Great Expectations, Deficient Implementations – Who Killed Patient Safety?

The patient safety community is inherently hopeful.

However, today Pascal wishes to comment on a recent article by Hemmelgarn et al in which the authors posed a question:  “Who Killed Patient Safety?” [1]Hemmelgarn et al, “Who killed patient safety?” Journal of Patient Safety and Risk Management.  Volume 27, Issue 2.  May 5, 2022, pages 56-58. While none of the co-authors — all of whom have lost a family member to preventable patient harm — wish for patient safety’s death, the provocative title intended to highlight a decline in urgency and progress in the movement that is considered to have launched in 1999 with the publication of To Err Is Human.

The first paragraph reads as follows:

“The medical community’s commitment to patient safety has withered to over the past 10–15 years after the original call to action in 2000 with the release of the IOM report, To Err is Human.[2]Institute of Medicine. To err is human: building a safer health system. Washington, DC: The National Academies Press, 2000. The tragedy of this decline in action around safety lies in the lives of the families like ours, who have lost loved ones, been harmed, and often permanently injured by medical error. What was once a motivating call to action, safety in hospitals and oversight by our government has been deprioritized, defunded, and devalued leaving patients like us to wonder: What happened to Patient Safety?”[3]National Academies of Sciences, Engineering, and Medicine. Peer review of a report on strategies to improve patient safety. Washington, DC: The National Academies Press, 2021.

The co-authors cite the following as evidence that the patient safety movement has lost steam:

• “Twenty years later, other than infection control to anesthesia, the American hospitals have not progressed in systemically meeting patient safety goals, and the medical community seems to have lost its commitment to safety.”

• “The National Academy of Sciences recently reported, “The country has not achieved the level of safety in daily patient care that we have come to expect from other industries, such as when we board an airplane. Continuing on the current trajectory is not likely to produce substantial improvements in patient safety.””

• “The organizations who used to oversee, lead, and support safety have moved on to other priorities. Safety is no longer a critical part of their strategies, oversight, and programmatic funding.” [4]Hemmelgarn et al, Ibid.

Further:

“It is time those organizations: Institute for Healthcare Improvement, National quality Forum, Agency for Healthcare Research and Quality, Joint Commission, Centers for Medicare & Medicaid Services, American Hospital Association, state hospital associations, and others do a deeper pause on their work to contemplate if they are leading in safety or they are complicit in the decline of safety in the U.S.” [5]Hemmelgarn et al, Ibid.

Why is patient safety struggling?

Necessary But Not Sufficient

There have been a host of initiatives promoted by researchers, regulatory and quasi-governmental authorities, health systems, nonprofit leaders, vendors, and other stakeholders over the last two plus decades that have raised hopes of material progress. For the most part, despite the best of intentions, hopes have been dashed by necessary but insufficient approaches and programs:

• Awareness campaigns:  raising awareness is helpful but will not address systemic or structural issues

• Cultural interventions:  a culture of safety is essential to progress but alone will not adequately change care for the better, at least fast enough

• HRO training:  a specific type of a cultural intervention, HRO training improves safety but it, too, requires accurate, timely data to evaluate and improve

• Real-time EHR data:  while eliciting wonder and promise when they first appeared, real-time EHR data by itself requires sense-making to be useful

• Automating triggers:  the automated trigger method, while critical for next generation safety, is a component of a comprehensive solution

• Advanced analytics:  although predicting outcomes is also likely to play an essential role in next generation safety, health systems will not predict their way to performance

Many health systems have launched one or more of the above initiatives in expectation of achieving patient safety.  All of these initiatives are helpful, if not important, but each alone or even together with a few others is inadequate to achieving safe care — leave alone reaching “zero harm.” Many of them cannot verify whether or not they are safer, as most of these health systems do not measure patient safety with evidence-based rigor, i.e. with clinically validated adverse event outcomes using EHR data (“AE Outcomes”).

What Else We Need

Indeed, the answer to “What else do we need?” starts with measurement.  As in most fields, outcomes measurement is the foundation of knowing what happened, what is happening now, and what should I do to improve future outcomes?  Specifically, in the adverse event domain this, means measuring AE Outcomes.

Missing in traditional patient safety programs, especially today, are the following:

• Outcomes measurement:  the foundation to patient safety, risk, and quality improvement

• Operational integration:  the inclusion of AE Outcomes into operational workflow in a clinically relevant and useful way

• Mission-critical execution:  the support of intervention and improvement with AE Outcomes in daily operations and up to 24/7

• Strategic resourcing:  the allocation of sufficient investment to generate and use AE Outcomes enterprise-wide

• ROI discipline:  sound safety & risk programs should measure its ROI through the lens of patient-specific AE Outcomes

• Beginner’s mind:  the next generation of patient safety will require the openness to learn and apply new methodology and technology

What Will Revive Patient Safety?

In summary, the following will revive patient safety:

1. Acknowledge the limitations of traditional approaches to patient safety and the need for a significantly expanded model — a cultural change

2. Measure AE Outcomes daily and, over time, up to 24/7 — an methodological change

3. Link AE Outcomes to financial outcomes to track and demonstrate ROI — a technological change

 

 

 

Great expectations graphic

Footnotes

Footnotes
1 Hemmelgarn et al, “Who killed patient safety?” Journal of Patient Safety and Risk Management.  Volume 27, Issue 2.  May 5, 2022, pages 56-58.
2 Institute of Medicine. To err is human: building a safer health system. Washington, DC: The National Academies Press, 2000.
3 National Academies of Sciences, Engineering, and Medicine. Peer review of a report on strategies to improve patient safety. Washington, DC: The National Academies Press, 2021.
4, 5 Hemmelgarn et al, Ibid.