serious harm and death events by blocking patients and families from gaining access to medical records, not returning phone calls made to hospital leadership seeking answers to their questions, and in many cases flat‐out lying to patients and families in efforts to protect the hospital and physician from a medical malpractice lawsuit. This cover‐up legal strategy is known as “delay, deny, and defend.” When hospitals put up this legal defense, as described by Rosemary Gibson in her book Wall of Silence, the only recourse patients and families have is to seek legal counsel and fight to gain the truth. In many states, that legal battle can take years to resolve.
The preventable death numbers in the United States are staggering, yet receive little attention or interest from the public, the media, or our government officials. Despite all the passionate and caring people leading improvement efforts over the past 20‐plus years, progress to reduce preventable medical harm and deaths has been very slow.
The annual mortality numbers due to preventable medical harm have only gotten worse for both patients and health care workers due to the COVID‐19 pandemic. Even before the pandemic hit, being a health care worker was not a safe occupation. Health care workers suffered numerous work‐related injuries—things like needle stick injuries, lifting and back injuries, falls at work, and an alarming increase in the number of workplace violence injuries suffered while trying to care for patients. Injury and illness rates in hospitals are nearly double the rate for private industry as a whole and injury rates are also higher than the injury rates in construction and manufacturing—two industries traditionally thought to be relatively hazardous.
Since the start of the pandemic, concerns for health care worker safety and well‐being have only escalated. Thousands of healthcare workers—nurses, physicians, environmental services personnel, emergency medical personnel—have lost their lives due to COVID‐19. Many more became gravely infected from the virus, requiring hospitalization and intensive care admission. A majority of these deaths and hospitalizations were preventable if adequate protective equipment (gowns, gloves, masks), diagnostic tests, and training were in place at the start of the pandemic. In addition, the emotional toll and well‐being of our caregivers will impact the safety of our health care system for decades to come.
The Patient Safety Movement Foundation (PSMF) is a global nonprofit organization committed to zero preventable deaths by 2030. The PSMF offers free tools, seminars, and workshops to hospitals and care teams that can save lives. Its Actionable Patient Safety Solutions (APSS) provide evidence‐based processes that help hospitals eliminate preventable harm. Improving patient and health worker safety requires a collaborative effort from all stakeholders, including patients, health care workers, medical technology companies, government, employers, and private payers. Visit https://patientsafetymovement.org to learn more about the PSMF mission.
Urgency is vital. It is time for a patient and health worker safety “Moonshot” that achieves zero preventable deaths by the end of the 2020s. This “Moonshot” approach would involve:
1 Creating a National Patient and Health Worker Safety Authority similar to the National Transportation Safety Board in place for the aviation industry.
2 Incentives and reimbursements aligned with the quality and outcomes of care provided, not the quantity or volume of care provided.
3 Creating a culture of safety that embraces transparency so we can learn from, not hide from, our preventable harm events and near misses. A program like the AHRQ’s Communication and Optimal Resolution (CANDOR) tool kit is one example of an open and honest approach to preventable medical harm.
Source: Based on Makary, M.A., and Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, i2139.
Summary
Twenty years since publication of To Err Is Human provides a moment in history to review progress in patient care safety and quality. A historical review reveals many initiatives for how organizations, educators, practitioners and all workers, and consumers have invested in moving the needle on patient care quality and safety, although with mixed results. Many areas of progress are offset by many unrealized ambitions and recommendations. Controversy on the goal of zero harm illustrates the diverse viewpoints and strategies. Sifting through the multitude of organizations, professional and consumer groups, reports, analyses, and indicators shows myriad regulations, educational programs, and action plans nationally and internationally for leading change. Though slow, there is progress in the priority of safety culture among health care organizations, with increasing attention to care outside hospitals in communities and populations. The QSEN project remains a robust intervention deployed across all levels of nursing education and is more and more evident in practice. Nurses have growth responsibilities as they increasingly apply systems thinking to lead continuous QI that encourages inquiry to investigate outcomes and critical incidents from a system perspective. The determination of quality and safety champions is evident in the first national action plan, Safer Together, and the WHO Global Patient Safety Action Plan. In 20 years it will be interesting to look back to these days to see if we get it right going forward.
Acknowledgments
The author acknowledges the contributions of Professor Cheryl Jones, University of North Carolina at Chapel Hill, in developing the chapter.
References
1 Allen‐Duck, A., Robinson, J.C., and Stewart, M.W. (2017) Healthcare quality: A concept analysis. Nursing Forum, 52(4), 377–386. doi: 10.1111/nuf.12207.
2 American Organization for Nursing Leadership. (2021) AONL Nurse Leader Competencies. Retrieved June 18, 2021 from https://www.aonl.org/resources/nurse‐leader‐competencies
3 Armstrong, G. (2019) QSEN safety competency: The key ingredient is just culture. Journal of Continuing Education in Nursing, 50(10), 444–447. doi: 10.3928/00220124‐20190917.
4 Aspen, P., Walcott, J., Bootman, L., Cronenwett, L., and the Committee on Identifying and Preventing Medication Errors (Eds.). (2007) Identifying and preventing medication errors. Washington, DC: National Academies Press.
5 Bachynsky, N. (2020) Implications for policy: The Triple Aim, Quadruple Aim, and interprofessional collaboration. Nursing Forum, 55(1), 54–64. doi: 10.1111/nuf.12382.
6 Berwick, D.M., and Cassel, C.K. (2020) The NAM and the quality of health care: Inflecting a field. New England Journal of Medicine, 383(6), 505–508. doi: 10.1056/NEJMp2005126.
7 Bowles, J.R., Batcheller, J., Adams, J.M., et al. (2019) Nursing's leadership role in advancing professional practice/work environments as part of the Quadruple Aim. Nursing Administration Quarterly, 43(2), 157–163. doi: 10.1097/NAQ.0000000000000342.
8 Brandt, B., Lutfiyya, M.N., King, J., and Chioreso, C. (2014) A scoping review of interprofessional collaborative practice and education using the lens of the Triple Aim. Journal of Interprofessional Care, 28(5), 393–399. doi: 10.3109/13561820.2014.906391.
9 Breyer, J.Z., Giacomazzi, J., Kuhmmer, R., et al. (2019) Hospital quality indicators: A systematic review. International Journal of Health Care Quality Assurance, 32(2), 474–487.
10 Brooks Carthon, J.M., Hatfield, L., Plover, C., et al. (2019) Association of Nurse Engagement and Nurse Staffing on patient safety. Journal of Nursing Care Quality, 34(1), 40–46. doi: 10.1097/NCQ.0000000000000334.
11 Carenzo, L., Elli, D., Mainetti, M., et al. (2020) A dedicated multidisciplinary
