Resources and considerations to support the physician’s role in patient safety

Modern healthcare is delivered in a complex, multidisciplinary environment. When this care delivery is well coordinated, patients benefit from timely, accurate, and safe care.  When poorly coordinated, the same systems and processes of care delivery can result in significant patient harm and mortality.

In 1999, a landmark report was released from the IOM – To Err is Human:  Building a Safer Health System. This report highlighted the need to focus on patient safety by improving the systems and processes surrounding care delivery. Many elements of patient safety have improved since 1999, however the risks of harm from care delivery remains.

In December 2015, the National Patient Safety Foundation released an expert panel report – Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err is Human.  This report identifies eight key recommendations that create proactive steps towards total system safety for the entire continuum of care. These NPSF recommendations provide a convenient framework for providers looking to formalize their patient safety efforts and understandings.

Physicians can take several steps in their daily practice to keep their patients free from accidental or preventable medical injuries.  These steps include:

Developing a working knowledge of your organization’s existing patient safety efforts.

A few key questions to ask:

  • Who is primarily responsible for patient safety at my organization?
  • How can I support this role?
  • What are the available resources to address patient safety concerns?
  • How can I access these resources?

Reporting the events and clinical scenarios to your patient safety team that could have resulted in patient harm.
Providers have good understanding of the need to report events with patient harm to their risk management and patient safety resources. However, the underlying clinical scenario – not just whether or not a patient was harmed – should also be considered for reporting. For example, an inaccurately scheduled procedure could place a patient at risk for a wrong site surgery.  Even if the wrong site procedure was prevented, this clinical scenario should be reported to prevent future patient harm due to the underlying care coordination processes.

By utilizing the resources identified here, physicians can support safer care for all patients.

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