions, referrals, and testing as important ambulatory care safety topics. Communications, health IT, teaming, patient engagement, organizational approaches, and safety culture are flagged as the most important areas in which to seek improvement.

    This is not just a U.S. concern, however, and it is encouraging to see the World Health Organization convene experts to develop ways to “bridge knowledge gaps” in primary care.

  4. Increasing emphasis on workforce safety (Recommendation 6): NPSF considers the physical, psychological, and emotional safety of clinicians and staff to be a precondition to patient safety. This year we have seen growing recognition that burnout is a huge issue for the health care workforce, with more than half of physicians reporting at least one symptom of burnout. This has a direct impact on patient safety, as we know that clinicians experiencing burnout are not only more likely to make an error, but also less likely to take the steps necessary to engage patients, families, and the health care team.

    In encouraging signs, the American Medical Association, the National Academy of Medicine, and other entities are beginning to take a hard look at solutions. There is now wide acknowledgment that we need to look beyond the toll on individuals and begin addressing burnout as a system-wide issue and even as a quality measure.

    Related to this, fatigue can be a significant contributor to burnout. This year, the Accreditation Council for Graduate Medical Education has been exploring changes to duty hour limits, despite the evidence that fatigued residents are more likely to make errors that harm patients or themselves. NPSF and others are opposed to any change and, instead, argue for improving handoffs and communication.

  5. Partnering with patients and families (Recommendation 7): Communication and resolution programs (CRPs) promote open communication after an adverse event is discovered, comprehensive analysis of the event, implementation of improvement initiatives, emotional support for patients and providers, and appropriate resolution. In 2016, we saw progress in the number of organizations putting CRPs into practice.

    In April, NPSF offered a complimentary webinar on this topic in partnership with the Collaborative for Accountability and Improvement. The following month, the NPSF Patient Safety Congress featured an all-day immersion workshop on implementing CRPs.

    Also this year, the Agency for Healthcare Research and Quality released the CANDOR Toolkit, designed to help expand use of an AHRQ-developed process called Communication and Optimal Resolution, or CANDOR. This program gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

If you have not had a chance to read the Free from Harm report, I encourage you to do so. These developments show that the issues discussed in the report remain vital to patient safety and are sure to be important as we move in to 2017.

What are your thoughts on the top developments in patient safety this year? 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:  culture  Health IT  leadership  workforce safety 

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Helping To Ensure the Safe Use of Copy and Paste

Posted By Administration, Friday, April 15, 2016
Updated: Friday, April 15, 2016

The Partnership for Health IT Patient Safety has released its first set of guidelines

to help correct unintended consequences of health information technology.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


The use of health information technology (IT) has increased dramatically over the past decade, and has helped to improve patient safety through practices such as electronic prescribing. Yet as many of us have seen, health IT can bring with it unintended consequences, some of which pose new risks to patient safety.


Ensuring that technology is safe and optimized to improve patient safety is among the recommendations of the National Patient Safety Foundation’s most recent report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, and health IT in particular is a key area of activity.


NPSF is a member of the Partnership for Health IT Patient Safety, a multistakeholder group convened by ECRI Institute’s Patient Safety Organization (PSO) in 2013. Other members include health care providers, health IT vendors, academic researchers, patient safety organizations, and professional societies. Through the collection, analysis, and sharing of health IT data and information, the partnership seeks to inform the national strategy for health IT patient safety, provide useful recommendations for all stakeholders, and in identify ways that health IT can be used to improve patient safety.


I serve on the partnership’s expert advisory panel and had the honor of chairing one of the first workgroups, addressing “copy and paste” functionality in health IT systems. Earlier this year, the partnership released the workgroup’s recommendations as part of a publicly available resource, Heath IT Safe Practices: Toolkit for the Safe Use of Copy and Paste.


Copying and pasting with the medical record is a widespread practice. Studies of varying disciplines in diverse settings indicate anywhere from 5% to 90% of notes contain copy and pasted text. This practice can improve documentation efficiency and completeness, but also represents a significant risk, as clinicians may unknowingly populate the record with old, inaccurate, or excessive information.


Our workgroup focused specifically on functionality and how to use it to increase, not detract from, patient safety. Our task was to define copy and paste, review the literature, and review events reported to ECRI Institute’s PSO. We also talked about vendor functionalities and looked at best practices of some exemplary organizations before finalizing the recommendations. The ECRI team and the workgroup did a terrific job of synthesizing the results of these deliberations.


Broadly, our recommendations cover four areas, most of which entail action by both health IT vendors and provider organizations:


Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.

It’s crucial for clinicians to be able to easily identify text that has been copied and pasted so they can more easily verify its accuracy and review it for needed edits. This potentially can be achieved by use of a split screen or different formats (for example, use of italics) for copied material.


Recommendation B: Ensure that the provenance of copy and paste material is readily available.

Clinicians need to be able to figure out fairly easily where the copied material originated, which helps verify its accuracy and appropriateness. One example of a potential solution is for information about the copied material to “hover” over it when it is being accessed.


Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
One of the benefits of copy and paste functionality is that it is a quick and efficient way to document complex information – especially if the information does not change much over time. Clinicians are of course responsible for the content and accuracy of their notes, but in the midst of a busy schedule, the safety risks may elude them. Ongoing education and training are needed about the best ways to optimize its use, and the toolkit provides examples of this kind of education.


Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.
Health care provider organizations and vendors need to work together to create audit tools and audit policies to monitor the use of copy and paste by providers. By auditing use, they can help ensure the integrity of the clinical record, as well as the quality and safety of care, and gather information on what type of data are commonly copied and pasted, in order to potentially create new solutions or tools. Examples of audit measures and policies are also in the toolkit.


I encourage all those involved in health care and in health IT to download the toolkit and consider implementation of the recommendations.

Have you experienced unintended consequences of copy and paste? 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:  Health IT 

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