Refocusing on patient safety

Refocusing on patient safety 

  • Tejal Gandhi, chief safety and transformation officer at Press Ganey Associates, LLC
  • Ruth Ann Dorrill, office of Inspector General at the U.S. Department of Health and Human Services
  • Martin J. Hatlie, founding member of Patients for Patient Safety U.S.
  • Mary Chris Jaklevic, independent journalist, AHCJ core topic leader/patient safety (moderator)


By  Adrianna Rodriguez

More than 250,000 patients are harmed in U.S. hospital events despite more than a decade of research raising the alarm.

Tejal Gandhi, M.D., Chief Safety and Transformation Officer at Press Ganey Associates, said some progress has been made in patient safety, but more must be done to achieve the aspirational “zero harm” goal. One way to do this would be to broaden the definition of “harm” to include both patient and hospital providers' physical, mental, and emotional health. As hospital leaders work towards this goal, Gandhi said they should also be addressing inequities along the way because “we won’t address all the harms unless we address the inequities that are occurring.” 

“If you chase perfection, you can catch excellence,” she said. 

Ruth Ann Dorrill from the Office of Inspector General at the U.S. Department of Health and Human Services, showed journalists how adverse events in hospitals have changed little in the past 10 years. In October 2008 alone, HHS estimated about 267,000 patients were harmed in hospital adverse events; 44% were preventable, according to a study published in November 2010. Another HHS study 10 years later found more than 258,000 patients were harmed in October 2018; 46% were considered preventable. 

Most events were caused by medications followed by patient care and surgery. Nearly three-quarters of events led to prolonged care that resulted in a longer hospital stay, more care, transfer to another facility or subsequent hospital admission. 

The report also found only 5% of the events were captured by the Centers for Medicare & Medicaid Services. 

“Most of the time, there was no accountability for the harm that was occurring,” she said. “Our key takeaway here is that high rates of harm still persist.” 

Martin J. Hatlie, founding member of Patients for Patient Safety U.S., pushed back against the idea that progress has been made to reduce patient safety. 

“We’ve not embedded this as a priority in the health care system, and we're very, very frustrated with this,” he said. 

He said the federal government must take more of an active role in patient safety and create an agency that will manage oversight and enforcement, and ultimately demand accountability. 

Hatlie also highlighted transparency in public reporting, asserting that organizations should be sharing patient safety data. He also called on more patient and family engagement to create a sense of urgency. 

“There’s nothing like the lived experience of having someone harmed in a way that’s preventable,” he said. 

Adrianna Rodriguez is a health reporter for USA Today based in the Washington, D.C. area. 

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