Preventable harm in healthcare is a leading cause of death in America and should be tackled as a public health crisis with its own coordinated response.
A new Call to Action, developed by the National Patient Safety Foundation, provides the framework for that response and identifies roles for key stakeholders. The detailed Call to Action (available at npsf.org) builds on successful efforts to reduce healthcare-associated infections and take advantage of critical lessons learned.
Essential for this initiative is the belief that a coordinated public health response—one that draws on the experience and expertise of public health professionals and organizations—will accelerate progress in the prevention of harm and establish the critical infrastructure needed to address this challenge across the U.S. healthcare system consistently and sustainably.
That belief is based on America's long history of coordinated public health responses to combat specific diseases and conditions. Public health efforts have brought about a 90% decline in deaths from motor vehicle crashes and a marked decline in deaths from infectious disease. It's time to put that history to work combating preventable harm in order to improve patient safety.
While efforts to improve patient safety have been ongoing for several decades, the scale of improvement has been limited and inconsistent. Meaningful advancement in patient safety requires a shift from reactive piecemeal interventions occurring at individual organizations to a coordinated, systemwide effort geared toward providing safe care delivery across all aspects of care. The coordination must bring together stakeholders who set healthcare policy, deliver care, insure care, receive care, support patients, fund or research innovations, advocate innovations and create partnerships.
The NPSF framework consists of six priorities—each accompanied by a recommended action, a suggested tactic and a set of key stakeholders. The six priorities and the recommended actions are:
- Define the problem and set national goals: Leaders and policymakers must establish preventable healthcare harm as a public health crisis and commit to reducing this harm across the care continuum.
- Coordinate activities across multiple sectors to ensure widespread adoption and evaluation: Create centralized and coordinated national oversight of patient safety involving a broad array of stakeholders.
- Inform, educate and empower the community: Partner with patients and families for the safest care.
- Measure and monitor progress at all levels effectively: Create a common set of objective safety metrics to ensure widespread adoption, evaluation and accountability.
- Identify causes and interventions that work: Ensure that leaders establish and sustain a culture of safety; provide sustainable funding for research in patient safety and implementation science; ensure that technology is safe and optimized to improve patient safety.
- Educate and train: Support and educate the workforce. Resources should be expanded or developed that support the workforce, including launching initiatives to improve working conditions; establishing an environment of teamwork and respect; creating programs to support staff and improve resiliency; and offering fatigue management systems and communications, apology and resolution programs.
To empower patients and their families, patients should be actively engaged in care (e.g., employing shared decisionmaking, playing an active role in bedside rounding, removing limits on family visiting hours and making available patient-activated rapid response teams) and in root-cause analyses.
A commitment to these six priorities—and related actions and tactics by the relevant stakeholders—will set the nation on a better course for preventing patient harm. But building out and implementing this framework on a national scale requires coordination as well. If such a coordinated response can be achieved, preventable patient harm can be dramatically reduced.
That should matter to everyone, as all of us have a stake—as potential patients—in improving the safety of our healthcare system. It's time to respond collectively to a Call to Action to improve patient safety. It's time to drive the collaborative work needed to ensure that patients and those who care for them are free from preventable harm.
