A Way Forward on Patient Safety?
Recently, a group of thought-leaders in the field of patient safety have considered
the rather alarming slippage in patient safety results related, in part, to the pandemic stress
test. 1 They began their report by noting important progress had been made in the twenty
years prior to the pandemic. “Most patient safety breakthroughs came from system design
focused on care delivery processes, where errors are considered to be consequences
related to upstream systemic factors.” So, what went wrong? “We find that two systems-
level factors contributed to those pandemic-related losses: highly variable deployments of
patient safety systems across care delivery groups, and high rates of turnover of frontline
staff arising from clinician burnout.”
“First, regardless of the particular safety metric at issue, almost all previous and
current patient safety efforts focused on elements such as establishing senior
management commitment, creating a “culture of safety,” ensuring workforce safety,
and seeking patient engagement, rather than focusing on nationwide frontline care
processes that span across all care delivery systems and account for the vast majority
of care-associated injuries…”
What happened is that each organization that seriously engaged in safety efforts had
to develop its own local, context specific approach to system management, which depended
heavily on the tacit knowledge of existing staff to operate successfully. As we have
considered previously, the massive increase in staff turnover experienced by almost all
health care organizations during the pandemic, shattered processes that were layered onto
usual clinical training and that required extended training to be able to use successfully. As
the authors put it, “The result of this pandemic-prompted disruption, which exposed the
systemic fragility of frontline staffing models, was the loss of comprehensive, coordinated
care, the foundation upon which safe care rests.”
In response to this analysis, the authors propose all the existing patient safety
organizations come together and work to identify best practices at the standard level and
disseminate these to essentially everyone. This would include standard measurement
systems that would be used by every care system, and so presumably not proprietary, and
aligning professional training with safety systems. In this schema, a “travel nurse” would
expect to find the same safety processes and monitoring systems in place no matter where
he/she was currently assigned, which, as the authors acknowledge, would help, but not
solve the problem of staffing issues.
This short paper is an idea piece, not a detailed roadmap, and implementation
would take time, effort, and money. But it does seem to be a positive first step in changing
the way we do safety, in a manner that is an improvement over the past, where we have
usually added it on.
7 January 2023
1 James BC, Savitz L, Fairbanks RJ, Bisognano M, Pronovost P. Patient Safety Performance: Reversing Recent
Declines Through Shared Profession-Wide, System-Level Solutions. 12 December 2022.
doi:10.1056/CAT.22.0318. Accessed 5 January 2023 at https://catalyst.nejm.org/topic/catalyst-article-
If asked about the greatest advances I have seen, my outside the box answer would be the insight that the quality and safety of medical care is as much about system design as it is about human performance. Current efforts to make providers financially accountable, though, threaten the utility of this insight.
When there is no room at the inn due to staff shortages, the standard of practice will have to change. We need to think about what this might mean.
Medicine has adopted the language of manufacturing with terms such as efficiency, reliability, and “lean processes.” An unintended consequence may be increased risk of system failure.
The Center Effect
Some dialysis units have consistently better performance than others, even after adjusting for individual patient variables, which is termed the center effect. This has important implications for hospitals and health care organizations as they respond to public reporting of data.
A work-around get past a problem with addressing either the root cause or a solution. Health care abounds with work-arounds.