Patient safety is a specialized field focused on enhancing healthcare quality through the systematic prevention, reduction, reporting, and analysis of medical errors and preventable harm that can lead to negative patient outcomes. Although healthcare risks have long existed, patient safety only gained formal recognition in the 1990s following reports of alarming rates of medical error-related injuries in many countries. The urgency of the issue was underscored when the World Health Organization (WHO) identified that 1 in 10 patients globally experience harm due to healthcare errors, declaring patient safety an "endemic concern" in modern medicine.
Robust healthcare management systems are critical to successfully implementing patient safety strategies, ensuring that safety protocols are seamlessly integrated into clinical operations to reduce medical errors.
Today, patient safety is a distinct healthcare discipline, supported by a developing scientific framework. It draws on a transdisciplinary body of theoretical and empirical research, with emerging technologies, such as mobile health applications, playing an important role in its advancement.
Prevalence of adverse events
Millennia ago, Hippocrates recognized the potential for injuries that arise from the well-intentioned actions of healers. Greek healers in the 4th century BC drafted the Hippocratic Oath, pledging to "prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone."National Institute of Health, History of Medicine: Greek Medicine Since then, the directive primum non nocere ("first, do no harm") has become a central tenet for contemporary medicine. However, despite an increasing emphasis on the scientific basis of medical practice in Europe and the United States in the late 19th century, data on adverse outcomes were hard to come by; the various studies commissioned collected mostly anecdotal events.The Anesthesia Patient Safety Foundation, A Brief History
In April 1982, the ABC television program 20/20 entitled The Deep Sleep presented a rising problem in American hospitals. Showing accounts of anesthetic accidents, the producers stated that, every year, 6,000 Americans die or experience brain damage related to these mishaps.Janice Tomlin (producer): The Deep Sleep: 6,000 will die or suffer brain damage, WLS-TV Chicago, 20/20. April 22, 1982 In 1983, the British Royal Society of Medicine and the Harvard Medical School jointly sponsored a symposium on anesthesia deaths and injuries, resulting in an agreement to share statistics and conduct studies.Anesthesia Patient Safety Foundation: The establishment of the APSF by Ellison C. Pierce, Jr., M.D. Attention was brought to medical errors in 1999 when the Institute of Medicine reported that about 98,000 deaths occur in the United States every year due to medical errors made in hospitals.
By 1984, the American Society of Anesthesiologists (ASA) had established the Anesthesia Patient Safety Foundation (APSF). The APSF marked the first use of the term "patient safety" in the name of a professional reviewing organization.Anesthesia Patient Safety Foundation: Comments From the Anesthesia Patient Safety Foundation Although anesthesiologists comprise only about 5% of physicians in the United States, anesthesiology became the leading medical specialty addressing issues of patient safety.
To Err is Human
In the United States, the full magnitude and impact of errors in health care were not appreciated until the 1990s, when several reports brought attention to this issue. In 1999, the Institute of Medicine (IOM) of the National Academy of Sciences released a report, To Err Is Human: Building a Safer Health System.
The IOM called for a broad national initiative focused on several key actions: creating a Center for Patient Safety, expanding the reporting of adverse events, implementing safety programs within healthcare organizations, and increasing involvement from regulators, healthcare purchasers, and professional societies. The majority of media attention, however, focused on the statistics: from 44,000 to 98,000 preventable deaths annually due to medical errors in hospitals, with 7,000 preventable deaths related to medication errors alone. Within 2 weeks of the report's release, Congress began hearings, and President Clinton ordered a government-wide study of the feasibility of implementing the report's recommendations. Initial criticisms of the methodology in the IOM estimates focused on the statistical methods of amplifying low numbers of incidents in the pilot studies to the general population.
To this day, there are only a few comprehensive studies on medical errors. A bibliometric analysis in 2020 revealed a steady growth of publications in this area. In 2016, Michael Daniels and Martin A. Makary published a piece in The British Medical Journal that claimed medical error was the third leading cause of death in America at nearly half a million deaths per year. This number has since been debunked, citing flawed and improper methodology in the paper. More recent analysis using data from the 2016 Global Burden of Diseases, Injuries, and Risk Factors (GBD) study obtained an estimate of 123,603 deaths in the United States from 1990 to 2016 due to adverse effects of medical treatment (AEMT), with the mortality rate decreasing over time despite an overall increase in the number of deaths.
The experience has been similar in other countries.Commonwealth Fund International Survey: Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries (2005) In 1992, an Australian study revealed 18,000 annual deaths from medical errors. Professor Bill Runciman, one of the study's authors and president of the Australian Patient Safety Foundation since its inception in 1989, reported himself a victim of a medical dosing error.Australian Broadcasting Corporation, The World Today: Concerns over medication errors in Australian hospitals In June 2000, the Department of Health Expert Group estimated that over 850,000 incidents harm National Health Service hospital patients in the United Kingdom each year. On average, forty incidents a year contribute to patient deaths in each NHS institution. In 2004, the Canadian Adverse Events Study found that adverse events occurred in more than 7% of hospital admissions and estimated that 9,000 to 24,000 Canadians die annually after an avoidable medical error. These and other reports from New Zealand, Denmark and developing countriesWorld Alliance for Patient Safety: Editorial, December 2004 (retrieved on July 15, 2006) have led the World Health Organization to estimate that one in ten persons receiving health care will suffer preventable harm.World Health Organization: 10 facts on patient safety Accessed 2008-05-19
Psychological safety Psychological safety aims to provide an environment where patients and medical professionals feel comfortable sharing concerns and mistakes without fear of embarrassment or retribution. This enables increased reporting, as well as the sharing of new ideas and honest feedback. A wider variety of information is thus shared throughout the organization, allowing for creativity, innovation, and learning. Psychological safety is believed to lead to better outcomes by providing basis for more informed decisions.
Psychological safety has been found to play an important role in both patient safety culture and in enabling quality improvement in the health care setting.
Communication Communication involves distributing relevant information across operational sites to ensure alignment. It also reduces administrative burden by using model-driven instructions, freeing up operational staff and easing procedural demands. This enables consistent execution with minimal but essential feedback, ensuring processes remain both efficient and controlled.
Effective and ineffective communication
The use of effective communication among patients and healthcare professionals is associated with a patient's health outcome. However, scientific patient safety research by Annegret Hannawa et al. has shown that ineffective communication can lead to patient harm. Communication regarding patient safety can be classified into two categories: the prevention of adverse events and the response to adverse events. Effective communication may help to prevent adverse events, whereas ineffective communication may contribute to their occurrence. If ineffective communication contributes to an adverse event, improved communication skills may be applied in response to achieve optimal outcomes for the patient's safety. There are different modes in which healthcare professionals can work to optimize the safety of patients which include both verbal and nonverbal communication, as well as the effective use of communication technologies.
Methods of effective verbal and nonverbal communication include treating patients with respect and showing empathy, clearly communicating with patients in a way that best fits their needs, practicing active listening skills, demonstrating cultural sensitivity and awareness, and respecting the privacy and confidentiality rights of the patient. To use appropriate communication technology, healthcare professionals must choose which channel of communication is best suited to benefit the patient. Some channels are more likely to result in communication errors than others, such as communicating through telephone or email (missing nonverbal messages which are an important element of understanding the situation). It is also the responsibility of the provider to know the advantages and limitations of using electronic health records, as they do not convey all the information necessary to understand patient needs. If a health care professional is not practicing these skills, they are not being an effective communicator which may affect patient outcomes.
The goal of a healthcare professional is to aid a patient in achieving their optimal health outcome, which entails that the patient's safety is not at risk. The practice of effective communication plays a crucial role in promoting and protecting patient safety.
Teamwork and communication
During complex situations, health professionals must communicate clearly and effectively. There are several techniques, tools, and used to improve communication. Any team should have a clear purpose, and each member should be aware of their role and be involved accordingly. To increase the quality of communication between people involved, regular feedback should be provided. Strategies such as briefings allow the team to be set on their purpose and ensure that members not only share the goal but also the process they will follow to achieve it. Briefings reduce interruptions, prevent delays, and build stronger relationships, resulting in a strong patient safety environment.
Debriefing is another useful strategy. Healthcare providers meet to discuss a situation, record what they learned, and discuss how it might be better handled. Closed loop communication is another important technique used to ensure that the message that was sent is received and interpreted by the receiver. SBAR is a structured system designed to help team members communicate about the patient in the most convenient form possible. Communication between healthcare professionals not only helps achieve the best results for the patient but also prevents any unseen incidents.
Safety culture
As is the case in other industries, when a mistake or error is made, people look for someone to blame. This tendency creates a blame culture where who is more important than why or how. A just culture, also sometimes known as no blame or no fault, seeks to understand the root causes of an incident rather than just who was involved.