patient safety

Patient safety can sometimes be a nebulous concept. Like quality, it is difficult to define, but most of us recognize it when we see it.

I was standing in a conference room, trying to explain to a group of vocal physicians why we needed to approve a Code of Conduct for the medical staff. It was one of our quarterly medical staff meetings, so there were a good number of physicians present.

Some of the physicians were concerned that such a code would be used to punish passionate and otherwise well-meaning physicians who became angry in the heat of a stressful situation. Another group felt that any new set of rules would jeopardize their autonomy.

That word, autonomy, had been used countless times to argue against various bylaws changes over the years. The thinking was that physician autonomy was sufficient to ensure quality of care.

Of course, that had been proven untrue many times. The quality improvement and patient safety literature repeatedly demonstrates that system breakdowns cause harm even when the most brilliant and dedicated physician is caring for patients.

Many of the staff members begrudgingly came to agree with the need for approving the code. This was primarily due to a fear of being accused of creating a hostile work environment. Very few had come to recognize the main concern that I had: that this was a serious patient safety issue.

The Code of Conduct had already been approved by the Medical Executive Committee. Members were convinced by a cultural survey completed earlier in the year. The survey demonstrated that staff, from pharmacists and nurses, to radiology techs and housekeepers, were hesitant to express concerns about potential safety issues. They would avoid calling physicians with important patient information, because of poor treatment during previous interactions.

I recalled several patients over the years, mostly in intensive care units, that I believe were harmed due to delays in contacting physicians. Most of those occurred before the implementation of in-house intensivists. But similar events still occur in recovery units and observation units in many hospitals due to delays in calling physicians.

So, the code of conduct is an integral piece of the patient safety puzzle. And its main purpose was to try to address the cultural and communication aspects of patient safety.


patient safety system failure

Definition of Patient Safety

The Institute of Medicine at one point defined patient safety as the “freedom from accidental injury.” My definition of patient safety is as follows: the discipline that is devoted to avoiding unexpected or avoidable harm to patients. 

Quality improvement and patient safety address similar issues, but I draw a distinction between the two. Generally, quality improvement involves the use of evidence-based care to optimize medical care. For example, reducing the length of stay or mortality rate for community acquired pneumonia by consistently selecting the appropriate antibiotic. If inappropriate antibiotic selection results in a poor outcome, then a quality issue has occurred.

Patient safety has to do with avoiding harm caused my mistakes or by breakdowns in communication, hand-offs, and other system failures. In the pneumonia example, if the wrong antibiotic is dispensed to the patient because of a similarity in name and labeling of the medication, then a patient safety issue has been identified.

Other examples of patient safety, as opposed to quality, issues in this case could be:

  • hand-off communication: the antibiotic is ordered in the ER but never given because the orders from the ER EMR (electronic medical record) do not transfer to the inpatient EMR;
  • disruptive communication: the physician hangs up on a phone call before the nurse can perform the read back, who then orders the wrong medication;
  • medication error: the nurse administers an inappropriate medication because the dispensing cabinet was stocked improperly;
  • preventable infection: patient develops C. difficile infection while hospitalized because of improperly followed infection prevention policies.

Addressing Patient Safety

Facing this topic can seem daunting, because there are so many potential safety issues, especially in the hospital setting. But I think the physician leader can use the following checklist when trying to devour the “elephant” of patient safety (one  bite at a time, of course). These steps follow an approach  similar to what I recommended for Becoming a Top 100 Hospital.

hospital safety

patient safety team

 1. Create a multidisciplinary Patient Safety Committee if you do not already have one.

This committee will typically include representation from the following areas:

  • Executive team
  • Medical staff
  • Nursing
  • Pharmacy
  • Quality Improvement
  • Risk Management
  • Infection Prevention
  • Informatics
  • Case Management
  • Documentation and Coding
  • Medical Records

Additional participants can be pulled in as the need arises. The team will need a charter and a chair. A champion from the medical staff may also be assigned.

2. Use national safety organizations to guide you to the top patient safety issues to consider.

These organization have spent millions of dollars determining which indicators are valid and have measurable impact on patient outcomes. Besides, your organization will ultimately be graded on how well it performs on these measures, which are generally reported to the public in some fashion.

Some of the entities that can provide direction include:

After reviewing the material provided by each of these entities, move to the next step.

3. Select patient safety indicators (PSIs) to measure.

I would recommend starting with the AHRQ measures. They are well-defined and already included in most hospital quality measurement tools. Here is the list of AHRQ PSIs (including a link to each PSI's technical specification):

Be certain that your team understands the definition of each measure. As I explained in How to Slash Your Hospital Mortality Rate you need to be certain that adverse events actually meet the definition before being counted in the measure.

patient safety dashboard

safety dashboard

4. Create a dashboard that compares quarterly results to an external benchmark or goal.

Track the metrics back over the prior 8 or 10 quarters. This will allow for identifying trends that need to be addressed. Select the PSI with the biggest opportunity or potential impact for improvement. Begin a concerted effort to work on it. Develop an annual goal and milestones to track.

5. Present regular updates to the executive team and then the board of directors.

This helps to keep everyone involved and serves to create urgency when measures do not meet expectations. Be prepared to define the various terms and use the opportunity to educate the executive team and board about patient safety concepts.

6. Address other supporting issues that will enhance patient safety efforts.

These include:

Addressing these issues will help to put your organization on strong footing when it comes to improving patient safety.

What questions or comments do you have about patient safety?