People, not processes, are the biggest patient safety issue

The term “patient safety error” often conjures up images of mixed up IV bags, unattended elderly patients falling out of bed, or retractors left inside the body after an overworked surgical team loses track of their instruments. While these events certainly happen with worrying frequency, they are only the tip of the iceberg when it comes to adverse events that can leave patients with temporary or lasting harm. 

In the post-pandemic era, however, there are broader workforce factors seeping into the care environment that are leading to avoidable harm, and these challenges are having an impact on care long before clinicians ever reach the bedside. 

ECRI, a non-profit which releases a yearly report on the top patient safety issues affecting the industry, is ringing the alarm bells on some of these systemic stress points, many of which stem from the challenges of developing and maintaining a staff that has the skills, confidence, and support required to keep patients free from harm. 

It’s not exactly news that healthcare has a workforce problem. Provider shortages have been building for decades, while burnout has been a top search term for nearly as long. And while the pandemic’s Great Resignation might be on the wane, its impacts are likely going to felt for years to come as those who stuck it out through the pandemic, and those who are joining the workforce after the most disruptive event in recent memory, adjust to the new normal a leaner, more stressful work environment. 

Two out of ECRI’s top 10 patient safety issues this year are directly related to workforce issues, with the first item on the list calling out the challenges of transitioning from education into practice in the absence of sufficient training and ongoing mentorship. 

During the pandemic, clinical students lost out on hands-on learning opportunities as teaching facilities locked down for infection control, leaving them less prepared than previous cohorts for the realities of direct patient care. 

Lack of confidence in their clinical skills can even lead to reduced reporting of patient safety events. According to a 2022 AHRQ survey, only 33% of clinicians with less than a year of experience voluntarily reported one or more safety events compared to 50% of clinicians with 6 to 10 years of experience. 

ECRI speculates that this could be “a sign that new clinicians lack a sense of agency around safety event reporting.” Newer staff may not be aware of what issues are reportable, and the leeching of experienced talent from the system due to burnout may make it more difficult for rookies to learn about what to do – or feel adequately supported by their peers when they want to raise an issue with supervisors. 

Both new and experienced clinicians are still experiencing burnout at unsustainable levels, with 57% experiencing anxiety symptoms and 34% experiencing depression symptoms in 2022, ECRI says. Economic uncertainty and sky-high expectations, coupled with increasing violence and harassment in the workplace, are making it more difficult for staff to stay in their positions and operate to the best of their abilities. 

The result is instability across all levels of the organization, which can quickly erode organizational culture and lead to decreased emphasis on non-punitive patient safety reporting and less capacity to provide additional training after an event to avoid future errors. This can easily spark a negative feedback cycle that puts patients at risk. 

The solution lies in prioritizing mentorship and peer-to-peer support for both new and experienced clinicians.   

Those transitioning into the workforce will need additional opportunities for preceptorship, ECRI suggests, which should align with diversity, equity, and inclusion (DEI) efforts to help all individuals build strong and meaningful relationships across the organization.   

To expand capacity and give clinicians a broader perspective on care, leaders should consider establishing creative partnerships with other organizations, including academic medical centers, specialty offices, or community health centers that can provide unique learning environments.   

Live training programs can also be enhanced with simulations to give clinicians additional insight into critical care situations without risk to living patients. Simulations are also helpful for training staff on new technologies, including AI-driven risk scores, alerts, and clinical decision support, to boost their knowledge and confidence as these tools start to enter the care setting. 

In conjunction with more robust training, staff members need to be reassured that their leaders are on their side when they experience significant stress or make minor mistakes. Leaders should actively work to develop an environment that prioritizes physical and psychological safety, and should model vulnerability, empathy, and compassion when discussing burnout with staff members. 

Targeted initiatives such as visitor/patient violence de-escalation teams, patient and family engagement committees, and peer support programs that provide “psychological first aid” after a traumatic event can also contribute to a healthy workplace that takes a preventive stance on burnout. 

All of these activities can assist with building a culture of patient safety and wellbeing that enables staff to adhere to safety procedures, report issues in a timely manner, and learn from errors to avoid future adverse events. 

By viewing patient safety through this “people-first” lens, healthcare leaders can start to prevent errors upstream instead of simply reacting to them after they occur. This can lead to better results for patients as well as a more engaged and empowered workforce that feels prepared to take on new challenges in the post-pandemic world.  

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.