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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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Resident Work Hours and Patient Safety

Posted By Administration, Tuesday, September 20, 2016

Putting limits on the number of hours that physicians-in-training can work makes good sense—
for patients and for trainees.

By Tejal K. Gandhi, MD, MPH, CPPS

Tejal K. Gandhi


Most people would agree that they do not perform at their best when tired.

For physicians in training, overwork and exhaustion has been shown to lead to motor vehicle accidents, needle sticks, burnout, and depression. It can also lead to medical errors and adverse events.

And yet, we are still debating work hour limits for resident physicians.

The Accreditation Council for Graduate Medical Education (ACGME) sets duty hour limits for physicians-in-training and this year conducted a planned five-year review of limits set back in 2011. For now, duty hour limits will remain at the current standard: first-year residents (interns) may work no more than 16 hours straight, while more senior residents may work up to 24 hours (and in some specialty areas, up to 28 hours). Other requirements include a maximum of 80 hours per week, averaged over a four-week period, and mandatory one day free of duty each week. Exceptions may be made on a case by case basis, for example, if a resident wishes to extend his or her hours to ensure continuity of care, but other patients must be appropriately handed off and the reasons for the extended hours must be documented.

A number of physician groups have lobbied to have duty hour standards relaxed, the argument being that shorter hours lead to more handoffs and a less comprehensive learning experience for trainees. ACGME granted waivers for residents participating in two research trials comparing outcomes between a group that followed the duty hour restrictions and another group that worked flexible, that is extended, hours. The FIRST trial found that outcomes were “no worse” with extended hours among surgical resident. The iCOMPARE trial, which looks at internal medicine residents, has yet to release results.

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Based on what we know, the National Patient Safety Foundation strongly advises maintaining duty hour limits for residents at all levels. In a statement given at the ACGME Congress on the Resident Learning and Working Environment held earlier this year, NPSF recommended that discussions of duty hours be held in the context of a drive to total systems safety; that residents be trained in effective handoff methods, such as I-PASS; and that meaningful measures of safety be applied in research on this issue. We should not have to choose between patient safety (that is, by limiting handoffs) and workforce safety (by increasing handoffs to allow residents sufficient rest) because, in fact, both are critically important, and we now have good methods available to ensure safe handoffs.


Recently the public has weighed in as well. A national poll conducted by Public Citizen, a nonprofit advocacy organization, found that 86% of respondents were opposed to lifting duty hour restrictions, and 80% support a 16-hour limit on all residents, not just first-year residents (interns).

Duty hours and patient safety are two of the areas that fall under the Clinical Learning Environment Review (CLER) program that ACGME announced earlier this year. The program was created to help “improve how clinical sites engage resident and fellow physicians in learning to provide safe, high quality patient care,” and among the first steps was to conduct site visits. The first program brief, released in July, shows that in the area of fatigue management and duty hours, many sites reported fatigue from volume of patients and increased fatigue among faculty.


The fact is that fatigue and burnout are serious issues among all members of the health care workforce that endanger both patients and health care workers. It will not be an easy issue on which to achieve consensus, but we must do better for those who care for the most vulnerable among us. We must see that they are afforded adequate rest and respite, while also receiving the training they need to deliver the highest quality care. This must be achievable—we need to creatively and rigorously determine how.

Do you agree that fatigue and burnout among health professionals is a problem? 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:  medical education  workforce safety 

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