Early in my career as a chief patient safety officer, a woman came to our medical facility for a surgical procedure. Her pre-op blood testing showed signs of cancer, and as a result of communication breakdowns, these test results were not addressed nor communicated to the patient. Her treatable leukemia progressed, and she passed away six weeks later. Afterward, hospital leaders tried to sweep the incident under the rug rather than being honest with the woman’s family and addressing the root causes of the mistake.
In the end, the hospital was sued and spent thousands of dollars on legal representation before settling for millions. Not only was the error that led to the progression of the patient’s cancer preventable, but the resulting lawsuit and reputational damage may have been avoided if leadership had responded to the incident properly— admitting to and apologizing for the mistake and taking tangible actions to prevent similar incidents from occurring in the future.
In a perfect world, medical errors wouldn’t happen. But nurses and doctors, like their patients, are only human, and humans make mistakes—especially when those humans are dealing with emotional exhaustion caused by understaffing, cumbersome technology, siloed data and a lack of peer support. Today, nearly 1 in 4 hospitalized patients experience a harm event, 25% of which are preventable.
To enable safer care, hospitals must cultivate a culture of safety through collaboration and open communication around medical harm. Healthcare’s “wall of silence”—the fear of speaking up about medical errors or being open and honest with patients and families— can lead to a vicious cycle of harm. Without thorough incident reporting, health systems are unable to uncover the contributory causes of errors and work towards safer patient care.
It’s time for a change. We need to work together as providers, healthcare technology leaders, patients and legislators to improve how healthcare organizations operate around harm and encourage a culture of safety.
The impact of legislation and partnerships on healthcare safety culture
Safer patient care requires cultivating a culture of safety where healthcare providers and leaders can learn from errors and near misses without fear of excessive retaliation. In 2005, Congress passed the Patient Safety and Quality Improvement Act (PSQIA) to create a safe space for healthcare personnel to submit and analyze their patient safety concerns without fear of retribution, legal discovery or litigation. The PSQIA was designed to increase the amount of data available to assess and prevent the root causes of patient safety incidents. The act also includes federal privilege and confidentiality protections for patient safety data and authorizes the use of financial penalties for violations of patient safety confidentiality.
The PSQIA works through Patient Safety Organizations (PSOs)—external organizations that collect and analyze patient safety data. By facilitating shared safety learnings from across organizations and healthcare institutions, PSOs encourage health systems to share and learn from each other and accept mutual responsibility for providing safer care. Condensing and analyzing data from across health systems helps us obtain a comprehensive understanding of existing patient safety challenges and target areas for improvement. Connecting siloed information both within and between organizations is key to reducing variability and risk, strengthening the culture around patient safety and providing deeper operational insights.
Patient safety action plans pave the way forward
Research on the prevalence and causes of medical harm has ignited organizations including the Centers for Medicare & Medicaid Services (CMS) and the World Health Organization (WHO) to set out new action plans to enhance patient safety standards. Recently, the CMS finalized the Patient Safety Structural Measure (PSSM), which will assess and publicly rate the quality of hospitals’ safety practices and implementation on a scale of 0-5. The PSSM will be scored according to five domains that aim to capture the core tenets of patient safety: leadership commitment to eliminating preventable harm; strategic planning and organizational policy; culture of safety and learning health systems; accountability and transparency; and patient and family engagement.
Similarly, in 2021 the WHO set out a Global Patient Safety Action Plan that outlined key priorities for the reduction of medical harm, including policy, high-reliability systems, healthcare worker education, risk management and partnerships. In the inaugural global report on patient safety released this year, the WHO assessed the current state of patient safety against its action plan. Unfortunately, we still have a long way to go to improve patient safety worldwide. The WHO report found that only a quarter of countries have made efforts towards developing a culture of safety in healthcare facilities, and unsafe care today accounts for up to 12.6% of total health expenditures in high-income countries.
These structural measures and action plans mark an important step towards the widespread implementation of evidence-based patient safety processes and reflect the increasing commitment to restoring compassion to healthcare. With the PSSM now mandating improved peer support and transparency around patient harm, hospitals and health systems will have the tools and support they need to approach patient safety from a systematic and empathetic lens. Hospitals and health systems can take immediate action to improve patient safety culture through the Communication and Optimal Resolution (CANDOR) peer support process. The CANDOR approach involves training healthcare staff in effective and compassionate patient safety event resolution and compassionate communication with patients and their caregivers. Similarly, BETA Healthcare Group’s BETA-HEART (Healing, Empathy, Accountability, Resolution, and Trust) approach, built with inspiration from CANDOR, offers a coordinated and holistic program designed to help healthcare organizations build and maintain a culture of safety.
Rather than be discouraged by the continued prevalence of medical harm, healthcare leaders and providers should take this as a challenge: to cultivate a stronger culture of safety at their workplaces and work towards safer care for all. By employing evidence-based processes and software for incident reporting, peer support, empathetic communication, and event resolution, healthcare organizations can move the needle on patient safety and build a stronger and happier workforce.
Timothy McDonald
Timothy McDonald, MD JD, is the Chief Patient Safety and Risk Officer for RLDatix and a Professor of Law at Loyola University – Chicago. Tim is a physician-attorney who has assisted more than 800 hospitals and health systems implement a culture of “normalized compassionate honesty” combined with “fair and accountable culture” transformation. His research has focused on conducting patient safety, Just Culture, and high reliability needs assessment/Gap Analysis for organizations along with assisting them in the principled approach to unexpected events with an emphasis on reporting of patient safety events, the use of simulation and human factors analysis, the provision of emotional first aid to affected health care team members and providing open and honest communication following harm events. This approach to unexpected events also includes a commitment to communicate and provide peer support within the health care team and to communicate with patients and families throughout the therapeutic relationship, especially after harm occurs. He has received numerous national and international Patient Safety awards including the American College of Medical Quality’s Founder’s Award, the Institute of Medicine – Chicago Patient Safety Award, and the Medically Induced Trauma Support Services [MITSS} Hope Award.
