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Building Capacity for Patient Safety

Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS, Sarah E. Mossburg, RN, PhD | July 31, 2023 
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In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steering Committee for Patient Safety (NSC), an interdisciplinary group focused on achieving safer care and reducing harm, developed recommendations on creating and coordinating a total systems approach to safety. This approach is built on anticipating risks, creating system-wide safety processes, and applying learnings across the entire healthcare continuum. One foundational area of this plan focuses on networked and continuous learning as key components of providing safer care. Education and patient safety are intrinsically linked. Many studies have shown the effectiveness of patient safety education. Healthcare organizations must build the capacity for the workforce and organizations for patient safety to continue learning and adapting to new best practices and evidence-based practices for approaching patient safety.

The Patient Safety Learning System

In a learning system, organizations use patient data, experience, and evidence-based practices to improve healthcare delivery and ultimately patient and population outcomes. Learning across organizations that encourage sharing, learning, and improvement is a foundation for the action plan that supports building a culture of safety and creating lasting improvements. The NSC recommends considering both intraorganizational and interorganizational learning in the development of a learning system. Effective collaborative learning organizations use high-reliability principles, develop feedback loops, and share findings and lessons learned with other learning systems.

Many organizations have pathways for learning within their organizations by sharing best practices and safety events with other units or across a hospital but do not share findings outside of their own organizations. Federal programs, like AHRQ’s Patient Safety Organizations (PSOs), make it possible for sharing and reporting data to help improve patient safety. On a state level, organizations like the Pennsylvania Patient Safety Authority use state-mandated reported data to inform facilities of findings and advise them on how to improve.

Patient Safety Education and Training

In addition to developing shared learning practices, the National Action Plan emphasizes collaboration to improve safety education and training not just for clinical staff, but for administrative staff as well. Learning networks can be leveraged to improve education and training that is provided at the systems level. Training on approaches to patient safety has increased over the years. Many organizations have recognized the need for patient safety education. Prior to entering the healthcare workforce, many students receive patient safety training, which has become a component of formal education in medical, nursing, and other clinical education settings. Schools have developed required courses and hours of training for clinicians to understand systems thinking and processes in anticipation of entering the healthcare workforce.1

Beyond formal education and professional training, patient safety education encompasses a variety of approaches and strategies aimed at promoting safe healthcare practices and reducing adverse events within healthcare organizations. Continuous learning and professional development opportunities, such as workshops, conferences, and online courses, help healthcare providers stay updated with the latest evidence-based practices and advancements in patient safety. Education can focus on promoting a culture of safety, implementing error-prevention strategies, recognizing the contributions of intersecting systems to patient care events, and fostering effective communication and teamwork. Trainings like TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) can foster mutual respect, understanding, and communication and coordination to improve patient safety. Simulation-based training allows healthcare workers to practice skills and decision-making in realistic scenarios without directly jeopardizing patient safety. Simulations replicating care in various healthcare settings can train staff to identify potential errors and improve prevention and response strategies before the errors occur in the real world. When paired with debriefing, simulation training can help support healthcare workers learn from patient care events. Debriefing skills learned in simulation can also be applied to actual patient care. Debriefing following an event, whether done immediately (hot debrief) or days to weeks following an event (cold debrief) can be a powerful tool that enhances education and performance.2

Challenges and Ideas for Developing Learning Systems and Building Capacity

While educational standards and learning systems are well-recognized essential needs in building capacity for patient safety, the shift toward learning systems can be challenging. One major challenge is the availability and quality of data. Incident reporting is a key component of understanding how patient safety is working within an organization. Analyzing reports contributes to both improved reporting practices and an increased understanding of how to create safer care. Taking it one step further, organizations can consider creating systems to report and analyze successes, beyond superficial praise, to bolster reporting and generate deeper insights for creating safer care. The challenges in reporting are well known, including fear of retaliation or punishment. A culture of blame can hinder reporting and prevent any improvements that can be made from shared learning. To address this challenge, organizations can work to build and reinforce a culture of safety focused on addressing systems and processes. Healthcare organizations can improve reporting by focusing reports on patient harms rather than requiring that a staff error be identified. Creating spaces of open and transparent dialogue, such as the Comprehensive Unit-based Safety Program (CUSP) or Schwartz Rounds, can improve healthcare workers’ openness to reporting and sharing lessons learned. This willingness to report can be further improved by creating feedback loops that can highlight how reporting has led to improvements.

Competencies for patient safety are a key component of patient safety education and provide a foundational set of knowledge in patient safety. Limited funding and resources can hinder the development and implementation of comprehensive patient safety education programs. Training materials, simulation equipment, and expert faculty require financial investment, which may not be readily available in healthcare settings. In addition, time constraints can compound the lack of education, as healthcare workers often face heavy workloads and demanding schedules. Leveraging existing training and emphasizing the importance of ongoing training across the different clinical settings and amongst interdisciplinary staff is key.3

Another challenge that organizations may face when sharing lessons learned is the concern for potential litigation and liability. The fear of disciplinary action and potential malpractice litigation and liability can hinder reporting efforts by individuals. On an organizational level, similar fears of litigation can result in a lack of sharing and openness across organizations. While national datasets such as the AHRQ Patient Safety Indicators are helpful in benchmarking performance against other organizations, there are missed lessons when organizations cannot share qualitative information on what occurred to lead up to a systems failure. To address this challenge, organizations should understand their legal ability to protect information from disclosure in order to encourage open discussions and sharing of information without fear of legal repercussions. Organizations should consider all protections afforded by both state and federal statutes that promote learning and optimize patient safety.

Looking Forward

The successful implementation of learning systems for patient safety will require ongoing collaboration among stakeholders, including healthcare providers, patients, researchers, administrative leaders, and policymakers. Addressing the challenges in reporting and sharing will help facilitate the shift toward developing learning systems to enhance organizational capacity for patient safety. By using recommendations outlined the National Action Plan and working collaboratively within and across organizations, organizations have the opportunity to improve patient safety across the entire healthcare setting.

  1. Wu AW, Busch IM. Patient safety: a new basic science for professional education. GMS J Med Educ. 2019;36(2):Doc21.
  2. Abulebda K, Auerbach M, Limaiem F. Debriefing Techniques Utilized in Medical Simulation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 26, 2022.
  3. Kiersma ME, Plake KS, Darbishire PL. Patient safety instruction in US health professions education. Am J Pharm Educ. 2011;75(8):162.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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