Improving Hospital Patient Safety: Six Basic Principles to Guide Our Pursuit

By Vincent Barba, MD, FACP, FHM, CPPS

“The very first requirement in a hospital is that it should do the sick no harm.”

—Florence Nightingale (1860)

Healthcare is, for the most part, a reality of modern existence. Most Americans encounter the healthcare system in their first seconds of life, as they emerge into the world at one of our birthing hospital units. For many, their last seconds are also spent as a patient in a hospital. Nationally, healthcare appears to be delivered at a 2%–4% error rate, with over 18 million adverse events occurring per year (Brennan et al., 1991; Classen et al., 2011). Yet despite two decades of intensive quality improvement work at hospitals, little has changed for the better (Chassin, 2013). How can we improve patient safety?

Current estimates place the patient safety death toll at approximately 250,000 people annually in the United States, with a total patient harm cost of more than $17 billion; this makes medical error the third leading cause of death (Makary & Daniel, 2016; Van Den Bos et al., 2011). Wrong-site, wrong-patient, and wrong-procedure surgeries are still commonly reported sentinel events to The Joint Commission every year, as are unintended retention of foreign objects after surgery, patient suicides, and patient falls (The Joint Commission, 2019a). Hospitals continue to have serious infection control problems as noted by Joint Commission survey data—in the most recent 21-month reporting period, The Joint Commission found over 4,000 infection control issues while performing 1,006 hospital accreditation surveys (The Joint Commission, 2018). These findings include failure to properly sterilize surgical instruments, failure to keep the hospital clean, and failure to properly store medical supplies. Life safety issues are also high on the accreditor’s list of findings; The Joint Commission reported that 0.7% of its hospital findings represented an immediate threat to health or safety, while 8.3% of its findings had a high likelihood to harm a patient, staff member, or hospital visitor (The Joint Commission, 2018).

Little has changed over time: For instance, there were 90 wrong-patient, wrong-site, or wrong-procedure events reported by American hospitals to The Joint Commission in 2005, and 98 reported in 2018, with a peak of 152 events reported in 2011 (The Joint Commission, 2019a). In another study focusing on harm events in North Carolina, the authors found that they remained common over the five years studied, with little improvement (Landrigan et al., 2010).

As we continue in our journey to protecting patients from harm, we should concentrate on six basic principles:

  1. We’re only human
  2. Leadership paves the road to high reliability
  3. Quality improvement is a part of everyone’s workday
  4. Planning is everything
  5. It’s what you know that matters
  6. One size does not fit all

1. We’re only human

Humans make mistakes. No human can be expected to perform perfectly 24/7. Unfortunately, that is what we seem to expect of our physicians and nurses, and with this in mind we have constructed a system of training and punishment under the myth of perfect medical performance. Being a myth, this goal is not attainable, yet we perpetuate it day after day. In so doing, we fail to properly examine the systems issues that fail to protect patients from the harm caused by human error. To meaningfully improve the quality of care, a paradigm shift must occur in these examinations. We must not think about individual failures and how the clinician failed the patient, but how the system failed the clinician and the team in properly caring for the patient.

The fact that healthcare appears to perform at only 96%–98% reliability seems to be at the core of the patient safety problem. Some processes in hospitals, such as hand hygiene, perform well only 50%–60% of the time. Attempting to eliminate patient safety harm events by adopting best practices has not led to success. Hospitals need to drive their reliability to 99.99%. The journey to high reliability is of paramount importance if healthcare is to improve (Chassin, 2013).

High reliability is attained by developing a state of mindfulness throughout the organization. That means every staff member, including medical staff, should be sensitive to operations, obsessed with failure, and resilient; they should avoid oversimplifying complex problems and defer to expertise over hierarchy (Weick & Sutcliffe, 2007).

2. Leadership paves the road to high reliability

By ensuring all management and staff members understand the importance of—and routinely report—close calls and harm events, leaders can discover and define problems. Healthcare executives, physicians, and nurses must be obsessed with delivering high-quality, safe care every day to every patient. This includes holding management and staff accountable not only for proper processes of care, but also for how patients perceive the quality of care.

3. Quality improvement is a part of everyone’s workday

All processes of care should have quality improvement built into them. This must include reporting close calls and harm events consistently for all patients. The system must respond and investigate these issues using reliable tools such as root cause analysis, failure mode and effects analysis, and prospective planning.

4. Planning is everything

As General Dwight D. Eisenhower once said, “Plans are nothing. Planning is everything.” Being obsessed with failure means that steps have been taken to plan for it. Employees of high-reliability organizations are encouraged to speak up and take part in improvement programs that affect their duties. Frontline nurses should be encouraged to participate in quality improvement teams for their own units as well as the hospital in general. Healthcare failure modes and effects analyses ought to be conducted on new systems to look for possible failure points before those systems go live. It is not adequate to bring in new care systems and then have an in-service for the people who will use them. Proactive planning should take place, with anticipation of failure and plans for recovery.

5. It’s what you know that matters

Hospitals are rife with hierarchical systems that preclude staff from speaking up and making their concerns known. High reliability, when it comes to systems development and quality improvement activities, requires deference to expertise over rank: what people know about a subject, not what their titles are. The best outcomes are realized by teams working in concert and not distracted by a disruptive hierarchy (Weick & Sutcliffe, 2007).

6. One size does not fit all

Given healthcare’s complexity, we must resist the allure of “one size fits all” solution sets and be concerned with correctly evaluating our systems head on. For instance, the one-size-fits-all Universal Protocol™ to prevent wrong-site/wrong-patient surgery has done little to achieve its goal over the past several years (The Joint Commission, 2019a). The solution did not delve into the issues that really hurt patients and therefore failed (Chassin, 2013). Some processes cannot be oversimplified; they must be taught in detail so staff can thoroughly understand the implications of what they are being asked to do.


Patient safety is the first domain of quality healthcare, but making healthcare safer has been a slow process. Many people are still harmed due to broken processes and leadership failures. The healthcare industry must strive for exceptionally safe, high-quality care delivered reliably and satisfactorily to every patient. These six principles ought to be foundational in our pursuit of eliminating preventable harm from hospital care.

Vincent Barba is clinical associate professor of medicine for the Rutgers New Jersey Medical School at Rutgers University in Newark. He is also vice president of patient care and safety, and chief medical officer and safety officer, at Matheny Hospital in Peapack, New Jersey.


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