Patient Safety Gains Were Devasted by the Pandemic — What Can We Do?

Hospitals lost 20 years’ worth of patient safety gains in less than two years, according to an analysis by the Amplifire Clinical Innovation Advisory Board (CIAB), recently published in the New England Journal of Medicine Catalyst. The authors attributed the loss of the progress that had been made in two decades following the initial publication of “To Err Is Human: Building a Safer Health System” (2000) to several factors, which most commonly aggregated around clinician strain and burnout, exacerbated by the heightened stress of the pandemic. Unfortunately, physician reviewers on patient harm data through the years since “To Err is Human” estimate that 40-60% of all care-associated injuries are preventable. Moreover, they estimate avoidable care-associated mortality in hospitals exceeded 210,000 deaths per year. Another analysis concluded in 2016 that avoidable medical injuries were the third most common cause of avoidable death in the United States. If harm is preventable, but patient safety is still declining, how can we better support healthcare workers striving to provide excellent care? 

The first step in preventing patient harm is to identify the source. Patient safety research indicates that the majority of patient harm stems from two causation categories. The Institute of Medicine Committee on Data Standards for Patient Safety research informed the CIAB, who identified the top 10 causes of patient harm; and the top two categories combined — adverse drug events and hospital acquired infections (HAIs) — account for ~80% of all harm. HAIs as a stand-alone category account for ~30% of all patient-harm incidents, including postoperative deep wound infections, catheter-associated urinary tract infections (CAUTI), lower respiratory infections, bacteremias and septicemias, and C. diff, MRSA, etc. Harm categories are organized around clinical processes, and therefore include some areas of overlap. For example, central line-associated bloodstream infections (CLABSI) can be approached as an HAI, or as “Complications of central and peripheral venous lines.” Because CLABSI can fall under either category, prevention methods can be implemented from more than one operational direction.  

CLABSI is a particularly dangerous type of preventable harm. The mortality rate for CLABSI ranges as high as 25%, and each incident costs $48,108. In the intensive care unit, these infections are associated with over 28,000 deaths yearly and cost over $2 billion. Even worse, this immense cost can be prevented. So, what can we do

Where can we go from here? 

Upon finding that most patient harm incidents fall under only a few categories, experts have recommended developing standardized best practices around these categories and making them widely accessible and reiterating them through effective training that suits the modern workforce (ex: hybrid, blended, online, etc.). If standard best practices were taught universally, all healthcare workers would have the life-saving knowledge they need wherever their career takes them. Hospitals can trust that their long-term staff, new hires, and temporary support across all roles have the knowledge they need to succeed. 

There are training systems on the market today that work and are moving the needle on improving patient safety. For example, a peer-reviewed study compared Amplifire’s training against a control group (legacy training) at several hospitals in the same health system revealed that cognitive science-based training can help health systems decrease CLABSI rates. In this study, the hospital that implemented Amplifire training saw 79% reduction in the hospital’s CLABSI rate, with zero CLABSIs occurring in the first eight months following training (compared to the nine CLABSI incidents that had been observed during the pre-training period), despite spikes in COVID-19 hospitalizations. The CLABSI rate at the control locations (locations that did not receive the cognitive science-based training) slightly increased in the observed time. This study illustrates the power of aligning standard processes with cognitive science-based, adaptive learning. 

The CLABSI course is just one of many courses co-developed by subject matter experts in the Healthcare Alliance. Some other courses developed around common causes of patient harm include CAUTI prevention, sepsis recognition and management, ICU liberation, and more. Browse healthcare courses in our Safety and Quality Essentials library or reach out for more information. 

From the beginning, Amplifire has relied on innovative brain science to guide its product development to create the most effective learning and training solution, perfectly tailored to the way the human brain works. Learn more about how Amplifire helps people learn better and faster with online learning by requesting a demo. 

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