Free from Harm

Roy H. Constantine  PA-C, MPH, PhD, FCCM, DFAAPA

Former CSPS Representatives and Chair

Article originally printed in Sutureline: May/Jun 2016 p. 13

Free from Harm – Accelerating Patient Safety Improvement Fifteen Years after To Err is Human is a report of an expert panel convened by the National Patient Safety Foundation. The authors note that competing priorities in health care can easily change our focus in preventing harm to patients. The Health and Safety Commission (1993) defines Safety Culture:  

“The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.”

To Err is Human outlined these serious public health issues by comparing annual deaths from medical errors 44,000-98,000 to annual car deaths 43,458. By some measures health care safety has shown improvement, yet 1 in 10 patients still develop a health-acquired condition, which includes infections, pressure ulcers, falls and adverse drug events (AHRQ Efforts, 2014). Current research found that 1 in 2 surgeries had a medication error and/or adverse drug event (Nanji et al., 2015).

The publication focuses on “Future Progress that Depends on a Total Systems Approach to Safety.”  Patient safety is now being considered a “core value”. The embracement of safety should go beyond competitive health care markets where all work together in cooperation.

In order to do this the following recommendations were made:


  1. Ensure that leaders establish and sustain a safety culture

  2. Create centralized and coordinated oversight of patient safety

  3. Create a common set of safety metrics that reflect meaningful outcomes

  4. Increase funding for research in patient safety and implementation science

  5. Address safety across the entire care continuum

  6. Support the health care workforce

  7. Partner with patients and families for the safest care

  8. Ensure that technology is safe and optimized to improve patient safety

Physician Assistants are important “patient safety” stakeholders. Since “human infallibility is impossible, the only chance to keep human errors from hurting patients is by creating collegial interactive teams (Nance, 2012).”

CSPS has endorsed this publication.

 

References:

  1. FREE FROM HARM – Accelerating Patient Safety Improvement Fifteen Years after To Err is Human. 2015. National Patient Safety Foundation.
  2. Agency for Healthcare Research and Quality (AHRQ). 2014. Efforts to Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013. Rockville, MD: Agency for Healthcare Research and Quality, AHRQ Publication No. 15-0011-EF
  3. Health and Safety Commission. 1993. Third Report: Organizing for Safety. ACSNI Study Group on Human Factors. London: HMSO
  4. Nance JJ. Why Hospitals Should Fly – The Ultimate Flight Plan to Patient Safety and Quality Care. 2012. Second River Healthcare Press
  5. Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. 2015. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology Oct 24.