From patient safety awareness to action: Time for a reset
After two decades of focus on reducing medical errors, it’s time to ramp up efforts and re-energize initiatives to boost commitments to patients and staff.
Patient Safety Awareness Week began in March 2002. Launched by the National Patient Safety Foundation — which merged with the Institute for Healthcare Improvement in 2017— it was envisioned as a time for healthcare organizations and colleagues to reflect on, celebrate and share practices and initiatives that advance safety.
Based on our experience with leading national safety initiatives, and as the former CEO and COO of the National Patient Safety Foundation (NPSF), we believe it is time to rethink the intention and spirit of this week.
PSAW has always served as an anchor for our focus on safety. Around the world, organizations host a range of events and presentations to recognize and make visible the important work of preventing harm to our patients. PSAW has also been an occasion to both raise public awareness and to coproduce safer care with patients, consumers, and the communities we serve.
However, the healthcare industry must now move beyond raising awareness and leverage this time as Patient Safety Action Week. We have had concerning setbacks in patient and workforce safety and well-being during the last three years. In the decades of pre-pandemic safety work, despite bright spots of excellence, the incidence of harm and progress in safety has been unacceptable.
It has too often been disappointingly eclipsed by a healthcare system that prioritizes profit and production over the safety and well-being of those we serve and the colleagues dedicated to making care better. Patients and families continue to experience harm in the experience of their own care and there is wide variation in whether and how health care delivery organizations partner with patients and family members to improve safety.
Healthcare organizations and leaders are experiencing unprecedented challenges related to staffing, finances and other competing pressures. Yet, prioritizing safety cannot come and go depending on current circumstances. There must be a constancy of purpose for improving patient safety. It is also important to remember that improving safety supports workforce retention and engagement, leads to better patient outcomes, and can have reputational and financial benefits.
Resetting safety
The evidence is clear that simply encouraging colleagues to do better and addressing safety through a series of improvement projects is insufficient.
For safety to be realized, healthcare leaders and members of the workforce must embrace safety as a core value. This means putting safety at the forefront of all that we do. It also means shifting from reacting to what goes wrong to proactively and intentionally designing foundational systems and cultures that anticipate and prevent harm. Organizations also must embrace a broader definition of harm to include physical and emotional harm, including inequities experienced by patients and caregivers across the continuum of care.
To this end, the Institute for Healthcare Improvement convened the 27 member organizations of the National Steering Committee (NSC) for Patient Safety and released Safer Together: A National Action Plan to Advance Safety on World Patient Safety Day in September 2020.
The plan emphasizes four foundational areas that create the conditions for safer care – culture, leadership and governance; patient and family engagement; learning system; and workforce safety and well-being.
Health equity is one of the plan’s guiding principles, and it includes recommendations and tactics, an Organizational Self-Assessment Tool, and an Implementation Resource Guide to support continuous action.
Key commitments
During PSAW 2023, we've asked healthcare leaders and colleagues to take three actions to reboot safety:
- • Commit to making the daily work of your organization the elimination of all harms to patients, families, visitors and the workforce.
- • Identify an executive sponsor and team to complete the National Action Plan Organizational Assessment Tool to identify opportunities and actions for your safety reboot, and use the Implementation Resource Guide to refresh your safety strategy and daily work.
- • Move beyond awareness to action, not only during PSAW, but every day, in every healthcare setting.
Patient Safety Action Week is an important opportunity to refocus and re-energize. We hope the actions we propose for this week will help the healthcare community around the world recommit to zero harm every day. Our patients, families and workforce deserve no less.
Tejal Gandhi, MD, chief safety and transformation officer at Press Ganey Associates. Patricia A. McGaffigan is an Institute for Healthcare Improvement vice president and president of the Certification Board for Professionals in Patient Safety.