Since the publication in 1999 of the Institute of Medicine report To Err is Human, which found that between 44,000 and 98,000 Americans die each year from preventable medical errors, the patient safety movement has gained significant traction. Throughout the 2000s, efforts focused on increasing safety reporting, correcting incidents like wrong-site surgeries, and introducing patient safety ratings to benchmark hospitals.
Tejal Gandhi, MD
Current efforts are tailored to ongoing issues like meaningful use and Affordable Care Act-driven cost reductions. But according to Tejal Gandhi, MD, president and CEO of the National Patient Safety Foundation, several new priorities are in the offing. Gandhi spoke to a crowd of biomeds June 8 on the changing nature of patient safety during the Dwight E. Harken Memorial Lecture at the 2015 AAMI conference in Denver. She outlined areas of focus and key challenges facing the healthcare industry, as well as potential solutions.
Care across the continuum. The classification “ambulatory care” typically applies to traditional primary care settings, but it also covers dialysis centers, nursing homes, rehab centers, and in-home care, all settings which differ vastly from primary care and face unique needs. Among the core problems are nonadherence (one in four prescriptions for essential medications are never filled, research has shown); missed or delayed diagnoses of serious diseases like cancer; and breakdowns in the diagnostic process, such as failure to order the appropriate tests. Introducing double checks and decision support can help mitigate the “cognitive errors” responsible for many of these problems, Gandhi says, while implementing closed-loop test result and referral management systems can help reduce systems errors.
Patient and family engagement and experience. Forming partnerships to promote patient engagement has been tied to better clinical outcomes, but barriers like paternalistic attitudes and the fragmentation of the healthcare system often stand in the way. According to Gandhi, organization leaders must establish engagement as a core value and train their personnel to be effective partners with patients and their families. Clinicians need to be open with sharing information and be willing to apologize when errors occur. Patients must serve as their own advocates, questioning clinicians when they don’t understand and inviting family members to join them at their appointments. Introducing patient family advisory councils and patient reporting systems can also promote these values.
Focus on the workforce. Just as higher rates of patient engagement have been correlated with positive outcomes, research has also shown that a positive workplace environment reinforces the principles of patient safety. Yet the healthcare industry as a whole continues to struggle with a negative workplace climate and risks not faced in other sectors—factors which can make employees more prone to make errors and neglect safety practices, thus endangering patients. The injury rate among healthcare workers is 30 times higher than other industries, with one third of nurses suffering from back or other musculoskeletal injuries. Bullying, demeaning language or treatment, and lack of support or appreciation frequently lead to high burnout rates and rapid turnover. However, cultivating a climate of mutual respect, consistently addressing disrespectful behavior, and establishing performance metrics for improvement can help facilities increase nurses’ enjoyment and satisfaction in their work, while also indirectly serving patient safety, Gandhi says.
Increased transparency and metrics that measure transparency. Across the healthcare enterprise, more transparency is needed to help ensure patient safety, Gandhi says. Patients and their families need to receive accurate, complete, and early disclosure about adverse events. Clinicians should be able to share data among themselves on adverse events to facilitate a higher standard of care. Similarly, organizations should share best practices among themselves. In addition, the industry needs to consider how to effectively implement metrics to facilitate transparency. That means determining what data the industry should be measuring in the first place, and discussing how to create useful metrics.
Optimizing the use of HIT to improve safety. A number of health IT solutions stand to improve safety by reducing errors, such as barcoding, electronic prescriptions, and computerized provider order entry. At the same time, Gandhi says, the industry needs to be prepared to deal with unforeseen consequences resulting from broader adoption of health IT solutions. For example, one study showed that 10% of electronic prescriptions still included errors. Electronic medical records, though they can make data more readily available and reduce errors resulting from manual data entry, have also been pinned as a source of burnout for clinicians: Physicians and nurses have complained about poor usability, time-consuming data entry, and interference with face-to-face patient care. However, emerging efforts like the Office of the National Coordinator for Health IT’s 2013 safety plan are designed to make it easier to report HIT hazards and help establish HIT research priorities for safety.
