Getting better: Staying ahead of the curve on patient safety

In patient safety, we are witnesses to a disturbing paradox: Even as the field has developed and matured over its three decades of existence, adverse events persist. There has been no sign of an overall decrease in the number of these events. Harm due to health care continues to be alarmingly common. The clearest evidence is from the inpatient setting. In repeated studies of the frequency of patient harm in acute care hospitals worldwide, the needle appears to be stuck at around 10%. A few studies have found rates of harm to be even higher. A recent study found at least one adverse event in nearly a quarter of all admissions to hospitals randomly sampled in the US state of Massachusetts. There have been some advances in specific areas, most prominently in healthcare-acquired infections, led by reductions in catheter-related bloodstream infections. It has been possible to reduce deaths related to cardiac surgery, and general surgery using quality improvement strategies and the World Health Organization (WHO) safe surgery checklist. Although there have been others, they are more difficult to measure. During the pandemic, many of these gains have been wiped out, with increases in healthcare-acquired infections, falls, pressure injuries, and medication errors. There were also harms due to delays in diagnoses and provision of surgical care. But even without the pandemic-related problems, there are potential explanations for the apparent standstill in reductions in healthcare-related harm. Health care has become more complex, with many more individuals involved in delivering care, and more places for errors to slip through. There has been a profusion of new therapeutic modalities, each with its own benefits but also with new risks. Each new procedure also has its own learning curve, as demonstrated by the early surge in complications with the introduction of laparoscopic cholecystectomy. New medications, with increased potency, also carry new adverse effects. In addition, with changes in healthcare delivery, the average patient treated in the hospital is sicker than in the past. Noninvasive treatments allow sicker patients to be treated. Economic and other forces have resulted in shifts of many complex treatments from hospitals to ambulatory settings. In addition, the population is aging, resulting in a greater prevalence of patients living with multimorbidity, and subjected to polypharmacy. All these factors render inpatients less resilient and more vulnerable to adverse events. The COVID-19 pandemic has layered on additional risks to patient safety. The global shortage of health workers and the parallel pandemic of worker burnout further endanger patient safety. WHO projects a shortfall of 10 million health workers by 2030, mostly in lowand middle-income countries. However, even high-income countries face problems in the training, employment, performance, and retention of their workforce. The problem of health worker burnout had already reached crisis levels prior to the pandemic. Since then, it has predictably imposed an even heavier burden on workers which in turn further increases the risk of medical error. As if this is not enough, there is a growing realization that patient outcomes are the product of more than healthcare—they are influenced by multiple social, economic, environmental, and structural factors. Impoverished social networks, poverty, unstable housing, food insufficiency, environmental hazards, and structural racism can all lead to inequities in patient safety. For example, compared to white hospitalized patients, US Black patients had a higher risk of healthcare-acquired infection and surgical injuries. What can hospitals and healthcare organizations do? Jack Welch, former CEO of General Electric stated, “if the rate of change on the outside exceeds the rate of change on the inside, the end is near.” If an organization does not stay ahead of changes, they and their patients are likely to fall further behind. Improvements and initiatives are needed at multiple points within healthcare organizations. These include in measuring and monitoring adverse events, aiming for improvements where they are most needed, and implementing them into routine processes of care. More research is needed to identify interventions that are most effective and face the fewest barriers to adoption. Dedicated leadership and development of an organizational culture of safety are indispensable, as are universal health worker literacy in patient safety, and a cadre of specialists in safety and quality. In this issue of the Journal, papers deal with several of these essential points. Benevento and colleagues analyzed 5 years of experience from their hospital’s incident reporting system in Italy. They found that underreporting was the main limitation of their system and proposed ways to increase health workers’ reporting. Editorial