How a National Patient Safety Plan Can Help Clinicians

Damian McNamara

September 16, 2020

The safety of the healthcare workforce is one of four foundational areas in a new national report on patient safety, highlighting how intertwined the well-being of patients remains with those who care for them, particularly during the COVID-19 pandemic.

The Safer Together: A National Action Plan to Advance Patient Safety , released September 14, took 27 medical and regulatory organizations, patients, and patient advocacy groups more than 2 years to create.

"We began work on the plan before COVID was a household name. But as the pandemic evolved, we've been as impressed by how the plan is as relevant for addressing the new challenges from COVID as it is for other longstanding patient safety problems," Jeffrey Brady, MD, MPH, co-chair of the plan's National Steering Committee (NSC), said during a news conference announcing availability of the new report.

"The pandemic has highlighted the need to take care of people on the front line everyday…and the plan tells us how," added Brady, who is also director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality.

Although the COVID-19 pandemic is highlighting workforce safety issues, risks from infectious diseases are not new, said Mary Beth Kingston, PhD, RN, co-chair of the NSC subcommittee on workforce safety.

"Preventing exposure to infectious diseases "is an issue we face every day in healthcare. However, it has been tremendously magnified by the COVID experience," said Kingston, who is also chief nursing officer at Advocate Aurora Health in Milwaukee, Wisconsin.

Addressing Risks to Workforce Safety

Workforce safety encompasses more than concerns about infectious disease exposure, and the plan authors emphasize that adverse effects can be physical, psychological, or both.

Healthcare workers can experience a wide range of injuries, from musculoskeletal issues, including back and shoulder pain, to workplace violence, Kingston said. "Healthcare has one of the highest rates of illnesses and work-related injuries among many industries, even among those we traditionally think of as being high risk — like mining, construction and agriculture."

"When an error occurs in a patient, obviously our first concern is about the outcome for that patient," she said. However, "we also have to think about the trauma for that physician or nurse…when they make an error that results in that harm."

Although working in healthcare "has always been fraught with risk to physical and psychological safety, we have to leverage the urgency of this moment to once and for all rid our systems of all types of harm," said Kedar Mate, MD, president and chief executive officer at the Institute for Healthcare Improvement (IHI). The IHI led and coordinated creation of the plan.

The aim is to "give our workforces the safety and support they need to fulfil their calling as healers," he added.

Patient safety and clinician safety remain intrinsically linked. "Workforce safety cannot be an add-on or an afterthought but is in fact a prerequisite for safe and effective patient care," Mate said.

Additional foundational areas in the plan focus on culture, leadership, and governance; patient and family engagement; and learning system. The learning system component refers to ongoing efforts to learn and share best practices.

Safety Is a Shared Experience

The plan also outlines potential solutions and actions that health systems can take to continuously address safety. Collaboration and sharing of best practices remain essential to success, experts noted during the press conference.

"So many organizations in the U.S. work on patient safety, which is great," said Tejal K. Gandhi, MD, MPH, co-chair of the NSC, Senior Fellow at the IHI, and Chief Safety and Transformation Officer at Press Ganey Associates.

"But we don't tend to work together in a collaborative way. Often [this] results in the front-line getting messages from multiple directions," she added.

"Working together is a must," Brady said. "No single person or organization alone can ensure patient safety." He hopes the plan will foster an "anti-silo effect" among different safety organizations.

Learning From COVID-19 Lessons

"We cannot ignore that this plan is being released during unprecedented challenges in healthcare," Mate said. However, the pandemic also has created some opportunities, including new initiatives that could help advance safety.  

"If we don't heed the countless lessons we've all learned this year, I feel we will waste the extraordinary courage, commitment, and creativity that health care has demonstrated during the pandemic," Mate added.

The pandemic has created a surge of innovation in healthcare, often out of necessity. "There are lots of hard-working leaders and clinicians solving new problems every day," Brady said. He agreed with Mate that "it will be tragic if we don't learn from some of that activity."

The past 6 months generated a "tremendous wealth of new ideas," Mate said. He described COVID-19 as an accelerant for change, and the plan offers multiple ways lessons learned can be incorporated into the "new operating system for health care."

Visit the plan website to download the full report, an Implementation Resource Guide and a Self-Assessment Tool. The Tool is designed to help leaders and organizations determine where to start.

The plan's release coincides with the World Health Organization's World Patient Safety Day 2020 on September 17, 2020.

The study authors report no relevant financial relationships.

Damian McNamara is a staff journalist based in Miami. He covers a wide range of medical specialties, including infectious diseases, gastroenterology, and dermatology. Follow Damian on Twitter: @MedReporter.

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