Search our Site
Reflections on Safety
Blog Home All Blogs
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.


Search all posts for:   


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 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.

Back to top

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 

Share |
PermalinkComments (0)
more Calendar

10/24/2019 » 10/30/2019
Patient Safety Executive Development Program

Copyright ©2019 Institute for Healthcare Improvement. All Rights Reserved.

Membership Software  ::  Legal