This year marked the 20^th anniversary of the National Patient Safety Foundation, and their 19^th Annual NPSF Congress. The NPSF was developed for the same reason that the Washington Patient Safety Coalition was born 16 years ago: to provide a platform for building awareness of patient safety concerns and sharing best practices to address them. Watch as NPSF founders and leaders recap the organization’s 20 year history, and read more about their annual event in today’s extended Friday Five.

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Friday Five: Reflections on the NPSF Annual Patient Safety Congress.

1. Merger of IHI and NPSF: This year’s congress took place 3 weeks after the merger of the Institute of Health care Improvement and the National Patient Safety Foundation. The organizations have long partnered on important patient safety initiatives. They’re are coming together now to increase “recognition that patient safety is a public health issue in need of fresh, robust approaches and constant focus for health care systems today.” The commitment to initiate a public health response framework to reduce medical error, was highlighted in an NPSF Call to Action discussed at the congress.

2. New Resource for Health Care Executives: Leaders from the NPSF Lucian Leape Institute announced a new resource to help build a culture of safety within health care organizations. The resource was developed by a panel of patient safety experts and researchers to bridge the gap between knowledge and resources around developing a safety culture. According to NPSF, “This guide can be used to help determine the current state of an organization’s journey, inform dialouge with the board and leadership team, and help leaders set priorities.” Download the blueprint here.

3. Opening Keynote: Don Berwick President Emeritus and Senior Fellow, Institute for Healthcare Improvement, addressed attendees about the current state of patient safety, reminding us to not allow our efforts to become a pendulum swinging too far in the opposite direction. He warned that the patient safety community has focused on one-off interventions, leading us to believe that the work of patient safety is “done” once certain metrics are met. He added that we’ve become bogged down by this pattern, and are currently in need of a “metric diet.” Berwick’s full keynote outlined these concerns and other major areas for concern that must be addressed to continue making progress in patient safety. The address is summarized here.

4. Day Two Keynote: The second day of NPSF Congress opened with a panel presentation and discussion from Dr. Tejal Ghandi (Predident and CEO, NPSF), Dr. Albert Wu (Professor of Health Policy and Management, John Hopkins University) and Dr. Chris Landrigan (Associate Professor of Medicine, Harvard Medical). Each member of the panel presented on their chosen hot topic within current patient safety research. Landrigan addressed the new evidence behind physician fatigue and warned that the new ACGME decision to raise the celing on maximum shift hours is dangerous to both patients and providers. In her presentation, Dr. Ghandi discussed diagnostic errors and the need to design care systems that reduce opportunity for human bias or memory lapse. Ghandi referenced a report by the National Academy of Sciences that outlines 8 important steps to reducing diagnostic errors, while noting her belief that the most crucial step is developing better mechanisms to capture these errors once they happen. Dr. Albert Wu discussed disclosure of adverse events. He emphasized that both patients and providers are often left with unmet needs after a harm event occurs. Dr. Wu pointed to advancements in error disclosure processes with tools such as the CANDOR toolkit, and the rise of Communication and Resolution Programs as best practice for resolving harm events.

5. Closing Keynote: Congress ended on a lighthearted note with a closing keynote by Dr. Zubin Damania, or “ZDoggMD.” Dr. Zubin is a healthcare comedian, who uses satirical music videos to initiate conversations around various complexities of the healthcare system. Dr. Zubin echoed the opening keynote by Dr. Berwick, stating his belief that we’ve moved too far into the world of measurement, leaving physician’s burned out. He outlined his vision of healthcare 3.0 as, “A world in which patients get effective coaching on their health and social determinants that impact health, where clinicians and patients are held accountable for care plans, and where the patients have an active role in building and contributing to their medical records.”

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