The Collaborative for Accountability and Improvement. May 19, 2022. 2:00 PM (eastern).
Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.
Rockville, MD; Agency for Healthcare Research and Quality: April 2022.
Kelman B. Kaiser Health News. April 29, 2022.
Human-centered design is a problem-solving approach that focuses on developing and optimizing the efficiency, effectiveness, and usability of products and interactive systems, thereby increasing their safety. This approach prevents patient safety incidents by considering human capabilities, skills, limitations, and needs. Solutions are developed by involving end-user perspectives throughout the process.
Broadly, harm refers to the impairment of the anatomy or physiology of the body and physical, social, or psychological issues arising from the impairment such as disease, disability, or death. In the context of patient safety, the term “adverse event” is used to describe harm to patients that is caused by medical care, as opposed to harm caused by underlying disease or disability. Adverse events can be preventable, ameliorable, or the result of negligence.
Patient and caregiver engagement is centered on providers, patients, and caregivers working together to improve health. A patient’s greater engagement in healthcare contributes to improved health outcomes. Patients want to be engaged in their healthcare decision-making process, and those who are engaged as decision-makers in their own care tend to be healthier and experience better outcomes. Efforts to engage patients and caregivers in safety efforts have focused on three areas: enlisting patients and caregivers in detecting adverse events, empowering patients and caregivers to ensure safe care, and emphasizing patient and caregiver involvement as a means of improving the culture of safety.
Deprescribing is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use. Deprescribing is one intervention that can be applied to reduce the risk for adverse drug events (ADEs) or medication errors associated with polypharmacy.
Debriefing is a brief, planned, and non-threatening conversation that is conducted to review a procedure or event. The goal is to get individuals involved together right after the procedure or event to discuss what went well and to identify areas for improvement. A debrief can help obtain new information after patient safety events such as near misses, adverse events, or medical errors.
Cultural competence includes individual attitudes and behaviors and refers to one’s capacity to appreciate, respect, and interact with members of a different social or cultural group. In healthcare, it includes the ability to provide culturally sensitive care to individuals. To provide person-centered, high quality, and safe care, health care professionals must be prepared to tailor care to prevent adverse events or harm to individual patients from different groups (e.g., race, ethnicity, gender, language, religion, social status). Research has shown that health literacy, English proficiency, lack of trust, and other cultural issues can lead to adverse events, particularly medication errors. Other terms that have been associated with cultural competence include cultural intelligence (knowledge about various cultures and their social context) and cultural humility, both of which assume an approach to care where the provider is sensitive to the cultural context of patients and avoids making assumptions about the patient’s beliefs and environment.
Crisis management is the process by which a team or organization deals with a major event that threatens to harm the organization, its stakeholders, or the general public. Examples of events that may require crisis management include significant adverse events (death of a patient due to a medical error) or a significant environmental event such as a fire. The COVID-19 pandemic is also an example – a public health emergency requiring crisis management early in the event.
Compassion fatigue refers to the physical and mental exhaustion and emotional withdrawal experienced by individuals who care for sick or traumatized people over an extended period. Compassion fatigue can decrease effective teamwork behaviors and increase secondary stress, burnout, depression, or anxiety as well as escalating the use of negative coping behaviors – all of which may have a negative impact on patient safety, as these healthcare workers may commit more errors.
Related term: Burnout
Communication (disclosure) and resolution programs (CRPs) emphasize early admission of adverse events and proactive approaches to resolving patient safety issues. CRPs offer patients empathetic treatment and care after adverse events, even when no harm occurs. These programs focus on transparency, recognizing accountability, acting in a fair, just manner; the use and sustainability of practices to enhance patient safety; and changing disclosure communications to be truly transparent. The CANDOR toolkit, developed by AHRQ, provides organizations with tools necessary to implement a CRP. Whereas the historical approach in response to unexpected harm often followed a "deny-and-defend" strategy (e.g., providing limited information to patients and families, avoiding admission of fault), the CANDOR toolkit uses a person-centered approach and promotes greater transparency and early sharing of errors with patients and families.
Related term: Transparency