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20 years since ‘To err is human’ U.S. hospitals have done much to address safety

Hospitals and health systems are engaged in collaborative efforts to further reduce infections, including sepsis, and improve antibiotic stewardship to preserve their effectiveness against deadly diseases.

By Jay Bhatt and Robyn Begley, Nov 25, 2019

Twenty years ago this month, the Institute of Medicine released its landmark report, “To Err is Human: Building a Safer Health System.” This report captured the attention of the public, hospitals and health systems, policymakers and the media—and rightly so—because it was an urgent call to action for the nation to make healthcare better, safer and smarter.

Over the past two decades, hospital and health system leaders have heeded this call and made bold changes to improve the quality of care and patient safety and have seen real results that have benefited patients.

Since the release of “To Err is Human,” hospitals and health systems have stepped up efforts to foster a culture of safety.

This encourages nurses, physicians and other caregivers to come forward with mistakes so we can learn from them and prevent them from happening again. We’ve also placed an emphasis on increasing effective communication between clinicians and hospital administrators and between clinicians and their patients, because empowering patients to be full partners in their care is one of the most important steps toward reducing errors.

Hospitals and health systems have also increased communication and transparency with the public on quality and safety. As care coordination becomes even more important to achieving good health outcomes, our field has prioritized patient safety throughout the continuum of care and across settings and care teams. And hospitals are setting bold goals, with a number of them achieving results such as going years without preventable infections on a unit.

On top of these improvements in the culture of care, we’ve also invested in and adopted numerous technologies and practices to support safer care. Examples include electronic health records and prescription order systems to alert clinicians to potential dangers, barcoding systems that confirm the right patients are receiving the right medication, outreach programs to ensure patients are taking their medications and following other directions after discharge and better technology to monitor patients in real time to prevent falls and changes in vital signs that can lead to health complications.

This persistent focus on improving care has resulted in important progress, including reductions in avoidable readmissions, medically unnecessary early elective deliveries, hospital-acquired conditions and healthcare-associated infections, to name just a few examples.

And between 2014 and 2018, hospitals directly engaged in the AHA Hospital Improvement Innovation Network saved $1.2 billion in healthcare costs and prevented 141,000 patient safety incidents, with every dollar invested in the program resulting in saving $12 in future spending. Importantly, patients are also reporting more and more favorable hospital experiences.

The bottom line: One preventable safety event is one too many, and more work remains to be done.

That’s why hospitals and health systems are engaged in collaborative efforts to further reduce infections, including sepsis, and improve antibiotic stewardship to preserve their effectiveness against deadly diseases. We’re also working to address the persistent inequities in care by connecting quality and safety efforts to equity in care. And our field is partnering with other stakeholders to redouble efforts to make sure women have safe pregnancies, from the first days of pregnancy through the postpartum period.

As the healthcare system continues to transform, some things remain constant for America’s hospitals and health systems: We are deeply committed to providing all patients with high-quality, safe and person-centered care. We are saving lives, performing miracles and keeping people healthy. And together we are working hard each and every day to advance health in America.

Jay Bhatt is the American Hospital Association’s senior vice president and chief medical officer, and Robyn Begley is AHA’s chief nursing officer and CEO for the American Organization for Nursing Leadership. This article was originally published in Fierce Healthcare.

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