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Three Patient Safety Advancements Shaping Our Time


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By Suzanne Gavigan MSN, CRNP, Acting Director, Office of Quality and Patient Safety 

Last year, The Joint Commission observed its 70th anniversary of working to improve patient safety.

Though I haven’t worked in healthcare nearly that long, it’s interesting to reflect on the changes in our industry over the years. For instance, it seems incomprehensible that hospitals ever allowed smoking inside their walls, yet this was a regular occurrence during many our lifetimes. (Just an FYI, The Joint Commission banned smoking in hospitals in 1962.)

My career in nursing started in the late 1980s, which seems like only yesterday but has been a lifetime in the realm of patient safety. With so much change in the world and our industry, it’s interesting to look back and reflect on how far we have come. Like many of you, I’ve been privy to a number of interesting conversations lately about our profession and wanted to focus on the patient safety advances that have already shaped our times.

High Reliability
In 2007, the concept of high reliability in healthcare was in its infancy. Many of us were familiar with the theory of an organizational culture striving for error-free performance every time, but it was a novel idea to make it part of healthcare delivery. It seemed like a daunting task to use ideas from other industries around healthcare delivery. “Our systems are unique, we can’t be cookie cutter” was a common refrain I heard as I tried to implement a Perinatal High Reliability Unit across a large system in the mid-aughts. 

Fast forward a decade or so, and high reliability is a concept that’s familiar to every healthcare worker. There was a time when it seemed incomprehensible for healthcare to ever be as safe as, say, a commercial airplane or a roller coaster ride. Now most major healthcare organizations are training their employees that there really is no acceptable level of harm and that we must be proactive, not reactive, in eliminating error.

There’s been an increased focused on cybersecurity in recent years and rightfully so. It becomes a matter of life or death when connected pumps are compromised. Infusion pumps provide critical point-of-care medication and are connected to the electronic medical record. Hackers who illegally access patient information can change medication doses and interfere with the pump’s ability to deliver life-saving medication.

We’ve been warned of the possibility that a cyberattack could cause fatalities for years. Still, I reacted with horror when reports of the first confirmed patient death linked to a cyberattack in Germany occurred after a hospital had to halt care during a ransom attack. It’s incredibly frightening but I am also highly impressed with the sophistication that our security experts have displayed in anticipating the next move of cyber attackers and keeping systems functioning. Some tactics are outlined in The Joint Commission’s Quick Safety, Issue 62: Building a Culture of Cybersecurity. We’ve made enormous advancements in cybersecurity over the last few years and it’s made for a fascinating time to work in healthcare.

Diversity and Inclusion
The third change that I expect to pick up steam in the very near future is the intersection of patient safety with diversity and inclusion. Diversity and inclusion efforts at healthcare organizations became more widespread after George Floyd’s death in 2020 but many have struggled with marrying these two concepts. 
I’m pleased that The Joint Commission has consistently made diversity and inclusion a priority over the last two years, as described in this podcast with our Executive Vice President and Chief Medical Officer, Chief Diversity, Equity and Inclusion Officer Ana Pujols McKee, MD. In addition to our internal efforts, our organization has published a:

We still have a long way to go but I think there’s a realization that safe patient care cannot exist in environments that don’t embrace diversity and inclusion. I expect much more conversation and action on this concept in the future.

Our industry is always changing and it’s been an amazing journey to keep evolving in the spirit of patient safety!

Suzanne Gavigan, MSN, CRNP is Acting Director, Office of Quality and Patient Safety.