Patients Everywhere Deserve Safer Care – Here’s How We Get There

Despite improvement efforts over the past 30 years, patient safety and preventable harm incidents remain significant challenges in the healthcare industry. According to a 2023 study in the New England Journal of Medicine, 25% of hospital admissions result in an adverse event, and of those adverse events, approximately a quarter are preventable. 

These high rates of preventable harm, however, have sparked a renewed passion across the industry to drive cultural transformation at the national level. Most notably, the Centers for Medicare & Medicaid (CMS) recently published the Final Rule on Patient Safety Structural Measure (PSSM), essentially mandating the implementation of a culture of safety within hospitals and health systems. Organizations will now have formalized measures in which they can measure their cultural efforts against.

While the PSSM is a remarkable step in the right direction, there is still more work to be done from a global perspective. Healthcare organizations tend to view issues in pockets – how they are impacting their specific organization and region – but patient safety is a collective mission. No matter what hospital or health system they are in, or which care model they belong to, patients everywhere deserve safer care. To improve patient safety, we as a healthcare ecosystem must think at both a regional and global scale, beginning with culture and process improvements within hospitals and health systems.

Factors impacting patient safety: Healthcare’s data overload 

Today’s healthcare professionals face unprecedented levels of emotional exhaustion, driven by heavy administrative workloads, ongoing staffing shortages and a surge of uncoordinated, compartmentalized data — all factors that contribute significantly to patient safety incidents.

With a growing patient population and the need for hospitals and health systems to comply with thousands of policies and guidelines, healthcare data has reached an overwhelming level. With ongoing innovation and technological advancements propelling the industry forward, healthcare collects a  greater volume of data than any other sector. This leaves our already overburdened healthcare workforce with the challenge of navigating through a complex web of data to glean actionable insights to improve patient safety. In fact, a 2022 survey of 3,000 practicing nurses and doctors found that 69% were overwhelmed by the volume of patient data. 

An added challenge of analyzing healthcare data is that much of it is locked in data silos, making it difficult for hospitals and health systems to identify the root causes of patient safety incidents. To achieve safer care for all, the industry must connect the head to the heart and work to break down healthcare’s data silos, creating a system that leverages tangible data insights to drive continuous improvement. 

Transforming the narrative around patient safety

Providing safer care also requires implementing technology and processes that promote healthcare workers’ well-being. Both patients and staff involved in patient safety incidents often leave the experience with lasting impacts, from psychological trauma to depression and anxiety. 

It is all too common for healthcare workers to experience feelings of shame when a harm incident occurs. Imagine a scenario in which a healthcare worker administered the wrong dosage of a medication, resulting in an adverse reaction. After reporting the incident, they are met with significant criticism from management. A few months later, a similar incident occurs but the healthcare worker is now too afraid to report the incident. Such experiences have led to healthcare’s “wall of silence” — where staff involved in safety incidents are too afraid to speak up for fear of retaliation. When providers are emotionally distressed, they cannot deliver the best quality care, leading to an increased risk of future safety incidents.

To achieve safer care for patients everywhere, hospitals and health systems must make a connected and collaborative effort to transform systems, processes and culture. Establishing a just culture within healthcare organizations is key, providing staff with a safe space to collaboratively participate in the analysis of harm events and understand the performance factors that contribute to them. 

This culture should extend beyond incident reporting – it is also about preventing future safety incidents and managing expectations. This can be achieved through education, training, policies and leadership support at every level of an organization. When a culture of safety is established from the very top of a hospital or health system, a culture of enthusiasm, positivity and transparency will follow at all levels. 

Transforming an organization’s culture is no easy task, but health systems can take a significant step forward by adopting the Communication and Optimal Resolution (CANDOR) approach, a critical method that also ties into the larger goals of the PSSM. CANDOR equips hospitals and health systems with the right tools and methods to effectively address harm events through rapid incident reporting, immediate response, empathetic communication, peer support and resolution. 

One children’s hospital in Arkansas, for example, is experiencing the positive impact of this approach firsthand. After implementing CANDOR a few years ago, the organization reduced communication delays in between the time a harm incident occurred and notifying the patient’s family and care support team. In some cases, this process could take up to dozens of hours, but with CANDOR, the organization was able to cut this communication window to under four hours. By leveraging the right technology, the organization tracked and drove data to highlight these measurable improvements. Not only does this kind of transformation significantly impact costs and liability, but it affects healthcare organization’s culture around patient safety, giving healthcare staff the confidence to quickly and efficiently address incidents. 

Driving patient safety on an international scale

To truly transform patient safety outcomes, the industry must enact appropriate processes at the local and global levels. In the U.S., Patient Safety Organizations (PSOs), external organizations that collect and analyze patient safety data, are just one avenue the industry is leveraging to advance safer care. PSOs can be instrumental in dissecting data across hospitals and health systems, fueling cross-industry research and the creation of actionable implementation strategies that can enact true change within the healthcare system. 

Legislation and policy are also part of the larger industry shift towards safer care. As previously mentioned, the PSSM is one initiative at the steering wheel in the U.S. The measure will evaluate health systems’ patient safety culture across five key domains that include leadership commitment to eliminating preventable harm, strategic planning around safety and health system accountability and transparency. The PSSM is designed to address leadership, governance, strategy and culture challenges, leveraging evidence-based patient safety practices and encouraging incident reporting and data sharing as an engine to drive improvement. With the Final Rule taking effect October 1 of this year, this initiative marks a significant step towards transforming the culture around patient safety at a systemic scale.  

On an international scale, several worldwide initiatives are currently shaping the future of patient safety. In 2021, the World Health Organization launched the “Global Patient Safety Action Plan 2021–2030,” which sets forth specific objectives and strategic direction for all healthcare stakeholders to avoid preventable harm, including guiding principles around incident analysis and learning.  

The Learn from Patient Safety Events (LFPSE) service in the UK is another example highlighting the global nature of this effort. Set forth by the National Health Service (NHS), the service is designed to make the incident reporting process easier by providing a centralized system that healthcare staff can use to record incidents and access data about patient safety events nationwide.

Sustainable improvements to patient safety aren’t achieved with a simple, “one-and-done” solution. It takes a combination of policy, culture changes, data consolidation, workforce management and more. Every patient deserves safer care – implementing the right evidence-based technology and processes is a critical step to making this global mission a reality.

Photo Credit: renjithkrishnan via freedigitalphotos

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