Patient Safety: Why is it Still an Issue in 2015?

As healthcare providers, we all know that it is no fun having to work during the holidays – but realize that it is less fun being a patient in the hospital during the holidays, especially if their stay was extended by a preventable infection, such as CAUTI or CLABSI, or by a medical error.


Patient safety continues to be a public issue that affects  in this country, patients and caregivers alike.


Many of us are quite familiar with the 1999 landmark report from the Institute of Medicine (IOM): To Err is Human: Building a Safer Health System. 


The number of hospital deaths by medical errors stunned the nation and the IOM report quickly became the catalyst that prompted the patient safety movement across healthcare.


So, 15 years later, how have we done?


Last week, the National Patient Safety Foundation (NPSF) released their report Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, which focuses on how patient safety has improved since the IOM report was published and where progress still needs to be made.

In a nutshell, we have made some advancement in patient safety numbers; but as a nation, we are nowhere close to where we need to be.

Initiatives such as the use of evidence-based care and the wide-spread implementation of interventions such as barcoding medications, use of checklists, increased training of staff and

patients, among countless other methods, has indeed helped to move the healthcare industry in the right direction; but it’s been slow in doing so.


Many, if not most, of these interventions and initiatives have been implemented to target specific safety issues in healthcare.

Although they have been successful in reducing some forms of patient harm, they have only had a slight effect on the overall numbers.


Why is this?


Likely it is due to the nature of these actions being reactive.

Meaning that hospitals are only putting processes in place AFTER they know that there is a problem.


In addition, the use of these types of measures or processes are generally only as effective as the

individual performing the function, meaning that there can be a high rate of human error, which can result in unusable or unreliable data.

Please don’t think that I am saying that these processes aren’t good or effective to a certain extent.

What I am saying is that they would be a heck of a lot better if they were put into place before deficiencies in care became safety issues and put patients in harm’s way.

So what’s the missing element?

It’s Proactivity.

Organizations need to shift their paradigm from implementing change as an after-effect of patient harm (reactive) to using change as a tool to anticipate and prevent harm (proactive).

There needs to be a well-designed and proven set of processes in place throughout all levels of the organization so every aspect of patient care can be monitored and action can be taken before safety issues arise.

Knowledge of these processes must be disseminated to all staff and their participation is mandatory.

Data or results must be transparent, so stakeholders are aware of activities that are performing well and those that need improvement.

In addition, a culture of safety must be fostered, with expressed support shown by those in management or leadership positions.

Just for a minute, think about your own hospital:

Do you know if any safety circle graphicmeasurement processes are in place?

If so, are you aware of the results or does it seem like the data gets lost in the great unknown, never to be seen or heard from again?

Have you heard about any performance improvement (PI) initiatives in your unit?

  • Do you and your co-workers participate in them or are they secrets only known to the “higher-ups” or certain departments? 

  • Most importantly, is the culture of patient safety a key focus for your organization – is it just occasionally talked about or is safety impressed upon every action that takes place within the hospital’s walls?

Rest assured, even if all of your answers to the above questions were “No,” proactivity doesn’t necessarily have to start with those in leadership positions - 


Anyone can strive be a more proactive healthcare provider, no matter what role they play.

, add some additional steps to your daily core processes to ensure that you are providing safe care to patients in a safe environment:

  • be vocal and persistent with concerns about safety issues

  • speak up for patients, visitors, and co-workers

  • develop a key understanding that  in healthcare is linked to patient safety – from the overall hospital environment to the care that is provided and share your knowledge with others.

As you are settling down for the holidays with your families and friends and begin to reflect back on 2015, ask yourself: "Most importantly, is the culture of patient safety a key focus for your organization? "

To clarify, is the idea of safety impressed upon every action that takes place within the hospital's walls or just a word that is occasionally muttered when surveyors are around?

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