Patient Safety Story: The Next Chapter



Today we wake up to a new day and the next chapter in our history. Collectively we may be experiencing joy, anger, fear, frustration, or even indifference. ​The last year has shaken our faith in "the system" to its core​. With our health on the brink of collapse—400,000 of our fellow Americans dead, our healthcare systems taxed to their limits, a showdown of science vs. politics, violence in our streets, and distraction caused by one of the most tumultuous elections in our history—we’ve  all had enough. 

Crisis diverts our attention from the ongoing foundational fractures in our society.​

​There will come a day in the very near future when crisis wil​l subside, and our nation will need to bring a renewed focus to the long-standing issues that plagued us well before COVID-19. 

Our healthcare system is one of those items. And while working from both sides of the aisle might sound cliché, without unity, we will continue to fail. We need to shift the focus from "whomever-care" to a "people's care" approach. In the words of President Harry S. Truman, 

"It is amazing what you can accomplish if you do not care who gets the credit."

Of course, the aspect of healthcare that interests me most is patient safety. I am hopeful that the next chapter brings radical chage to how we approach patient safety as a nation.

Free from harm: 400,000 of our fellow Americans died from COVID-19 in the last year. Some studies suggest that the same number of people-400,000-die from healthcare-associated harm every single year in this country

The Patient Safety Authority (PSA) was formed to collect data on patient safety events and to share the information we learn to reduce harm. We partner with healthcare facilites, researchers, improvement organizations, and patients to improve patient safety in the Commonwealth of Pennsylvania. We are not the only one. There are dozens of organizations across the country working on the common problem, each with our own strengths and weaknesses.​​

While the work feels fast and furious, the progress has been slow and steady​.

We cannot afford to continue accepting slow and steady progress. We need to enact policies that will catalyze rapid improvement. Where do we start?​

​We start by making patient safety a national priority​​.

Our national approach to patient safety is a fragmented one at best. And while many organizations are working on patient safety, critical gaps exist. 

  • Coordination of approach​ A coordinated approach among existing federal,​ state, and private organizations is largely nonexistent. Coordinating efforts would reduce duplication, identify unmet needs, prioritize and divide work, and enhance transparency. 
  • The National Action Plan to Advance Patient Safety​​​​ places an emphasis on expediting cooperation and collaboration across the industry to accelerate the pace of improvement— essentially creating a national network of learning systems. Additionally, the plan describes the importance of culture, leadership, and governance; workforce safety; and patient and family engagement in improving safety across the board.

  • ​​External investigation of safety events –​  No organization, regulatory or otherwise, investigates safety events at the root cause level in healthcare organizations.  We are dependent on individual facilities conducting their own investigations and choosing to share, or not to share, lessons learned. 
  • Creating an approach like that of the National Transportation Safety Board (NTSB) in aviation would eliminate this gap. Its purpose is to independently investigate accidents. It then issues recommendations based on its findings and disseminates inormation to prevent future errors. 

    I had an opportunity to brainstorm the creation of a National Patient Safety Authority with thought leaders Dr. Karen Feinstein, president and CEO of the Jewish Healthcare Foundation, and John James, founder of Patient Safety America, for Altarum's Healthcare Value Hub. The need for a centralized approach is apparent, and this discussion​ addresses some of the practical considerations.

  • ​​Patient safety immersion at the ground level –  Most patient safety edcation takes place as healthcare workers move through their careers. Foundational concepts like high reliability, human factors, patient engagement, and teamwork are not taught consistently in medical, nursing, and other health profession programs. 
  • Patient safety curriculum should be required for the accreditation of all health profession programs. Continuing patient safety education should be required for all licensed healthcare professionals. The Patient Safety Movement Foundation developed a free patient safety curriculum for all healthcare professionals, which is available on their website​.

  • ​​Health disparities and patient safety – Words and phrases like disparity, inequity, and social determinants of health need to enter the mainstream lingo of patient safety. Research is proving what many already knew: race, ethnicity, gender, sexual orientation, socioeconomic status, and other factors are associated with health disparities. We know that Black women are more likely to die during or after childbirth than white women. We know that Native Americans are more likely that whites to die of heart disease, contract tuberculosis, commit suicide, have type 2 diabetes, and die as a newborn. We know that LGBT youth are more likely to be depressed and more likely to commit suicide than their non-LGBT peers.
  • What we don't know is how disparities intersect with traditional patient safety concerns like misdiagnosis, medication errors, complications of care, errors related to procedures, etc. The first step to understanding is collecting the appropriate information. The PSA, as part of its new strategic plan, will begin to incorporate this type of information into its data collection and analysis. I encourage others to do the same.​

​The next few months will continue to be trying times. But this too shall pass and when it does, we will need to refocus and reprioritize.​

​No matter our differences coming into today—we must have hope, we must have collaboration, and we must have action. ​

About this blog

Regina Hoffman serves as the  executive director of Pennsylvania’s Patient Safety Authority and editor-in-chief of Patient Safety, its award-winning journal.  Ms. Hoffman was recognized by Becker’s Hospital Review as one of the top 50 experts leading patient safety in both 2018 and 2020. This blog serves as a source for her to share her insights in patient safety and leadership with Pennsylvania’s healthcare leaders.



1. National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division; Board on Population Health and Public Health Practice; Committee on Community-Based Solutions to Promote Health Equity in the United States; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11.2, The State of Health Disparities in the United States. Available from : https://www.ncbi.nlm.nih.gov/books/NBK425844/​​

***​ The views and opinions expressed at or through this blog are the opinions of the author alone and may not reflect the opinions or positions of the Patient Safety Authority or the Commonwealth of Pennsylvania, nor do these views represent in any way medical or legal advice. ​ 

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