New NPSF report calls for a total systems approach to patient safety


Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue, according to a report by the National Patient Safety Foundation.

The report, titled Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human, calls for the establishment of a total systems approach and a culture of safety.

The report proposes eight recommendations for achieving total system safety and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.

The eight recommendations are as follows: ensure that leaders establish and sustain a safety culture; create centralized and coordinated oversight of patient safety; create a common set of safety metrics that reflect meaningful outcomes; increase funding for research in patient safety and implementation science; address safety across the entire care continuum; support the health care workforce; partner with patients and families for the safest care; and ensure that technology is safe and optimized to improve patient safety

The new report is the work of a panel of experts brought together by NPSF earlier this year to assess the state of the patient safety field and set the stage for the next 15 years of work.

The panel was led by co-chairs Dr Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI) and lecturer in the Department of Health Care Policy at Harvard Medical School, and Dr Kaveh Shojania, director of the Centre for Quality Improvement and Patient Safety at the University of Toronto and editor-in-chief of the journal BMJ Quality & Safety.

“The field of patient safety has not achieved enough, despite definite progress having been made,” said Dr Tejal Gandhi, president and chief executive officer, NPSF. “Health care is still not nearly as safe as it can and should be, and the recommendations of this expert panel set a path for achieving total system safety and making safety a primary focus.”

Institute of Medicine, National Patient Safety Foundation, NPSF, US, Patient Safety