Risk Management: Patient Safety Summary

1. Progress and Challenges Ahead

Patient safety became a priority as the magnitude of medical errors resulting in patient harm gained worldwide attention in 1999 through the Institute of Medicine Report “To Err is Human: Building a safer health system.” Even though we have made incremental improvements since then, we still face a monumental global challenge. The recognition of human factors, safety science, accident causation, and human factors engineering to redesign healthcare systems is essential to this journey. However, we need a broader systems approach to include the entire continuum to reach our goal of zero harm - a true integration of systems to achieve patient safety. As discussed in the previous module, safety culture is fundamental to total system safety. The absence of a robust, effective safety culture has been singled out as one of the main reasons patient safety has not achieved sustainable improvement. It is not just a means to an end but an essential part of a system to achieve safer care. As you can see, this cannot be overstated.

big idea

Remember, Culture eats safety for lunch! Really.

It has been suggested that the following recommendations are necessary to take safety to the next level (Gandhi, Berwick, Shojania, 2016).

• Ensure that leaders establish and sustain a safety culture
• Create centralized and coordinated oversight of patient safety
• Create a common set of safety metrics that reflect meaningful outcomes
• Increase funding for research in patient safety and implementation science
• Address safety across the entire care continuum
• Support the healthcare workforce
• Partner with patients and families for the safest care
• Ensure that technology is safe and optimized to improve patient safety

2. Resources

For further information on Patient Safety, visit:

• AHRQ Patient Safety Net
• Understand the Science of Safety
• World Health Organization on Patient Safety

Support

If you are struggling with a concept or terminology in the course, you may contact RiskManagementSupport@capella.edu for assistance.

If you are having technical issues, please contact learningcoach@sophia.org.