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Expert Reflects on New Patient Safety Action Plan: 'Healthcare Organization Leadership Is Integral'

Analysis  |  By Christopher Cheney  
   November 04, 2020

The new patient action plan stresses leadership, patient and family engagement, workforce safety, and learning systems.

A new "action plan" to advance patient safety addresses fundamental elements of improving safety at healthcare organizations, a leader of the initiative says.

Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.

The new initiative is detailed in an action plan published on September 14. The document was crafted by the National Steering Committee for Patient Safety, which was formed in May 2018. There were 27 organizations represented on the steering committee from the following groups: healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies.

Jeffrey Brady, MD, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality, and co-chair of the National Steering Committee for Patient Safety, recently shared his perspectives on the four focal points of the action plan with HealthLeaders.

1. Culture, leadership, and governance

The action plan calls on healthcare leaders, governance bodies, and policymakers to demonstrate a commitment to safety as a core value and to foster cultures of safety.

Healthcare organization leaders play a pivotal role in improving patient safety, Brady says. "Culture, leadership, and governance are one of the foundational areas of the action plan. Any healthcare organization leadership is integral to patient safety."

The action plan provides a patient safety improvement road map to healthcare organization leaders, he says.

"In terms of how we envision the action plan, we view it as being helpful to healthcare organization leaders who play a critical role in establishing, maintaining, and promoting a culture of safety. Over the years of our work on patient safety at AHRQ, patient safety starts at the top. The leadership establishes the culture, and they enable resources to flow to the things that set a safe environment for patients and the healthcare workforce."

2. Patient and family engagement

The action plan calls for propagation of effective patient and family engagement. Specifically, healthcare organizations should include patients, families, and care partners in the design and delivery of care.

"The research shows us that when patients are engaged in their healthcare it can lead to measurable improvements in safety and quality. If a patient or family is paying attention, they are more likely to see something that could be a problem. That is one aspect of patient and family engagement—enlisting patients to help be watchful and mindful of potential safety hazards," Brady says.

Patient and family engagement also provides healthcare organizations with an opportunity to redesign care to be more patient-centric, he says. "Another aspect of patient and family engagement begins even before care is provided. It is the idea of co-production of care with patients and families. This aspect addresses the best ways to organize care, plan care, and structure care. You talk with patients and families about the best way to set up care and how to make it easier for them."

3. Workforce safety

The action plan says patient safety and workforce safety are linked closely. To boost workforce safety, healthcare organizations should take a unified and total-systems approach, the action plan says.

Healthcare workforce safety and patient safety go hand in hand, Brady says. "It is hard to ask anyone who themselves do not feel safe to focus on making sure someone else is safe. When someone does not feel safe, they are understandably distracted by that. If you have a healthcare worker in a situation that does not feel safe to them, even if it is subtle, you want them to feel supported, you want them to feel safe, and you want them to feel someone cares about them."

Healthcare organization leaders are essential to achieving workforce safety, he says. "We state in the action plan that workforce safety is a duty of healthcare leaders. They need to engage in continuous improvement of workforce safety. Because of the potential for distraction, healthcare workforce safety is a precondition for advancing patient safety."

Healthcare workforce safety extends beyond physical harm, Brady says.

"When we talk in the action plan about the safety of the healthcare workforce, we include not only physical harms such as falls and back injuries from moving patients but also psychological harm, which has been magnified during the coronavirus pandemic. There are risks to everyone in healthcare associated with this new infection. Those threats are not only physical but also psychological—there is a dark cloud of risk associated with the virus."

4. Learning system

The action plan calls on healthcare organizations to foster networked and continuous learning such as promoting the sharing of information and improvement efforts.

Learning systems harness data, Brady says. "Learning systems are more than just about the data—this is where the quantitative understanding of patient safety comes alive. These are reporting systems, data systems, and analytical systems."

Building learning systems help healthcare organizations understand their patient safety challenges and boost sharing of best practices between organizations, he says.

"These systems help healthcare organizations understand what is happening in their own organization such as how many safety events they are having and what is the most common problem. Every organization needs to have a learning system that informs them about safety risks in their own organization. In addition, organizations need to look outside—across the field—to peer organizations from which they can learn."

Learning systems generate benefits beyond boosting patient safety, Brady says.

"The nice thing is we have some efficiencies to be gained through learning systems. The resources, technical requirements, and organizational competencies that are needed for learning systems can be applied to multiple problems. For example, these data systems can be adapted to new problems such as COVID-19. What we can expect is that investment in learning systems will reap additional benefits over time as they are used for more problems."

Related: Patient Safety Still Problematic 20 Years After 'To Err Is Human' Report

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark report To Err Is Human: Building a Safer Health System.

The new patient safety action plan was crafted by a steering committee representing 27 organizations from across the healthcare sector.

Healthcare organization leadership has a key role to play in patient safety, including creation of a culture of safety and promotion of workforce safety.

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