March 28, 2023
During recent travels, I was reminded of the jarring statistic from the Institute of Medicine’s (IOM)1999 report, “To Err is Human,” that we lose the equivalent of a jumbo jet full of passengers daily in the US due to patient safety events. It boggles the mind to think that millions of people fly each day and yet they are more likely to die in a car accident on the way to the airport than in a plane crash. The safety record within aviation can mostly be attributed to a culture of safety that permeates the industry.
What makes flying so safe? Importantly, there is a just culture in aviation. This means that anyone – the pilot, a flight attendant, or a mechanic – can report an error, event, or near-miss without fear of retribution. Being able to raise a red flag by any team member ensures that more people are able to surface safety concerns before they become events.
Since the IOM report came out, the lessons learned in the aviation industry have been applied to patient safety. When comparing the two, many features in aviation can be likened to healthcare – the doctor or lead clinician often serves as the “pilot” supported by other critical team members. Team members in healthcare can include not only clinicians, but food and environmental services staff, other non-clinical staff members, and importantly, patients and families. Many healthcare organizations have adopted a just culture to ensure that anyone can surface a safety concern.
The theme of 2023’s National Patient Safety Awareness Week (March 12-18) was “Be a Patient Safety Hero: Anywhere, Anytime – Always.” This theme especially resonates this year as we evaluate the impacts of COVID on patient safety. During the height of the pandemic, fewer family members were able to visit with their loved ones, reducing the number of team members able to surface safety concerns. Additionally, ongoing workforce shortages have stressed the systems that were in place to catch safety concerns before they became events. A recent analysis shows that the gains which were made over the past 25 years in patient safety have been significantly impacted since COVID was first discovered in the US in late 2019, including increases in central line and catheter-associated urinary tract infections and ventilator-associated events.
During this National Patient Safety Awareness Week, HCIF acknowledges and celebrates all of the patient safety heroes who remain committed to the provision of the safest care for our patients. These include members of our Clinical Advisory Committee who steadfastly identify safety concerns in their own institutions and raise these as priorities in the region. We thank and recognize participants in our Partnership for Patient Care programs who take time out of their busy schedules to collaborate and learn together about topics such as medication safety, improving healthcare disparities, and healthcare associated infections. Through the PPC program, we are pleased to provide forums, such as Safe Table, that provide space for patient safety and quality professionals to come together to address serious safety events in a punitive-free and supportive environment.
Similar to the aviation industry – where every member of the team serves an important role in safety – anyone can be a patient safety hero, not just a doctor, nurse, or pharmacist. Even patients themselves and their family members can serve as patient safety heroes. We all have a role to play in regaining the gains made in patient safety prior to COVID.