New national action plan aims to reduce medical errors, improve patient safety

September 16, 2020
by Valerie Dimond, Contributing Reporter
The Institute for Healthcare Improvement (IHI)-convened National Steering Committee for Patient Safety (NSC) has released a new National Action Plan to help healthcare systems reduce medical errors and improve patient safety.

The new plan, Safer Together: A National Action Plan to Advance Patient Safety, was developed using evidence-based practices, effective interventions, case examples, and newer innovations. The work began in 2018 with more than two dozen entities from federal agencies, safety experts and patient/family advocates involved.

“Over the past 20 years, the field has amassed a tremendous body of knowledge to improve healthcare safety,” said NSC co-chair Jeffrey Brady, who directs the Center for Quality Improvement and Patient Safety at the U.S. Agency for Healthcare Research and Quality, in a news release. “What’s been missing is the use of this knowledge for more coordinated action. That’s what we want to rectify.”

In a survey conducted in February 2020 by Sage Growth Partners, C-suite executives, physicians, nurses, infection preventionists, pharmacists, and others were asked about their top patient safety challenges, where the most safety improvements are occurring, if technology is enhancing patient safety, and which patient safety improvement approaches are most successful. Nearly one quarter of respondents said they were unhappy with their organization's safety performance and more than a quarter said they are less confident about hospital safety than the typical consumer.

And according to ECRI’s Top 10 Patient Safety Concerns 2020 report, diagnostic errors are the top patient safety concern for the third year in a row. Diagnostic errors are characterized as missed and delayed diagnoses and are commonly caused by communication failures of information. This prevents the right person from initiating the right action at the right time of care, and can lead to patients suffering, adverse outcomes, and death. Previous versions from 2018 and 2019 also ranked diagnostic errors as the top concern for patient safety.

The new National Action Plan offers core principles and recommendations that IHI says are also extremely relevant to the current COVID-19 pandemic and is centered on four foundational areas that have a widespread impact on safety across the continuum of care:
• Culture, Leadership, and Governance: The imperative for leaders, governance bodies, and policymakers to demonstrate and foster deeply held professional commitments to safety as a core value and promote the development of cultures of safety.

• Patient and Family Engagement: The spread of authentic patient and family engagement; the practice of co-designing and co-producing care with patients, families, and care partners to ensure their meaningful partnership in all aspects of care design, delivery, and operations.
• Workforce Safety: The commitment to the safety and fortification of the healthcare workforce as a necessary precondition to advancing patient safety; the need to work toward a unified, total system perspective and approach to eliminate harm to both patients and the workforce.
• Learning Systems: The establishment of networked and continuous learning; forging learning systems within and across health care organizations at the local, regional, and national levels to encourage widespread sharing, learning, and improvement

“With so many competing priorities and requirements that health systems face, it has become difficult to focus on key areas that are foundational for improving across the board,” stated Tejal K. Gandhi, NSC co-chair, IHI senior fellow, and chief safety and transformation officer at Press Ganey. “The Action Plan helps direct attention to these interdependent areas, which have substantial, wide-ranging influence on many aspects of patient safety. Accelerating improvement in each of these areas will mutually support improvement in others and create the fertile soil that allows broader safety initiatives to take root and be cultivated.”

This year’s World Patient Safety Day, organized by the World Health Organization, takes place on September 17 and will focus on workforce safety. The theme recognizes the risks to health and safety that frontline caregivers and workers have faced while taking care of patients before and during the COVID-19 pandemic.

“IHI joins with the 26 other organizations who have contributed to this National Action Plan and pledges to help healthcare leaders take advantage of the new guidance to catalyze the patient safety agenda and continue to drive meaningful change,” stated Kedar Mate, IHI president and CEO, in a news release. “We urge everyone across health and healthcare to embrace this same pledge, stand with the NSC, and take decisive action to advance these recommendations.”

NSC members maintain that medical errors remain too frequent, and improvement tends to target particular types of harm in isolation from one another, not as part of a total system of safety. Without greater attention to the foundational factors that impact workforce and patient safety, they say more substantial and lasting change is impossible.