More than five years after the Institute of Medicine report, "To Err Is Human," put patient safety on the agenda at health care institutions nationwide, there have been significant improvements in quality. But Paul M. Schyve's perspective this month suggests that it is going to take real commitment to reach the next, critical stage of improvement: a "patient safety culture."
Paul M. Schyve, M.D., senior vice president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), made his comments in response to a recent Milbank Quarterly article, Stories from the Sharp End: Case Studies in Safety Improvement, highlighting the findings of six case studies written by Douglas McCarthy, M.B.A., president of Durango, Colo.–based Issues Research Inc., and David Blumenthal, M.D., M.P.P., director of the Institute for Health Policy at Massachusetts General Hospital/Partners Health System.
The article—and a longer version, Committed to Safety: Ten Case Studies on Reducing Harm to Patients, published by The Commonwealth Fund this month—conclude that a culture of safety does not just evolve but must be actively created and encouraged by health care organizations, policymakers, educators, and other stakeholders. In addition, the cases demonstrate improvement is possible—that applying the emergent knowledge and tools can result in higher-quality care and greater patient safety.