This post is part of our two-week series commemorating the 10-year anniversary of the seminal IOM Report "To Err Is Human." To see all posts in the series, please click here.
As President and CEO of the National Quality Forum, Dr. Janet Corrigan sits on the frontline of the patient safety movement. In addition to her leadership of the non-profit standards-setting organization, she served as Senior Board Director at the Institute of Medicine when the seminal report on medical errors and patient safety -- “To Err is Human” -- was released. We caught up with her to talk about what needs to happen to improve patient safety, and nurses’ role in making that happen.Are patients safer today than they were 10 years ago?
Dr. Corrigan: We don’t know the answer to that question because we have not conducted large-scale studies. Based on the smaller-scale focused studies, there clearly have been important advancements in certain areas. We have some very good efforts aimed at reducing infections. Peter Pronovost’s work [on cutting hospital-acquired infections] has shown some very important results in reducing infections. We can point to a plethora of interventions that have made some patients safer.
Are all patients safer? No. There are some disconcerting findings -- 100,000 or more patients still die from infections each year. We still see wrong-side surgery.
How did your experience at the IOM and that report inform your work today?
Dr. Corrigan: One thing I learned from that process is that it’s really challenging and difficult to make change happen in health care for reasons I don’t fully understand, health care doesn’t change easily. It’s highly decentralized. It’s also one where the culture resists standardization of care processes, even when that standardization is needed to get to a safer environment.
What needs to happen to improve patient safety?
Dr. Corrigan: We need to do several things differently. We need to focus on high-leverage areas where major national organizations can establish national priorities and goals to transform delivery. We need to align activities of public and private purchases. We have to create an environment that sends clear signs to providers on the front lines, set priorities and focus and align our efforts around them.
Our health care delivery system is in need of a major overhaul. It is fragmented. Many errors occur because there is no clear handoff once patients leave the hospital. They don’t follow the treatment protocol. We need systems of care that can support that patient and have a clear handoff.
We also really need to reform the payment system. Current fee-for-service modalities are really an impediment to safety. Under fee-for-service, some providers find that they make the needed improvements to improve quality and get penalized financially. We need payment programs that reward providers [for quality].
Has the role of nurses changed in response to the IOM’s call to action on patient safety?
Dr. Corrigan: The IOM report clearly recognized the role of nursing and opened up a wonderful opportunity for nurses to assume a leadership role [in patient safety]. Nurses are our front-line providers. They are the ones most likely to notice when an error is about to occur or has occurred.
Nurses also have tremendous knowledge about how to reform the care processes. As members of the care team, they make errors as well. It’s important to realize that multiple things go wrong when an error occurs. There are many actions that can be taken so that nurses can help redesign care processes so that it makes patients safe. Nurses clearly play a role in that.
What’s next for the NQF in terms of the role you play in advancing patient safety?
Dr. Corrigan: We are moving more toward patient-focused measures. That’s another core message of the IOM report. Patient care is a team sport and we really need to focus a lot more on interdisciplinary teams. It will be very important for nurses and all clinicians to think about their relationship to the team.
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