Since the landmark "To Err Is Human" report in 1999, patient safety has evolved alongside technological and care advancements in healthcare. Despite significant progress and numerous initiatives aimed at reducing preventable harm, the statistics remain stark: 1 in every 10 patients experiences harm in healthcare, and more than three million deaths occur annually due to unsafe care1. Importantly, over 50 per cent of these incidents are preventable2,3.
There has been a growing call for renewed action and transformation around eliminating preventable harm. ECRI and ISMP PSO, along with 26 other organisations, contributed to the National Action Plan to Advance Patient Safety, calling for a total systems approach to redesign the complex system in which healthcare is delivered. In late 2023, the President’s Council of Advisors on Science and Technology released bold recommendations in the Report to the President calling for a transformational effort on patient safety. As a patient safety organisation, ECRI is committed to supporting healthcare providers in their journey to redesign systems to eliminate preventable harm.
Looking forward, total systems safety emerges as the imperative path for advancing patient safety. This holistic approach integrates system design, human factors engineering, health equity, and advanced safety science to create a robust framework for safety enhancement. However, achieving meaningful and sustainable change demands a fundamental shift in how healthcare environments, systems, and processes are conceptualised and redesigned4. It necessitates cross-stakeholder collaboration to effectively address safety challenges.
In its National Action Plan to Achieve Patient Safety, the National Steering Committee for Patient Safety outlines four foundational pillars crucial to achieving total systems safety5:
- Cultivating leadership: Establishing governance and cultivating a safety-centric culture.
- Engaging patients and families: Involving them as partners in care design and delivery.
- Fostering a safe environment: Promoting workforce resilience and ensuring a healthy, safe workplace.
- Supporting continuous learning: Sharing and applying lessons learned to enhance safety and quality of care.
ECRI’s annual Top 10 Patient Safety Concerns report is grounded on these four pillars, drawing insights from extensive data analysis conducted in collaboration with ISMP. This report not only identifies pressing patient safety concerns but also proposes strategies for continuous improvement in healthcare. It underscores the pivotal roles of culture, leadership, patient engagement, and workforce safety in driving systemic improvements. ECRI and ISMP’s collective expertise illuminates how systemic factors can either contribute to harm or enhance safety, providing actionable guidance to organisations adopting a Total Systems Safety approach.
In conclusion, the Total Systems Safety approach enables comprehensive system redesign and fosters collaborative engagement across stakeholders. By prioritising leadership commitment, patient partnership, workforce resilience, and continuous learning, healthcare organisations can significantly improve safety outcomes and mitigate risks effectively.
As we navigate the complexities of healthcare delivery, ECRI remains steadfast in supporting stakeholders on their journey towards safer healthcare environments. I strongly encourage healthcare leaders, providers, and policymakers to leverage ECRI's insights and resources to drive continuous improvement and foster a culture of safety across the industry.
References
1. Slawomirski L, Klazinga N. The economics of patient safety: from analysis to action. Paris: Organisation for Economic Co-operation and Development; 2020 (http://www.oecd.org/health/health-systems/Economics-of-Patient-Safety-October-2020.pdf).
2. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 2019;366:l4185. doi:10.1136/bmj.l4185.
3. Hodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 2020;18(1):1–3.
4. Kaplan G, Bo-Linn G, Carayon P, Pronovost P, Rouse W, Reid P, Saunders R. Bringing a systems approach to health. Institute of Medicine, National Academy of Engineering. 2013 July 10. https://nam.edu/wp-content/uploads/2015/06/SAHIC-Overview.pdf
5. National Steering Committee for Patient Safety (NSC). Safer together: a national action plan to advance patient safety. Institute for Healthcare Improvement (IHI). 2020. https://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx
Eric Woo is the Vice President at ECRI Asia Pacific. His colleague Stella Cheong, Senior Consultant, Business Development, ECRI Asia Pacific, Selangor, Malaysia, will be speaking on 'Top 10 patient safety concerns' at the Patient Safety track on July 11 at Medlab Asia and Asia Health.
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