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Viewpoint published in JAMA by C-QuIPS Director, Kaveh Shojania, along with Drs Tejal Gandhi and Donald Berwick

This Viewpoint published in JAMA by C-QuIPS Director, Kaveh Shojania, along with Drs Tejal Gandhi (President of the US National Patient Safety Foundation) and Donald Berwick (Founding CEO of the Institute for Healthcare Improvement) summarizes the views of an international group of experts convened last year to review the progress in the field of patient safety and develop recommendations for moving forward.

The JAMA viewpoint outlines the 8 recommendations developed and presented in greater detail in the full NPSF report. In the 15 years since the landmark “To Err Is Human: Building a Safer Health System” report and new research that finds medical errors are the nation’s third-leading cause of death, patient safety stands at a crossroads, according to a commentary published in JAMA.

The 8 recommendations necessary to achieve total systems safety include: ensuring that leaders establish and maintain a safety culture, partnering with patients, supporting the healthcare workforce, and ensuring that healthcare information technology is optimized to improve patient safety, among others.

The authors argue hospitals’ boards, leaders, regulators and managers must all possess foundational education in patient safety science, with the education based on evidence-based best practices. Rather than simply discussing patient safety, leaders must zero in on specific strategies they can apply across the healthcare system.

The process of creating a safety culture must also involve practical day-to-day strategies, from formal agreements about roles and responsibilities to safety huddles to the use of patient stories in board meetings.

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