Healthcare Patient Safety Quotes

Lean is about the total elimination of waste and showing respect for people.

There is no justifiable reason why any man, woman or child on this planet should ever have to endure a single day without access to nutritious food,clean water,adequate shelter,healthcare,education and safety.

At the very least, to set our healthcare workers, patients, and patient caregivers up for success, we must modernize the systems that guide their work and enable their voices to be heard—especially when they see opportunities to prevent harm and improve care environments.

Many of us in healthcare entered the profession because we wanted to help, heal, and serve. At our core, we have compassion, empathy, and a drive to help people live their best lives. Recognizing and implementing actions to prevent patient and employee harm has the greatest potential effect on the quality of care delivered in our health care system, just as preventative care and wellness efforts slow or stop the progression of disease.

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which found that nearly 4 percent of hospitalized patients suffered a serious injury, of which 14% were fatal and 69% were due to errors and were thus preventable.

These efforts were dramatically successful: they reduced the mortality of anesthesia 90%, from 1 in 20,000 to 1 in 200,000, within a decade

George realized that my paper would be a red flag for many doctors, who were very sensitive to anything that might make them look bad . Their institutional arm was the AMA , which saw its primary responsibility as the defense of physicians’ pride and privilege. Naively, I thought the paper offered so much in the way of opportunity to reduce harm to patients that it would be rapidly embraced by doctors. Here was the way they could reduce harm to their patients and decrease the risk of malpractice suits.

Most importantly, however, the paper influenced Ken Shine , president of the Institute of Medicine (IOM) and its Quality of Care Committee, to make safety a focus of its work in quality of care. (See Chap. 9.) The Committee’s later report To Err is Human [14] was in many ways a detailed explication of the information in Error in Medicine, amplified with patient examples and specific recommendations for policy changes. It brought to public attention what the paper brought to the profession

We established an investigative team at each hospital and selected 11 nursing units for the study at the 2 hospitals: 5 intensive care units and 6 general, non-obstetric care units. David Bates was the leader of the Brigham team and David Cullen led the MGH team.

This rate of ADEs , 6.5 for every 100 patients, was astounding! It was almost ten (10) times higher than had ever been reported. And this was at the two flagship teaching hospitals of Harvard, institutions that considered themselves the best in the country!

Based on this evidence, the NQF endorsed bar coding , and it has since been adopted as standard practice in hospitals nationwide.

The IOM urges Congress to pass legislation extending peer review protections to data related to patient safety and quality improvement that are collected and analyzed by healthcare organizations for purposes of improving safety and quality. (We all agreed this was essential if we were ever to get people to talk about error in the current litigious environment.)

It’s not bad people, it’s bad systems.

Suddenly PSIs were viewed not as tools for improvement, but as instruments of punishment—a complete inversion of what we were trying to do in patient safety.

AHRQ created a website, psnet.​ahrq.​gov, with the latest news, research, legislation, and tools for patient safety.

On the other hand, within days of the publication of Error in Medicine, I received letters from friends and others congratulating me and thanking me for the paper.

The Lehman case was a life-changing event for DFCI , which underwent a major reorganization under the leadership of Jim Conway to dramatically improve its safety and ultimately achieve the lowest medication error rate in the nation.

The paper also influenced the thinking of future leaders in patient safety. Within a year, Jerod Loeb , from the Joint Commission, and Mark Eppinger of the Annenberg Center decided to convene a conference on medical error . Despite the displeasure with Lundberg at the AMA , its legal counsel, Marty Hatlie , convinced the leadership to shift its efforts from tort reform to error prevention . That ultimately led the AMA to found the National Patient Safety Foundation .

The before-after study at BWH showed that CPOE reduced all medication errors by 83% and ADEs by 17% [4]. The estimated cost saving if the system were implemented hospital-wide was $480,000 per year. The controlled study of pharmacist participation on rounds at the MGH showed a 66% reduction of ADEs caused by errors in prescribing [5]. Finally, we had evidence that systems change worked in healthcare.

Ninety-six hospitals completed the collaborative . They reduced the mean rate of CLABSI /1000 catheter days from 7.7 to 1.4 in 18 months.

The other was Atul Gawande , a surgical resident who I had gotten to know during his year at the Harvard School of Public Health . Atul later developed the surgical checklist for WHO and created Ariadne Labs, an influential collaboration of innovators, implementers, and healthcare leaders focused on quality and safety.

Further analysis showed that disclosure of the AE to the patient by the medical team only occurred 40% of the time. Disclosure was more likely if additional treatment was needed and less likely if the AEs were preventable (an error ). Patients were twice as likely to rate the quality of care high when there was disclosure [4]. High patient participation in their care was associated with fewer AE (49%) and higher likelihood that patients would rate the quality of their care good or excellent [5

the NPSF rolled ahead. Patient safety was beginning to be talked about widely. In the report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry , led by Don Berwick , head of the Institute for Healthcare Improvement (IHI) , reduction of error was one of six recommended national aims, and NPSF was cited. JCAHO revised their sentinel event policy to make reporting voluntary, and the Agency for Healthcare Policy and Research (AHCPR) (later renamed the Agency for Healthcare Research and Quality (AHRQ) identified patient safety as a priority.

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Clinical handovers are high-risk situations for patient safety. Errors lead to delays in diagnosis and treatment, unnecessary tests and treatments, incorrect patient treatment, increases in the length of hospital stay, patient complaints, and malpractice claims.

The moment he spoke in Telugu with them, something in the room changed. There was a new sense of comfort in the air, a sense of ease and safety. It was the feeling of assurance that came with being surrounded by their own people.

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The most common source of injury caused by treatment in the hospital, of course, is a surgical operation,

In our sample of 30,121 records, we found that 1133 patients had suffered an adverse event , which computed to a serious injury rate of 3.7%, a bit lower than what the Mills study found. Twenty-seven percent of AEs were judged to be due to negligent care. From these data we estimated that in 1984 there were 98,689 adverse events in New York hospitals, of which 13,451 (13.6%) were fatal [3].

Adverse event rates were higher in large academic medical centers than in community hospitals, but the fraction due to negligence was much lower.

This meant that of the projected 180,000 deaths each year, more than 120,000 were potentially preventable.

Latent errors create “accidents waiting to happen.” Latent errors result from poor system design [1, 4].

From this distinction between active and latent errors came the fundamental principle that underlies essentially all safety efforts: errors are not fundamentally due to faulty people but to faulty systems. To prevent errors, you have to fix the systems.

No one knew how many people were hurt by negligent care—that is, substandard care.

How many people were harmed by medical treatment in hospitals? What percentage was caused by errors ? By negligence ? Of those harmed by negligent care, how many sued? What were the costs of medical injury —not just for those harmed by bad care, but for all patients, including those who suffered nonpreventable injuries? How were these costs paid for? All was unknown. All was potentially knowable.

several studies of overuse of healthcare services and was leading a study of underuse.

more than two-thirds of the injuries seemed to be potentially preventable.

then nationwide 1.3 million patients were injured by medical care in American acute care hospitals that year, and 180,000 died

The results of the study were published in two papers in the New England Journal of Medicine in February 1991 [3, 4].

Swiss cheese” model

Donald Norman, director of The Design Lab at the University of California, San Diego, is the author of the delightful book, The Design of Everyday Things,

On balance, we believed that our rates, shocking as they were, underestimated the true extent of harm . In fact, later studies would bear this out.

Although it was designed to address malpractice , its far greater significance came from the revelation of the horrendous extent of harm that resulted from routine medical care.

The Harvard Medical Practice Study confirmed what smaller studies had shown earlier—that nearly 4% of patients in acute care hospitals suffered a significant injury from their medical treatment.

The Harvard Medical Practice Study confirmed what smaller studies had shown earlier—that nearly 4% of patients in acute care hospitals suffered a significant injury from their medical treatment. What was shocking, and previously totally unrecognized, was that two-thirds of those injuries resulted from errors

James Reason, of the University of Manchester, UK, is without doubt the person who has contributed the most to the understanding of the causes and prevention of errors. His book, Human Error (1990), is the “Bible” of error theory.

It seemed inescapably clear that healthcare needed to take a systems approach to medical errors . We needed to stop punishing individuals for their errors since almost all of them were beyond their control, and we had to begin to change the faulty systems that “set them up” to make mistakes. We needed to design errors out of the system. I had no doubt we could do that.

documentation issues were more common in small private hospitals, where records were less standardized and notes were sparse because only the patient’s physician writes progress notes. In teaching hospitals, by contrast, there are multiple notes by residents, medical students, and nurses as well.

I wanted to work on quality improvement; injury and costs were clearly quality issues. At the time, I had not thought much about medical errors

States required hospitals to report deaths but rarely investigated their causes. The Joint Commission asked hospitals to report “sentinel events” (serious injuries), but few hospitals did. Surgical departments had M&M meetings, but neither other departments nor the hospitals kept tabulations or continuing records of iatrogenic injuries. Medical injury was largely invisible, and hospitals and doctors liked it that way.

We finally settled on “adverse event .” We spent many hours debating its exact definition and ultimately agreed on “an unintended injury that was caused by medical management rather than the patient’s underlying disease.” The important point was to distinguish harm caused by treatment from harm caused by disease, independent of whether there was an error or negligence . We knew that making this judgment would be difficult for doctors, as it indeed proved to be.

we estimated that the total lifetime cost of adverse events in New York State in 1984 was $3.8 billion

Charles Perrow , professor of sociology at Yale, studied risks and accidents in large organizations. His book, Normal Accidents: Living with High-Risk Technologies,

We would focus on adverse events that could potentially trigger a malpractice suit. These were injuries that resulted in some degree of disability, temporary or permanent, including death, or were sufficiently severe to prolong the hospital stay.

But more was needed if patient safety was to be recognized as a true discipline. Accordingly, in 2011, NPSF established the Certification Board for Professionals in Patient Safety . The Board set appropriate educational and training requirements and developed a qualifying examination for its credential, Certified Professional in Patient Safety (CPPS). In recognition that patient safety must be a team effort with broad responsibility, certification is open to interested parties across multiple disciplines. Within 4 years 1100 individuals were certified. To meet the educational needs of students and professionals, NPSF created a comprehensive online Patient Safety Curriculum. By 2018, over 5000 had taken this online course, and 3000 individuals held the CPPS credential. In

The Advisory Commission’s 1998 report, “Quality First: Better Healthcare for All Americans,” brought together the evidence for quality problems and the broad consensus for reform [1]. It concluded that quality problems were pervasive and by no means confined to managed care systems. The report was aimed at Congress and policy-makers in Washington and made clear recommendations, including a call for a “Patient Bill of Rights,” which the Clinton administration enacted. Otherwise, even though it got a lot of attention, the report resulted in little action.

A focus on safety might also enlist the support of the medical profession, which had become defensive about efforts to improve quality. When challenged, doctors would typically counter with “My patients are different.

Safe: the reporter must not be at risk of losing their job or being disciplined for reporting a mistake they have made.

Simple: people will not report if the process is too complicated (a long form) or takes too much time.

Productive: reporting must lead to a response by the organization to address the issue reported.

that care should be safe, effective, patient-centered, timely, efficient, and equitable. The aims resonated with all and were quickly embraced. They became the centerpiece of the recommendations in the final report, Crossing the Quality Chasm

The report on quality ( Crossing the Quality Chasm) would be targeted to healthcare professionals and would spell out the theoretical concepts and details of what was needed to improve quality of care overall, based on the six aims .

The report was titled To Err Is Human [4]. It “made the case” for patient safety, explaining the science of error-making and the theoretical and practical evidence for human-factors -based systems changes.

To Err Is Human explained the concept of using a systems approach based on human factors principles and proclaimed that application of this methodology could have a profound effect. It boldly called for a 50% reduction in medical harm in 5 years.

What got attention was the estimate that there were up to 98,000 preventable deaths a year due to medical errors . That number also headlined the newspaper stories the next day.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) This survey initiative began in 1995, before the Agency became involved in patient safety, in response to the recognition that quality of care issues that are important to consumers, such as communication skills of providers and ease of access to healthcare, were often overlooked. The obvious way to find out about them was to ask patients. The Agency began to fund, oversee, and work closely with a consortium of research organizations to conduct research on patient experience and develop the survey. The survey has since been expanded to ask patients to evaluate their experiences with health plans, providers, and healthcare facilities regarding care coordination , shared decision-making, and patient engagement . The survey is now widely used by healthcare organizations, health plans, purchasers, consumer groups, and accreditation organizations to evaluate providers and improve quality and safety of care. It has been a major factor in teaching clinicians and hospitals to be more aware of patient’s concerns and to engage them more meaningfully in their care. It has magnified their voice

In the end PSIs may have done more harm than good over the years. Meyer agrees. He considers them “the worst thing I ever did” at AHRQ .

WebM&MTo engage and inform physicians, AHRQ initiated WebM&M, using the familiar format of mortality and morbidity rounds to make available analysis of real-world medical error cases by experts, monthly.

But the need for support of health IT was clear. Hospitals and doctors were being required to implement electronic health records (EHRs) and were having serious problems.

We defined “serious, avoidable adverse events” as patient harms that hospitals can reasonably be expected to prevent 100% of the time.

However, the group did not agree with Ken’s interest in calling them “never events,” undoubtedly rooted in the firmly held doctrine in medicine that you cannot say that anything “never” happens. So it was decided that the list should be officially titled “Serious Reportable Events.” Nevertheless, they quickly began to be referred to as “never events.

Later, CMS used the list to deny payments for Medicare patients. This was not our intended use, and the matter was vigorously debated and discouraged during the Committee’s deliberations

It is in such vast gray zones that highly reliable healthcare organizations demonstrate that they possess more than just policies and procedures: they have philosophies and cultures.

Individuals and teams can’t improve in these areas simply by following new and better rules.

It’s not just patients who suffer from accidental harm, but employees. The Bureau of Labor Statistics (BLS) reports the illness and injury data that healthcare administrators submit to the Occupational Safety and Health Administration (OSHA).5

organizational philosophies and cultures bear on all aspects of performance, including safety, patient experience, technical excellence, and efficiency.

A more recent (2016) estimate of patient harm found that errors and omissions were the third leading cause of mortality in healthcare, accounting for 251,000 deaths each year, or one every two minutes, six seconds.3

In his view, people couldn’t define goodness by mindlessly applying rules.

Although the handover report is crucial to ensuring patient safety and continuity of care, it is surprising that most training programs neglect to focus on or develop this skill.

Hospitals cannot continue to hemorrhage. For the country as a whole, medical insurance premiums include a surcharge that pays for treating the uninsured. However, if the proportion of uninsured indigent patients exceeds a certain figure, a hospital has no choice but to close. In California alone, the heavy cost of free medicine for foreigners forced no fewer than 60 hospitals to shut down between 1993 and 2003; many others were on the verge of collapse. From 1994 to 2004, the number of hospital emergency rooms in the country as a whole dropped by more than 12 percent. In May 2010, Miami’s health care system was so strapped, it was considering closing two of its five public hospitals. This would mean laying off 4,487 employees and the loss of 581 acute-care beds. Experts explained that treating uninsured patients had stretched the system to the breaking point. Houston is a good example of a city whose hospitals are barely making ends meet. In the nation as a whole, about 15 percent of the population has no medical insurance, but Texas, with its large population of Hispanics, has the highest percentage at 24 percent. In Houston, the figure is 30 percent. The safety net cannot accommodate so many people who cannot pay. “Does this mean rationing?” asks Kenenth Mattox, chief of staff at Ben Taub General Hospital. “You bet it does.” There is such a crush at Houston’s emergency rooms that ambulances often wait for one or two hours before they can even unload patients. The record wait is six hours. Twenty percent of the time, hospitals end up sending patients to other hospitals, and some have died after being diverted. Politicians and businessmen pull strings so friends can cut in line. Americans who fall sick in Mexico do not get free treatment. The State Department warns that Mexican doctors routinely refuse to treat foreign patients unless paid in advance, and that they often charge Americans for services not rendered.

There is no justifiable reason why any man woman or child on this planet should ever have to endure a day without access to nutritious food,clean water,shelter,healthcare,education and safety.