Patient Safety: A look back to gain direction for the future
10 of the most important patient safety concerns for healthcare
American Organization of Nurse Executives Conference (AONE)
National Rural Health Association Conference (NRHA)
* course numbers may vary by facility
Sixteen years have passed since the publication of To Err is Human: Building a Safer Health System, the Institute of Medicine’s (IOM) groundbreaking report on medical errors in the U.S. Claims within the report stunned the nation: hundreds of thousands of patients are harmed every year as a result of healthcare with almost 98,000 of those incidents leading to death. Years later, new research proved those claims to be inaccurate – the actual numbers were much higher than those originally reported. Swift and aggressive actions were recommended by the IOM with a minimum goal of a 50% reduction in errors within 5 years. On a fundamental level, it challenged customary beliefs that errors occur in isolation and are primarily the result of incompetence and reckless behavior, instead placing the burden of responsibility on systems that should make it easier to do things right and harder to do things wrong.
Systematic improvement in patient safety has been the driving force behind vast changes and new initiatives at every level of the healthcare system over these 16 years. According to a recent report by the Agency for Healthcare Research and Quality, hospital cases of central line-associated bloodstream infections fell 49% from 2010 to 2013 with a cost savings of $149.6 million. Other noted improvements over that period, included a 28% reduction in catheter-associated urinary tract infections, a 20% reduction in pressure ulcers, and a 19% reduction in both adverse drug events and surgical site infections. Overall, the report for that period estimated a 17% reduction in in patient harm and a cost savings of nearly $12 billion.
While improvement has occurred in some areas, leaders in the field of patient safety say we’re nowhere near where we need to be. Last July, experts testified at a Senate Health, Education, Labor and Pensions subcommittee on preventable medical errors that lead to death or serious problems. “If the question is, are patients safer in U.S. hospitals today than they were 15 years ago, the unfortunate answer is no. We have not moved the needle in any demonstrable way overall,” said Dr. Ashish Jha, a Harvard School of Public Health professor whose research focuses on improving quality and reducing costs.
Last month in Boston, the National Patient Safety Foundation (NPSF) convened an expert panel to assess the state of the patient safety field since the release of the IOM report in 1999 and to set the stage for the next 15 years of work. Panel co-chairs are Donald Berwick, MD, MPP, former administrator of the Centers for Medicare and Medicaid Services and president emeritus and senior fellow at the Institute of Healthcare Improvement, and Kaveh Shojania, MD, director of the Centre for Quality and Improvement and Patient Safety, University of Toronto, and editor-in-chief of the BMJ Quality & Safety. The panel has been tasked with producing a retrospective of achievement in the field and developing strategic recommendations to drive patient safety through the next decade. A review of the evidence will play a role in forming the report, along with input from a wide range of experts and other stakeholders. The panel’s meeting, “The State of Patient Safety: 15 Years Since the IOM Report ‘ To Err is Human,’ “ takes place February 23-24, 2015 with a final report expected this summer.
April 15-18, 2015
Phoenix Convention Center – Phoenix, AZ
April 14-17, 2015
Marriott Philadelphia Downtown – Philadelphia, PA
According to the ECRI Institute in 2014, the following are 10 of the most important patient safety concerns for healthcare.
A. Surgical Site Infection
B. Central Line-Associated Bloodstream Infection
C. Catheter-Associated Urinary Tract Infection
A. Catheter-Associated Urinary Tract Infection
B. Ventilator Associated Pneumonia
D. Surgical Site Infection
Share your story, tell us where your hospital will be this month or
what topics you would like to see in upcoming newsletters.