IHI Patient Safety - December 2020

Innovative Inputs

Environmental Scanning

IHI Patient Safety

By Mary Harper,  PhD, RN, NPD-BC

Despite a focus on patient safety for the past two decades, evidence-based practices for patient safety have not been widely implemented on a national scale. As a result, in 2018, the Institute for Healthcare Improvement (IHI, 2020) convened 27 national organizations representing medicine, pharmacy, nursing, and other healthcare stakeholder groups to develop an action plan to address the ongoing issue of preventable patient harm. The team expanded the definition of preventable harm, which remains a leading cause of death in our country. Preventable harm includes “physical, psychological, emotional, moral, economic, and societal harm to patients and the workforce, as well as harm caused by inequities and lack of care for patients, families, and the workforce” (p. 7).

The report, released in recent months, identified four essential areas for creating safety in our healthcare system. Seventeen evidence-based recommendations are organized around these four areas:

  • Culture, Leadership, and Governance
  • Patient and Family Engagement
  • Workforce Safety
  • Learning System

While NPD practice is impacted by all of these areas, the Learning System recommendations, which comprise 5 of the 17 recommendations, are most pertinent. These action items include:

  • Facilitate both intra- and inter-organizational learning.
  • Accelerate the development of the best possible safety learning networks.
  • Initiate and develop systems to facilitate interprofessional education and training on safety.
  • Develop shared goals for safety across the continuum of care.
  • Expedite industry-wide coordination, collaboration, and cooperation on safety (IHI, 2020, p. 7).

The full report, along with a self-assessment tool and Implementation Resource Guide, are available on the IHI website. Click here to download the report for free.


Institute for Healthcare Improvement. (2020). Safer Together:  A National Action Plan to Advance Patient Safety. http://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx

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