While there is still room for improvement, let’s take a moment to reflect on progress that has been made.

When I entered nursing school 30 years ago, we had to decipher handwriting for orders, medication doses, and treatment times. Advancements like patient portals never entered our consciousness and delivering care on a smartphone—during a pandemic—would have only seemed plausible on The Jetsons. Even as recent as 15 years ago, some of us were still walking carbon copies of physician orders to the pharmacy several times a shift.

We weren’t using checklists or striving for something called “high reliability.”
Culture was something you worked on in the lab.

So, take a moment to reflect and celebrate; it’s important to remember how far we’ve come. But we must keep pressing forward, because while we celebrate the wins, another patient may be harmed.

We need to bring a laser focus to patient safety—not just for a week, but in every moment, of every day, for every patient.

Safety is supposed to be inherent in every action, every process, every decision, clinical or otherwise. If every person from caregiver to shareholder took that approach, we wouldn’t need to differentiate patient safety, it would just be how we operate.

It’s for this reason that some patient safety reward programs give me pause. I know it may sound strange, but many of those programs are well intended but often fall short of their goal to effect measurable, lasting change.

Take good catch programs. Ask yourself why your facility implemented one. Yes, it’s to encourage event reporting and to honor an employee for a job well done, and hopefully to inspire others, but the foundational reason is to prevent recurrence of whatever was “caught” in case you may not be so lucky next time.

Despite this goal, similar stories continue to emerge again and again: almost administering an incorrect medication, preventing a fall from an environmental hazard, or reminding a colleague to wash their hands. The details change, but the crux of the stories persist. How can we change this? Some ideas to consider:

1. Treat good catches like serious events. Have a multidisciplinary team select a sample of incidents and review what happened and why the event was caught. Compare the good catches to similar serious events to see why one incident reached the patient and another did not. If the only explanation seems to be “luck”—for whatever reason, a caregiver caught one would-be error and not another—what systemic changes can be enacted to prevent future “misfortune”?
2. Recognize the differences between quantity and quality. Healthcare workers in Pennsylvania are required to report all near misses, but you should be selective with the cases you celebrate. Yes, recognizing the hard work, dedication, and sacrifice of staff, especially now, is important. But when you’re analyzing monthly submissions for promotion with your staff, select the exceptional stories instead of ones that overlap with someone’s job description. Consistently recognizing excellence, helps set the expectation that safety is part of everything we do.
3. Treat your good catch program like any other improvement initiative. Select measures to analyze its effectiveness. Are reports of near misses increasing over time? Are events of harm decreasing? Are your safety culture indicators moving in a positive direction? Assessing for impact is critical to identify potential opportunities for improvement and to focus your efforts where they matter most.

It’s time for fundamental changes in the way we plan for, orchestrate, and deliver patient care. It’s time for more people to start asking why we need a week each year to bring attention to this issue.

If we all start asking those questions and demanding change, we might come closer to reaching a point where Patient Safety Awareness Week becomes obsolete. And that will be something to celebrate.