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How Cross-Sector Conversations Can Help Drive Hospital Patient Safety Improvements

More than two decades ago, the Institute of Medicine published a report estimating that as many as 98,000 people die annually from medical errors. The report prompted a sense of urgency for hospitals to reduce patient harm. While that data is nearly four decades old, subsequent reports indicate there has been little improvement. 

A recent study looking at admissions across 11 Boston-area hospitals underscored the scope of today’s patient safety problem. The study, known as the SafeCare Study, found that nearly one in every four hospital admissions resulted in an adverse patient safety event. Nearly one-quarter of those events were deemed preventable, and nearly one-third were considered serious or of high severity.  

In an effort to fuel a new conversation around hospital patient safety, healthcare consulting firm Sage Growth Partners recently released a new report: “Leading Through Change — Because Patients Deserve More.” This report features the perspectives of five safety leaders from across the industry, including our own Chief Operating Officer and Chief Clinical Officer, Hayley Burgess, PharmD, MBA, BCPP, CPPS. The individuals featured in the report come from various industry sectors, including hospitals and health systems, healthcare technology companies, and safety nonprofits. 

In addition to Dr. Burgess, the report explores the perspectives of:  

  • David Westfall Bates, MD, Medical Director of Clinical and Quality Analysis, Mass General Brigham and Chief of General Internal Medicine, Brigham and Women’s Hospital (and author of the SafeCare Study)
  • Edward Decker, BS, BSN, MHA, RN, CPPS, Associate Vice President of Patient Safety Integration, HCA Healthcare
  • Rita Jew, PharmD, MBA, BCPPS, FASHP, President, Institute for Safe Medication Practices (ISMP)
  • Michael A.E. Ramsay, MD, FRCA, Chief Executive Officer, Patient Safety Movement Foundation 

These experts agreed that while there have been some advancements in patient safety over the past few years, preventable safety events are still happening too often. Many said that part of the problem is due to fear of sharing proprietary knowledge, fear of retribution, and/or poor safety event reporting capabilities. Two things are clear from their comments, and that is: 

  • All hospitals should be prioritizing safety data acquisition and transparency and leveraging technology to identify areas of improvement and facilitate interventions.
  • Hospital leaders need to be committed to a culture of safety.

“You can’t talk about a culture of patient safety with just lip service,” Dr. Jew noted in the report. You have to put the money where your mouth is, and when you talk about patient safety as being your utmost focus, the money and the time commitment needs to follow that as well.” 

Each of the experts agreed that hospital leaders should be regularly discussing patient safety, investing in resources to improve patient safety, establishing processes that allow employees to easily report events, sharing data across teams, and even recognizing and congratulating team members for identifying risks. 

I encourage leaders to be on the frontlines with their teams doing walkarounds, performing live gap assessments, and asking those hard questions such as, ‘What is the next accident or error that is likely to happen?’ and, ‘What keeps you up at night?’” said Dr. Burgess. “The more we ask these questions and follow through with actionable change, the more comfortable teams will be with answering honestly. When you start with that approach, and then combine that with existing technology and data—this combination will enhance care.”

Some of the methods shared for organizational and industry-wide support toward improving patient safety included enacting a National Patient Safety Board, similar to the National Transportation Safety Board, posting signs related to patient safety throughout health systems, training teams on safety strategies and patient education, developing employee commitments to safety, and creating “Safe Table” programs where staff and safety leaders can have open dialogue on safety risks in their hospitals.

From innovative new approaches within hospitals to patient safety-enhancing technologies to a growing push for advances by nonprofits—our hope is that this unique report will inspire industry-wide conversations around data sharing that lead to new approaches to improve patient safety. The more we share safety challenges and advocate for positive changes, the more we learn from each other, elevate best practices, and improve safety in all hospitals for all patients and staff.