Patient Safety 24/7/365

Added on Mar 16, 2017

By Craig Clapper, PE, CMQ/OE, Partner, Press Ganey Consulting Services

24_safety1 This week, March 12 to 18, is Patient Safety Awareness Week, an annual education and awareness campaign for health care safety led by the National Patient Safety Foundation (NPSF).

During this week, as we take time to think about, establish or confirm our dedication to safety, we also must remember that safety is an all-day, every-day commitment that affects every one of us. Virtually all of us are now, have been or will be patients. And as patients, we are all influenced by the effectiveness and quality of our health care system.

Although Patient Safety Awareness Week is an annual event, this in no way suggests that patient safety should not come first during the other 51 weeks of the year. Every day is a patient safety day, and every week is a patient safety week. Patient safety has to be a 24/7/365 commitment.

There are many reasons that safety culture must always be “on” in health care. Three of the most compelling are the frequency of patient harm in the United States, the speed of human error in patient care and the relationship between safety and both the quality and experience of care.

1. Frequency of Patient Harm

The following table summarizes three studies of patient harm in the United States. The differences in the number of patient deaths are more likely the result of differences in study methodology than of changes in patient safety over time. Of the three reports, the lowest estimate of patient deaths due to human error is 98,000 per year and the highest is 440,000 per year—the equivalent of one patient death every 50 seconds. Without question, these data indicate that every day must be a patient safety day. In fact, what the data really tell us is that every second must be a patient safety second.

 

Deaths per Annum

Frequency

IOM Report, To Err Is Human, 1999

98,000

5m 22s

BMJ, Makary & Daniels, 2016

251,000

2m 6s

J Pat Saf, James et al., 2013

440,000

50s

 

2. Speed of Human Error in Patient Care

In a common cause analysis of 2,336 harm events from 84 sites in the Healthcare Performance Improvement (HPI)/Press Ganey client community, 76% of errors that led to serious patient harm could have been prevented had a patient safety culture been in place, and 85% of the errors that led to preventable harm events arose from two types of errors that happen in less than one second:

  • Rule-based errors (70%), which reflect conscious choices based on learned operating principles or rules and occur in 600 to 800 milliseconds

  • Skill-based errors (15%), which occur with routine actions in familiar environments that require little attention and take 100 milliseconds

    Because 85% of system-caused human error happens in less than one second, patient safety has to be part of every second, every day. 

3. Safety as a Producer of Quality and the Patient Experience
Health care safety does more than keep patients safe, although that alone would be enough. Safety is a good producer of quality, and safety and quality together drive patient experience excellence. The reliability needed to keep people safe is what drives optimal clinical outcomes and experiences for every patient, every day. In this way, safety culture is the “operating system” for your patient experience.

Share these three reasons with your leaders, staff and medical staff, not just because this is Patient Safety Awareness Week, but because every day is a patient safety day. And thank them for all the good work they have done and will continue to do to ensure patient safety.