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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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Top tags: leadership  culture  diagnostic error  patient safety  patients  public health  transparency  AHRQ  ambulatory  Health IT  IOM  workforce safety  2016 NPSF Congress  2017 Patient Safety Congress  board certification  collaboration  communication  communication and resolution  CRP  diagnosis  education  emotional harm  families  flu  health communication  health literacy  IHI  measurement  medical education  medication 

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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Leadership, Culture, Communication at the Heart of Safety

Posted By Administration, Monday, June 13, 2016
The 18th Annual NPSF Patient Safety Congress emphasized the importance of psychological safety, patients and families as partners,
and greater transparency to make us safer.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Regular readers of this column know that the National Patient Safety Foundation has been very focused in recent months on the issues of leadership and culture in health care. Our attention to these interdependent factors, which are vital to advancing patient safety, continued at the 2016 NPSF Patient Safety Congress—the Heart of Safety—held last month in Scottsdale.

Amy Edmondson, PhD, AM,
Novartis Professor of Leadership and Management at Harvard Business School and a member of the NPSF Lucian Leape Institute, led an enlightening keynote session on teaming, which she defined as “coordinating and collaborating, across boundaries, without the luxury of stable team structures.” In health care systems that operate 24 hours a day, 7 days per week, the need for effective teaming is obvious. If the team is not effective, they won’t perform at their best, and safety could be compromised.

Prof. Edmondson explained that psychological safety is essential for patient safety and is a hallmark of effective teams. Psychological safety, “a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes,” is best created by inclusive leadership. Leaders can create this kind of environment by being accessible, by proactively inviting opinions of others, and by acknowledging that they, too, are human, and subject to fallibility.

We also talked a lot this year about communication. Ben Moulton, JD, MPH, senior vice president, Informed Medical Decisions Foundation, led a panel on shared decision making, emphasizing that, often, there is no “right” course of action; the patient’s wishes are paramount in deciding upon a care plan. Among the evidence he cited was a study showing that decision aids lead to greater knowledge among patients, greater comfort with their decisions, fewer patients remaining undecided about a procedure, and fewer choosing major surgery.

Communication and resolution after medical error was the focus of one of our Immersion Workshops led by Tom Gallagher, MD, professor and associate chair, Department of Medicine, University of Washington, and Rick Boothman, JD, chief risk officer, University of Michigan Health System. During our meeting, the Agency for Healthcare Research & Quality released its Communication and Optimal Resolution (CANDOR) Toolkit, and Erin Grace, MHA, of AHRQ was on hand to discuss it with attendees. The new toolkit 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.

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These topics were brought to life for attendees by Patty Skolnik and Beth Daley Ullem, mothers, patient advocates, and members of the NPSF Board of Advisors, who shared tragic and powerful personal stories of how their families were affected by medical harm. When it comes to engaging patients in their care and creating transparency around medical errors and adverse outcomes, the health care sector has a long way to go. But our faculty for these programs showed us what is possible and how much it truly matters.

Professional meetings are designed to provoke thought, and Kaveh Shojania, MD, director of the Centre for Quality and Improvement and Patient Safety at the University of Toronto and editor-in-chief of BMJ Quality & Safety did just that in offering his assessment of recent, important patient safety research. He discussed a range of topics, including diagnostic error, the impact that rudeness has on team performance, trends in adverse events over time, incident reporting, fall prevention, and high-risk prescribing in primary care. His suggestions that we revisit our thinking on areas such as harm measurement, falls, and safety reporting, have surely generated discussion among attendees.

We closed with a valuable keynote session led by resiliency expert Paula Davis-Laack, who inspired us with her tips for how health care professionals can beat burnout.

We were also very pleased to recognize exceptional work through the awards given at Congress. (Read about the poster awards here and other awards here.)

This year, as every year, I learned a lot from the presentations and from those I had a chance to speak to during our networking sessions. I know attendees left with practical tactics to take home to advance their patient safety activities. The feedback we receive is very important as it helps us shape the program over the years, so we are grateful to those who’ve gotten in touch as well as those who have completed the attendee survey. We are already working on next year, so stay tuned.

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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:  2016 NPSF Congress  communication  culture  leadership 

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Getting into the Game on Safety Culture

Posted By Administration, Friday, January 22, 2016

Leaders need practical tools to work toward a culture of safety in their organization, and board members need to be more than cheerleaders — they need to be in the game.


By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


A search of the words “culture of safety” in Google brings more than 9 million results. Not all of these relate to health care, of course; theories about a culture of safety started in other industries. Yet, the abundance of material about a culture of safety is reason enough to wonder why such a culture is so difficult to achieve and sustain in health care organizations.


To understand why, we must first define what we mean. In the new NPSF report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, we use a definition of safety culture that is widely used in health care, which states in part:


Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures (Health and Safety Commission 1993).


A culture of safety provides the means for robust reporting of errors and near misses, as well as the feedback loop to inform staff of what was done to prevent recurrence. It is a learning environment, where adverse events do not get hushed up, but instead are shared throughout the organization to educate all. It is a culture that does not punish human error, but that does address unprofessional and disruptive behavior that can undermine safety. It is a culture where everyone is preoccupied with the possibility of failures and how to prevent them and mitigate harm.


The expert panel members who contributed to the NPSF report cited culture change as the biggest struggle around effecting improvement in patient safety. As others agree, it’s difficult to imagine making long-term progress in patient safety if our culture remains dysfunctional.


In making culture the focus of our number one recommendation, we tied it to leadership, because the leaders and board members of health care organizations hold extraordinary power to impact the culture.


But knowing that, even accepting it, in theory alone is not enough. We need to give our leaders practical tools to use to improve their organization’s culture. And board members need to be more than cheerleaders for this work. They need to be in the game.


Where to begin? Sadly, I would wager that every hospital in the country has an adverse event or near-miss story to tell at least once a month. Why not open every board meeting with a patient story, so board members get a sense of the real people they are serving by being in the room? Why not demand that safety data be reported at every board meeting?


We also call for all board members and leaders of health care organizations to receive education about the fundamentals of patient safety science, just culture principles, and systems thinking. This is really an essential first step toward “shared perceptions of the importance of safety.”


I’ve said many times in recent talks and interviews that we cannot simply tell people: “Go change your culture.” It’s hard work that is never really done. Leaders must prioritize the importance of safety culture and learn strategies to effectively create it.

What tactics are implemented in your organization to encourage a culture of safety? 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  leadership 

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Lessons Learned from the NPSF Patient Safety Congress

Posted By Administration, Thursday, May 14, 2015
Updated: Thursday, May 14, 2015

Leadership, Culture, and the Power of Patients Made a Strong Showing at the 2015 NPSF Congress.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi

The National Patient Safety Foundation hosted the 17th Annual NPSF Patient Safety Congress last month in Austin, and it was wonderful to see so many health professionals gathered in one place to learn and share best practices about patient safety. We are so grateful to our enthusiastic attendees, our committed faculty and planning committee, our exhibitors, and of course, the supporting organizations that helped make the Congress such a success. It was particularly exciting to meet so many members of the NPSF membership programs, the American Society of Professionals in Patient Safety and the NPSF Stand Up for Patient Safety program, and get to hear from them in person.


One of the lessons I took from the meeting is how much the discussions about culture and leadership resonated with attendees. We weren’t mired in theory—our speakers focused on practical ways to help change culture—which, of course, requires strong leadership commitment. During our opening keynote session, Dr. Gary Kaplan, chief executive officer and chairman of Virginia Mason Health System, said that leaders—be they CEOs or unit managers—should aim to be “idea coaches.” They need to support their staff in working on ideas, encourage root cause thinking, be straightforward with feedback, and ask questions to spark creativity and critical thinking. As he noted, this kind of behavior can be a stretch for some who think that they, as the leader, need to solve all the problems.


Dr. Gerald Hickson, senior vice president for quality, safety, and risk prevention and assistant vice chancellor for health affairs at Vanderbilt University Medical Center, talked about the people, processes, and technology that are necessary to bring about culture change. Disrespect and disruptive behavior, even when rare, can be very damaging to an organization, and Vanderbilt uses a detailed and well-defined process for addressing such behavior when it occurs. Their tools and approach have shown real results, with improvements in hand hygiene compliance, improved adherence with clinical protocols, and reduced malpractice claims and expenses.


The bookend to this discussion was our closing keynote, by Dr. Allan Frankel, chief medical officer, Safe and Reliable Healthcare, and author of The Essential Guide for Patient Safety Officers. Dr. Frankel gave examples of organizations that are generative in their approach to patient safety—meaning safety and improvement are hardwired into their operations. He pointed out that professionalism, behavioral norms, psychological safety, and culture are measurable. “Cultures catapult from mediocrity into excellence when all the components come together,” he said.


Another top takeaway came from three speakers who began their work in patient safety as patients or family members of patients. Through their powerful stories, Kim Blanton, Chrissie Blackburn, and Beth Daley Ullem showed the many ways that health care organizations can better partner with patients. Their journeys from places of loss and fear to positions of influence show that some organizations are making real progress in patient engagement, and I know a lot of our attendees took these lessons to heart. (Read more about this topic on the P.S. blog.)


Last but not least, I came away from the meeting with a renewed appreciation for the value of networking. Many attendees told me how much they gain from talking face-to-face with others—be they peers in similar organizations or industry representatives discussing new and innovative tools. Some attendees made new friends and professional connections, while others caught up with colleagues they met at past NPSF Congresses. The strength of our connections and commitment to making health care safer truly brought this year’s Congress theme, United in Safety, to life.


Visit for more news about the annual meeting. If you attended the 2015 Congress, we’d love to hear your comments, either via the survey we sent, or comment below.

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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  leadership  networking  NPSF Congress  patients 

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