It has been just over a decade since the Institute of Medicine (IOM) issued To Err Is Human, the landmark report that vividly documented the scope of patient safety problems within U.S. health care system. A series of Commonwealth Fund case studies released on the fifth anniversary of that report highlighted health care organizations that had taken promising steps toward creating an organizational culture of safety—one of the IOM's key recommendations.
In a follow-up to that earlier series, The Commonwealth Fund released today a new set of case studies exploring the progress made by four of these early leaders in patient safety:
Johns Hopkins Medicine, an academic medical center and nonprofit integrated health care system in Maryland that set a goal in 2002 of making its care the safest in the world.
Sentara Healthcare, an integrated system serving parts of Virginia and North Carolina that developed a systematic program to foster a culture of safety throughout its member hospitals.
OSF HealthCare, a system based in Illinois and Michigan that has promoted a collaborative approach to patient safety improvement.
U.S. Department of Veterans Affairs, which formed the National Center for Patient Safety to instill an organizational culture of safety within its nationwide network of hospitals and outpatient clinics.
Each of the cases describes the development of practical methods for training, coaching, and motivating staff to engage in patient safety work; the deployment of information systems, standardized clinical processes, and other tools to facilitate clear communication; and the systemwide adoption of safety as a chief priority.
"Keeping the commitment to patient safety has required a sustained focus on making safety a core organizational value," says Douglas McCarthy, the lead author of the series. "It demands a willingness to innovate and to apply learning about what works, and, perhaps above all, perseverance in staying the course."
