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20 years of patient safety

Julia Haskins , Special to AAMCNews
June 6, 2019

It has been two decades since the modern patient safety movement was born. Here’s how we got to this milestone — and what lies ahead.

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In 1999, in its pioneering report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM) revealed that as many as 98,000 patients died from preventable medical errors in U.S. hospitals each year.

Twenty years later, such errors remain a serious concern, with tens of thousands of patients experiencing harm each year. But while much work remains, the patient safety movement has achieved several significant successes, experts say.

Today, patient harm from medical errors is no longer considered inevitable, notes Peter Pronovost, MD, PhD, a safety expert and the chief clinical transformation officer at University Hospitals in Ohio. “What really changed was the narrative we told” about medicine’s ability to avoid safety problems, he says. “It’s both hopeful and humbling where we’ve been.”

“As we work toward achieving the goal of zero harm to patients, every person on the health care team needs to think of safety as their job and focus on the best ways to work with all other members of the team to prevent mistakes.”

Janis Orlowski, MD
AAMC

Underlying many of the advances in patient safety is a fundamental reenvisioning of the causes — and cures — for medical mistakes. “We've learned that errors in health care are not typically related to a single person’s error or lack of education,” says Janis Orlowski, MD, AAMC chief health care officer. “Now it is thought that mistakes often occur because of a series of miscommunications, loss of information, or other system errors.”

As a result, leaders now take an interprofessional approach to improving care and use a broad range of tools to ensure patient safety, from checklists to robust quality and patient safety committees at hospitals. “As we work toward achieving the goal of zero harm to patients, every person on the health care team needs to think of safety as their job and focus on the best ways to work with all other members of the team to prevent mistakes,” says Orlowski.

Academic medicine also is educating medical students and resident physicians differently, emphasizing teamwork, system factors, communication, and partnering with patients and caregivers to prevent errors, says Alison Whelan, MD, AAMC chief medical education officer. “Our culture has shifted from shame and blame to recognizing the need to continuously learn and improve through collaborative practices,” Whelan notes.

Here’s are some of the advances that have come to define the modern patient safety movement over the past 20 years — and where we still need to go.

Feds on the front lines

Soon after the release of To Err Is Human, Congress passed legislation requiring the Agency for Healthcare Research and Quality (AHRQ) to issue annual reports designed to monitor progress in improving care. Just 60 days after To Err Is Human was published, AHRQ released Doing What Counts for Patient Safety, which outlined several specific strategies to curb medical errors.

Since then, the AHRQ has made various other advances. These include developing Patient Safety Indicators to collect data that hospitals can use to identify safety problem areas. AHRQ also oversees Patient Safety Organizations, which enable providers to report adverse events confidentially. In 2011, it created the National Scorecard on Hospital-Acquired Conditions, and the most recent version showed a 13% drop in such conditions from 2014 to 2017, which saved approximately 20,500 lives.

The Joint Commission unveils safety goals

Just a few years after To Err Is Human, the Joint Commission leveraged its role as an accrediting body to identify required steps for preventing medical errors. The National Patient Safety Goals program released its first list of standards in 2003 and continues to update them annually. Most recently, the 2019 edition added protocols for preventing patient suicide.

Over the years, the commission has taken numerous other steps as well. In 2011, for example, its Center for Transforming Healthcare brought together health systems across the country in an 18-month effort to reduce hospital falls. The effort, which included creating an organizational culture of commitment to safety, yielded a 62% reduction in fall-related injuries.

Goal: Save 100,000 lives

In 2004, the Institute for Healthcare Improvement (IHI), a nonprofit dedicated to improving patient care, launched its 100,000 Lives Campaign, led by Donald Berwick, MD. Its goal was to drastically reduce preventable deaths over 18 months.

The campaign encouraged hospitals and providers to take six key steps to reduce patient harm, including deploying rapid response teams at the first signs of patient decline. Over the course of the initiative, there were 122,000 fewer preventable deaths, according to the IHI.

In 2006, the IHI spearheaded an even more ambitious initiative: its two-year 5 Million Lives Campaign. That effort enrolled more than 4,000 hospitals and provided additional recommendations, such as using evidence-based guidelines to prevent pressure ulcers. Among the campaign’s successes were 65 hospitals going a year or more without a single case of ventilator-assisted pneumonia, a condition that is deadly in nearly half of patients who contract it.

The Safe Surgery Saves Lives challenge

Noting that more than 200 million operations are performed around the world each year, in 2007 the World Health Organization (WHO) set out to tackle the ambitious goal of reducing dangerous surgical errors. Its Safe Surgery Saves Lives global challenge gathered experts and patients from around the world to identify key surgical concerns. The group decided to focus on surgical site infection, safe anesthesia, safe surgical teams, and measurement of surgical services.

The WHO and a team from the Harvard T.H. Chan School of Public Health led by safety expert Atul Gawande, MD, also developed a Surgical Safety Checklist. The list, available in 19 languages, reminds practitioners to confirm such key pieces of information as the patient’s name, procedure, and incision site. After implementation of the checklist, participating hospitals’ death rate dropped by nearly half, a 2009 study published in the New England Journal of Medicine reported.

Working to halt hospital infections

Health care-associated infections (HAIs) — surgical site infections, catheter-related bloodstream infections (CRBIs), and more — are common and dangerous. In fact, approximately 1 in 31 hospital patients has an HAI, according to the Centers for Disease Control and Prevention (CDC), and the effects can be painful, costly, and even deadly.

In 2001, Peter Pronovost, MD, a professor at Johns Hopkins University School of Medicine, set out to tackle central line infections. He came up with a checklist of five basic steps, such as handwashing and cleaning the patient's skin with chlorhexidine, and asked Hopkins staff to use it whenever they inserted a line. That effort yielded a dramatic drop in the infection rate, from 11% to zero. Next, Pronovost and a research team further tested the list in the Keystone ICU Project, an effort at more than 100 Michigan hospitals that also included steps to create a strong safety culture. The project had a dramatic impact — a 66% reduction in rates of CRBIs over an 18-month period — and its success led other institutions to adopt similar infection-prevention protocols.

Safety initiatives have also reduced other HAIs. By 2007, for example, all Department of Veterans Affairs (VA) medical centers had implemented a project to tackle methicillin-resistant Staphylococcus aureus (MRSA) infections. The effort included taking certain precautions around patients with MRSA and making prevention the responsibility of anyone who came in contact with patients. Data from the CDC published in 2019 noted an impressive two-thirds decrease in hospital-onset MRSA infections from 2005 to 2017 in VA centers.

The AAMC promotes quality and safety

In 2008, the AAMC created the Integrating Quality Initiative to help its member medical schools and teaching hospitals achieve safe, high-quality, and high-value care rooted in continuous quality improvement and implemented through interprofessional education and practice. In support of this goal, the initiative has spearheaded a certification program that trains clinical faculty in teaching quality improvement and patient safety. In addition, it has distributed awards to recognize and support teaching hospitals’ efforts to enhance the safety of clinical care.

Other AAMC patient safety efforts include the annual Integrating Quality Conference, a major professional development conference for faculty, students, and other stakeholders on improving quality care and patient safety. This year’s conference, being held June 6-7, focuses on patient safety and quality through a lens of health equity. Sessions cover such topics as reducing diagnostic errors and increasing resident engagement in patient safety.

Most recently, the AAMC has been working to develop a set of quality improvement and patient safety competencies that will be released later this year. The competencies are meant to lay out agreed-upon patient safety expectations for medical students, residents, and practicing physicians. They will be used by leaders in such key areas as curricular and professional development, performance assessment, and improvement of health care clinical services.

Healthier patient handoffs

Each day, about 4,000 patient handoffs happen at teaching hospitals across the country — and if provider communications fail during these transitions, the results can be dangerous. In fact, poor communication is a contributing factor in two out of three serious, preventable adverse events in hospitals, one study noted.

To improve handoff communications, a team from Boston Children’s Hospital created the I-PASS project. The effort centers on using a simple mnemonic: Illness severity, Patient summary, Action list, Situation awareness and contingency plans, and Synthesis by receiver. The I-PASS Bundle also includes a workshop to improve teamwork and tools to train faculty, along with several other supports.

In a study at nine hospitals from 2010 to 2013, the bundle yielded a 30% drop in harmful medical errors — with zero extra time added to handoffs. Since then, the project has worked to disseminate I-PASS and is studying a version of it designed to improve communication with patients and family members.

The Affordable (and safer) Care Act

Often, people associate the 2010 Affordable Care Act (ACA) with efforts to expand health care coverage to millions of Americans. But the ACA also has helped advance patient safety.

The Partnership for Patients, one outgrowth of the ACA, focuses on reducing hospital-acquired conditions such as infections, pressure ulcers, and adverse drug events. In 2016, the Department of Health and Human Services reported that the partnership and other government initiatives had contributed to 125,000 fewer patient deaths from hospital-acquired conditions between 2010 and 2015. Currently, the partnership is aiming to reduce hospital-acquired conditions by an additional 20% compared to 2014.

What’s next?

“We have come a long way since the launch of the patient safety movement in providing safer care and in educating students, residents, and faculty in safety,” says Whelan. “But we must continue to look for ways to build strong connections between education, quality improvement, and clinical practice.”

Looking ahead, experts say more work needs to be done. Possible areas of growth include increased use of checklists, involving patients and families in safety efforts, and integrating health equity into patient safety.

Increasingly, academic medicine also will be looking at “metrics that matter,” Orlowski predicts. Over the past decades, she notes, experts have been accumulating extensive data on health care processes. Next, she says, “we will look at all this information and ask, where is there a leverage point that will make a dramatic improvement in the outcome of this patient?”

Edward Pollak, MD, medical director and patient safety officer in the division of healthcare improvement at the Joint Commission, points to the importance of designing safer systems. “Using education alone is not as effective as initially designing a patient safety process to achieve desired outcomes, rather than just communicating how to achieve better outcomes … with a poorly designed process.” He also emphasizes the need to create environments in which staff feel comfortable speaking out about any safety concerns.

Leaders remain committed to a safer future, says Orlowski. “We’re going to continue to push the boundaries and say, ‘What else should we be doing?’”

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