WIHI: Building Systems of Safety

Date: November 3, 2016


  • Carol Haraden, PhD, Vice President, Institute for Healthcare Improvement
  • Allan Frankel, MD, Principal, Safe and Reliable Healthcare

Hundreds of hospitals in the US, Canada, Europe, and elsewhere have made significant progress reducing incidents of harm related to hospital-acquired infections, pressure ulcers, surgical errors, and more. At the end of September, when the Centers for Medicare & Medicaid Services (CMS) announced a new initiative to improve patient safety, it reported that the US hospitals that took part in its prior program saved some 87,000 lives. CMS now wants to build on those results. That’s all good news, but there's more work to be done.
Carol Haraden and Allan Frankel, who between them have worked with hundreds of hospitals on improving safety, point to a few factors as sources of concern: research in the US using Trigger Tool methodology, which suggests that overall rates of harm remain stubbornly high despite all the hard work; ongoing challenges health care is having building safety across the continuum of care; and increasing preoccupation with meeting certain targets due to payments or penalties for performance. Haraden and Frankel argue that the last item in particular has shifted the focus away from communication and handoff failures, two major underlying contributors to patient harm.
So, what’s the alternative? Systems of safety, culture change, reliability, and a continuous learning system. These are not just theoretical concepts; they’re grounded in a lot of keen observations and careful work over many years — and they're the focus of this episode of WIHI.


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