Patient Safety
Chair: Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health
Patient safety is a critical topic in today’s health care environment. The health care community received a major wake-up call in 1999 when the Institute of Medicine (IOM) published the landmark report, To Err Is Human, and noted that as many as 98,000 Americans die annually due to medical errors. This was followed in 2000 by the United Kingdom (UK) Department of Health report, An Organization with a Memory, that estimated 850,000 adverse events per year in UK hospitals, or 10 percent of hospital admissions. A 1995 Australian study estimated an adverse event rate in hospitalized patients in that country of 16.6 percent.[1]
The IOM defined patient safety as “freedom from accidental injury”; patients should not be at greater risk for accidental injury in a hospital or health care setting than they are in their own homes. Improving patient safety — reducing and ultimately eliminating harm to patients — relies on identifying failures in our processes and systems that lead to breakdowns and errors and then redesigning these processes to make them safe.
[1] Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australia Health Care Study. The Medical Journal of Australia. 1995 Nov;163(6):458-476.
In 2001, the National Academy of Science’s Institute of Medicine (IOM) laid out six dimensions of quality for health care. According to the IOM, care should be safe, effective, patient-centered, timely, efficient, and equitable.
Carol Haraden, a Vice President at IHI and patient safety expert, tells us why safety is at the top of that list.
Patient Safety Faculty
PS 101: Fundamentals of Patient Safety
PS 102: Human Factors and Safety
PS 103: Teamwork and Communication
February 24, 2009: Sorrel King, Founder, Josie King Foundation - Sorrel King, after her 18-month-old daughter Josie was killed by medical errors at Johns Hopkins Hospital, turned grief into action, launching a foundation and working with Johns Hopkins and many other hospitals to improve patient safety.
November 3, 2008: Peter Pronovost, MD, researcher and physician - Peter Pronovost helped Michigan hospitals adopt checklists — simple lists of all the steps involved in routine tasks. Within 18 months, the intervention saved an estimated 1,500 lives.
August 6, 2008: Carol Haraden, PhD, Vice President, Institute for Healthcare Improvement - Have you ever been spared a dead car battery by a beeping noise that reminded you to turn your car lights off? A nurse administers a wrong dose because medication labels look similar. A doctor is interrupted by a page and then gives the nurse incomplete patient orders...
May 15, 2009: Parker Palmer, sociologist, Paul Batalden, Dartmouth Medical School professor, David Leach, former CEO of the Accreditation Council for Graduate Medical Education - When you spot a patient who’s not getting the best possible care, what do you do? How do you speak up? Join the discussion.
June 16, 2008: Donald Berwick, MD, MPP, FRCPPresident and CEO, Institute for Healthcare Improvement - “I then realized that I had infused almost the entire bag of heparin … I thought that I was probably going to throw up.”
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health - Millions of people suffer every year from mistakes in health care. Lucian Leape, MD, explains why those mistakes happen — and how to prevent them.
Inappropriate use of IV haloperidol to manage psychosis in an AIDS patient causes polymorphic v-tach ("torsade de pointes"), necessitating a transvenous pacemaker.
Faced with a patient who’s too confused to remember his medication regimen, a care team administers an overdose of the anticoagulant Warfarin.
A child is mistakenly vaccinated for hepatitis A, rather than B. Despite forthright disclosure and no evident harm to the child, the father becomes incredibly angry at the providers.
In the midst of a high-risk surgery, the senior resident injects 100 times the correct dosage of insulin.
A healthy 57 year old man underwent a liver donation procedure. He began to manifest some tachycardia late on the second postoperative day. Early on the third post-operative day, he began to hiccup, complained of being nauseated and was pronounced dead later that day.
A young woman's lupus flares up, along with a complicating infection. Her providers struggle to coordinate care as her condition deteriorates.
The term “patient navigator” is often used interchangeably with other terms such as “nurse navigator” and “care coordinator,” depending on how the role is defined by the organization. Utilizing this role, AnMed Health Cancer Center and Clemson University’s School of Nursing sought out a plan to improve patient-centered cancer care. (Presented at the 2008 20th Annual National Forum in Nashville, TN)
“By and large, hospitals that want to educate health professionals about quality, safety, and teamwork have to start from scratch with each new graduate they hire,” says Linda Cronenwett, PhD, RN, FAAN, Dean and Professor at the University of North Carolina, Chapel Hill School of Nursing (Chapel Hill, North Carolina, USA). She is involved in a national initiative to change that reality.
Have you ever left the doctor’s office in a rush without asking all of the questions you had? This brief article summarizes a few organizations’ method of guiding patients through their care. The article also explains how this approach to care provides benefits to patients and health care organizations.
A selected bibliography of essential books and articles about patient safety in health care, categorized by major topics in the field.
What would you do after a wrong-site surgery?
Everywhere you look — both in health care and in ordinary retail settings — you can spot circumstances that make it easy for regular people to make mistakes. In this exercise, you’ll go out and analyze everyday situations to determine what human factors issues are at play. You’ll also decide what interventions should be introduced to minimize the opportunities for mistakes.
In 2005, Mayo School of Graduate Medication Education implemented a program to train all its resident and fellows — more than 1,500 students on three campuses — in quality improvement and safety.
When you make a mistake that affects a patient, what should you say? Should you apologize, or will that put you at greater risk of being sued? Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, describes how to talk with patients and families after a mistake has occurred.
Our leaders look to us to spread the importance of changing the quality of care for our patients. On October 22nd, we held two national webcasts to discuss the first opportunity for all Chapters to unite for a common cause, help spread the WHO Safe Surgery Checklist, and work to implement, measure, or raise awareness of its use.
Keynote plenary sessions and 10 other sessions from the 2009 International Forum in Berlin, Germany are available to view online, for free, for your continued learning.
Eighteen-month-old Josie King died from medical errors incurred at Johns Hopkins Hospital. Her mother, Sorrel King, later worked with hospitals to develop a way for patients and their families to summon a Rapid Response Team to the bedside within minutes.
A patient suffers horrible burns. An operation takes twice as long as it should. A child dies from internal bleeding. All because a doctor, a nurse, or another care provider made a mistake. In this video, prominent clinicians describe the errors that still haunt them today — and point out ways those errors could have been prevented.
A baby falls gravely ill after a botched blood transfusion. A student nearly commits a medication error. A patient dies after a clumsy surgery. In this video, current and former clinicians (including IHI’s CEO Don Berwick) describe the errors that still haunt them today — and point out ways those errors could have been prevented.
In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital. How did this happen? Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere. [Excerpt from a speech given at IHI’s National Forum in 2002.]
Millions of people suffer every year from mistakes in health care. Lucian Leape, MD, explains why those mistakes happen — and how to prevent them.
With all the challenges that health professionals face, their jobs are still among the most rewarding out there. Former IHI Fellow Joanne Watson talks about the patient she can’t forget, and why being a doctor brings her joy every day.
Carol Haraden, a Vice President at IHI and patient safety expert, tells us why safety is at the top of the National Academy of Science’s Institute of Medicine (IOM) dimensions of quality for health care list.
Achieving Competence Today (ACT) is a teaching resource for health care educators. ACT develops and provides resources for the ACGME Systems-Based Practice and Practice-Based Learning and Improvement, and for the AACN Essentials of Graduate Nursing Practice competencies. Educators have several options for finding and downloading high-quality curriculum materials.
Quality and Safety Education for Nurses (QSEN) is a comprehensive resource for nursing educators. This website is a place to learn and share ideas about educational strategies that promote quality and safety competency development in nursing.
