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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 2015

Posted By Administration, Monday, December 28, 2015
Updated: Sunday, December 27, 2015

As the year comes to a close, it's time to reflect on some of 2015's most important
patient safety stories.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


It’s hard to believe that the final days of 2015 are upon us. It’s been an incredibly busy and productive year for NPSF and for the broad patient safety community. As the year winds down, here in no particular order is a look at some of the most notable developments in patient safety this year.

  1. Reductions in patient harm. Earlier this month, the Agency for Healthcare Research and Quality (AHRQ), reported a 17% reduction in patient harm in hospitals over three years. The report quantified the efforts of the Partnership for Patients and as well as Medicare payment incentives, estimating that 1.3 million fewer patient harms and 50,000 fewer deaths occurred between 2010 and 2013 than would have been expected had hospital-acquired conditions continued at the 2010 rate. While this is good news, the report also noted that incidents of harm are still too high, with 1 in 10 hospitalized patients experiencing a hospital-acquired condition.

  2. A new focus on diagnostic error. In September, the Institute of Medicine released a consensus report pointing out the depth of the problem presented by diagnostic errors. By some estimates, diagnostic error affects 1 in 20 patients, or approximately 12 million people in the U.S. each year. The IOM report’s recommendations include enhancing culture and teamwork, improving health care professional education and training in the diagnostic process, ensuring health IT supports the diagnostic process, and increasing research into identifying and learning from diagnostic errors. The report launched an important conversation about a serious patient safety issue with broad impact across the continuum of care.

  3. Public interest in measurement and transparency. Over the summer, ProPublica, a nonprofit news agency, issued the Surgeon Scorecard, which calculated complication rates for eight relatively low-risk surgeries at the hospital and surgeon level. While some may argue about the accuracy of the risk-adjusting and the use of claims data to assess outcomes, the ProPublica reporters did an admirable job of trying to be fair and measured in their approach. Love it or hate it, the Surgeon Scorecard makes my list simply for the discussion it sparked around the need for greater transparency about outcomes in health care. Was it perfect? No. Was it a step in the right direction? Absolutely.

  4. A growing appreciation that harm is not just physical. Over the past few years, NPSF has focused a lot on disrespect within the health care workforce and the emotional and psychological harm it breeds. But the truth is, even patients—those who are at their most vulnerable state—can be the victims of emotional and psychological harm during care. A recent viewpoint article calls emotional harm the “neglected preventable harm.” We need to continue discussing, learning about, and preventing emotional harm to patients and families.

  5. Recommendation for total systems safety. My final pick is one close to my heart: the new NPSF report, Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human. While we’ve seen pockets of improvement in patient safety, it’s time for a new approach. Our report provides eight recommendations for achieving total systems safety and a culture of safety. I urge you to download the report and share it with your leaders and teams. We’ll be focusing on many of these themes as we embark on 2016.

It is gratifying to see movement and achievement in patient safety, but there is still much work to be done. Whether you are a patient, a clinician, an executive, or a consumer who will someday be a patient, it’s your business to be engaged and involved as part of the solution. Let’s accelerate progress in 2016. 


What would you choose as the most notable development 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:  diagnostic error  emotional harm  transparency 

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Improving Health Literacy: One Key to Improving Health Care Safety

Posted By Administration, Friday, October 9, 2015

October is Health Literacy Month. There's no better time to start learning more about how we can become better health communicators. 

By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi    


If you’ve ever misheard a conversation or misread directions, you know the pitfalls of written and spoken language. Messages are not always clear, even to those who are normally considered proficient communicators.


Think, then, of the complexities involved in health literacy, which requires not only understanding words, but also following instructions, using numbers, and reasoning. By some estimates only 12% of English-speaking adults in the U.S. are proficient in health literacy. At the same time, those of us in the patient safety field strongly advocate for greater patient and family engagement. It follows then, that we must identify good, useful tools to help patients become engaged and to help health care professionals communicate more effectively.


The National Patient Safety Foundation program Ask Me 3 is a patient education program designed to improve communication between patients and health care providers. It encourages patients to become active members of their health care team by asking their clinicians three questions:

  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?

The newest report from the Institute of Medicine takes the patient’s point of view into consideration, defining diagnostic error as the “failure to (a) establish an accurate and timely explanation of the patient’s health problem(s) or (b) communicate that explanation to the patient.” The report comes down firmly on the side of patients being a central part of the solution to improving diagnosis, so it makes sense to view things the way a patient would.


In its “toolkit” of resources, the IOM report includes a secondary list of questions that NPSF developed several years ago in collaboration with the Society to Improve Diagnosis in Medicine. These questions specifically focus on the diagnostic process:

  1. What could be causing my problem?
  2. What else could it be?
  3. When will I get my test results, and what should I do to follow up?

Question 2 — What else could it be? — is particularly important, because it can lead physicians to think twice, potentially avoiding “premature closure.” A 2011 review of research in ambulatory safety published by the American Medical Association defined premature closure as “the failure to continue considering reasonable alternatives after reaching an initial diagnosis.” Though the report found that most diagnostic errors occur through a combination of systems errors and cognitive errors, premature closure was the most common contributing cognitive problem.


October is Health Literacy Month, so there is no better time to start learning more about how we can become better health communicators. The Centers for Disease Control and Prevention offers robust resources to health professionals who want to learn more about health literacy. But there are also relatively simple tactics that clinicians can use to improve communication with patients right now:

  • 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.

What will you do this month to improve communication? 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.


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:  diagnostic error  health communication  health literacy 

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Diagnostic Error in the Spotlight

Posted By Administration, Friday, September 11, 2015

As we anticipate the upcoming Institute of Medicine report on improving diagnosis, NPSF joins with other organizations to think about the next steps. 

By Tejal K. Gandhi, MD, MPH, CPPS

  Tejal K. Gandhi    


Later this month, I will be among the speakers at the Diagnostic Error in Medicine 8th International Conference, hosted by the Society to Improve Diagnosis in Medicine (SIDM). The theme of this year’s meeting — After the IOM Report: What's Next? — gets to the heart of what many of us have been anticipating: release of an Institute of Medicine report on improving diagnosis.


While we don’t yet know the report’s findings, early news reports indicate that it will build upon existing research and knowledge about diagnostic error:

  • There are multiple causes and reasons for missed, delayed or wrong diagnosis, from communication breakdowns and inadequate use of information technology to cognitive errors by physicians, such as confirmation bias. In fact, in a study published in 2006, my co-investigators and I found that most cases of diagnostic error involve both systems-related factors and cognitive errors.

  • More research is needed into how diagnostic errors occur and how we can help prevent them. A 2012 paper suggested interventions such as greater patient engagement, better use of information technology, and focused interventions to avoid specific, known pitfalls.

  • Missed, delayed, or wrong diagnoses are a neglected area of patient safety, and no one is really measuring the problem. The approaches we normally use to identify adverse events won’t work for diagnostic errors. Even the Global Trigger Tool, created by the Institute for Healthcare Improvement and widely thought to be the best tool available to identify adverse events in hospitalized patients, captures few cases of diagnostic error, because it is designed to assess treatment flaws.

While most patient safety efforts have been made in the inpatient setting to reduce treatment errors, far more care is delivered in outpatient settings, and studies of malpractice cases show that diagnostic error is the chief claim in ambulatory care. By some estimates, 1 in 20 adults in the US have been or will be affected by diagnostic error.


The good news is that the IOM report is sure to bring much needed attention to this area of vulnerability for patients. NPSF recently joined the Coalition to Improve Diagnosis, which is led by SIDM and comprises a number of organizations committed to bringing awareness, attention, and action to the problem of diagnostic error.


As we await the IOM report, I encourage you to read Myths and Facts About Diagnostic Error, which NPSF and SIDM prepared jointly for Patient Safety Awareness Week 2014.


Have you experienced missed, delayed, or wrong diagnosis, either as a clinician or a patient? 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.


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:  diagnosis  diagnostic error  IOM 

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