“I believe we are at an inflection point in the history of improving patient safety. Changing payment models, the uncertainty surrounding health reform, and the ever-increasing scrutiny of the modern digital age demand fresh and creative thinking on how best to ensure harm-free care.
At IHI’s National Forum in December 2016, I proposed six patient safety “resolutions” for the new year — to ensure the great strides already made are sustained and to expand our thinking about safety:
1. Focus on what goes right as well as learning from what goes wrong;
2. Move to greater proactivity;
3. Create systems for learning from learning;
4. Be humble — build trust and transparency;
5. Co-produce safety with patients and families; and
6. Recognize that safety is more than the absence of physical harm; it is also the pursuit of dignity and equity.
The first five aren’t wholly new, and they align with IHI’s approach to quality improvement in general. The sixth is one I’ve been thinking a lot about over the past few years. Now that we know how to reduce and even eliminate harms that some once thought inevitable — ventilator pneumonias, central line infections — we need to devote our efforts to eliminating harms we’ve yet to focus on explicitly. Harms caused by indignities and inequities in health care are just as preventable, and just as unacceptable, as wrong-site surgeries and medication errors. We’re only beginning to understand how physical health is affected by psychological trauma. Ensuring patient safety is about ensuring the right all patients have to a free-from-harm care experience, which includes being treated equitably and with dignity.”