Perspectives on Safety—Patient Safety at 20

This month's interview features Shantanu Agrawal, MD, MPhil, president and CEO of the National Quality Forum (NQF). We spoke with him about the National Quality Forum, including its role in quality measurement, patient safety, and improvement.

In the accompanying perspective, Sumant Ranji, MD, and Robert M. Wachter, MD, both of UCSF, explore the evolution of PSNet and WebM&M since their inception (WebM&M in 2003 and PSNet in 2005) and summarize changes in the patient safety landscape over time.

Perspectives on Safety
Published September 2019

Patient Safety and the Evolution of WebM&M and PSNet

by Sumant Ranji, MD, and Robert M. Wachter, MD

Perspective

Progress in any field requires scholarship and dissemination of knowledge. From the early stages of the patient safety field, beginning with the 1999 To Err Is Human report, there was a recognition that preventing harm would require more than just calling attention to the problem—the safety field would need to focus on developing evidence-based practices to prevent adverse events and disseminating these practices broadly to clinicians and safety professionals. The Agency for Healthcare Research and Quality, directed at the time by pioneering safety and quality expert Dr. John Eisenberg, prioritized this need by funding the development of AHRQ WebM&M (initially funded September 2001; launched February 2003) and AHRQ Patient Safety Network (PSNet; launched April 2005). The sites have evolved considerably over the past nearly 17 years, paralleling shifts in the safety field as a whole. Our team of UCSF-based editors have been privileged to run the sites during this time, giving us a unique perspective on the evolution of the field. As we prepare to turn the sites over to new leadership, we would like to take this opportunity to discuss PSNet's and WebM&M's contributions to the discipline of patient safety.

The early years of the patient safety movement were devoted to developing evidence-based standards, synthesizing existing research to define best practices that should be implemented widely. PSNet has addressed the need to disseminate these practices by summarizing the rapidly growing field in an accessible, thought-provoking fashion. The UCSF editorial team has used its expertise and judgment—aided by our invaluable editors and cybrarian—to identify innovative and practice-changing studies from a wide variety of journals and disciplines, and to summarize them in carefully written annotations that highlight the findings while placing individual studies in the context of existing knowledge. From the start, PSNet also has gone well beyond the published literature, recognizing the role of the news media, nongovernmental organizations, and patient advocates in advancing the field. The site currently includes more than 15,000 annotated resources, ranging from seminal publications in leading journals and bestselling books to a late-night comedy episode. As the amount of material on PSNet grew, we recognized that the sites lacked a resource to allow novices in patient safety to gain a rapid understanding of foundational content in the field. This led to the development of the Patient Safety Primers in 2008, which now cover more than 50 core topics and are among the most widely read part of PSNet.

In parallel, WebM&M has sought to provide "leading edge" content by using real cases submitted by readers to highlight important and emerging safety issues, which are analyzed and discussed in depth by a broad range of relevant experts. In addition, interviews and perspectives illustrate how larger trends in health care may affect patient safety and provide an in-depth, personal perspective on influential research. WebM&M plays a very important role in patient safety education, with the Spotlight Cases being widely used for teaching purposes across the health professions. Both sites (now merged into one PSNet site) have also helped disseminate the groundbreaking work conducted and funded by AHRQ and other influential organizations.

Patient safety is fundamentally a sociotechnical enterprise; while the field is grounded in the same scientific approach that underpins other biomedical sciences, achieving progress requires an understanding of human behavior, the sociology of teams, and the culture of health care organizations. As the safety field has evolved, PSNet has sought to articulate this principle through highlighting influential ethnographic research and studies in nonmedical journals that are relevant to patient safety. It has also drawn on expertise from a broad range of fields outside of medicine, including aviation, human factors engineering, and organizational leadership. Progress in patient safety has also, at times, been accompanied by controversy. PSNet has not shied away from these issues but has always attempted to use annotations, interviews, and perspectives to acknowledge differing perspectives and encourage healthy debate.

At its outset, patient safety was largely a hospital-based field, focusing mainly on adult patients in academic settings. The continued growth of the field has increasingly extended across settings of care, increasingly involving ambulatory care, maternal health, and long-term care. PSNet has kept abreast of developments in these areas as well as lesser-known areas such as home health and prehospital emergency care. The editorial team has also sought to be mindful of changes in the practice of health care that impact patient safety; topics such as clinical informatics, high-value care, and scribes were little discussed (or did not even exist) at the inception of the sites, but have been prominently featured lately. As the field has developed, some safety topics (such as rapid response teams) have gained prominence and then receded from attention, while others (such as the opioid epidemic and maternal mortality) have received in-depth coverage as their toll has become painfully clear.

What has also become clear after 20 years of the patient safety movement—and 18 years working on the PSNet/WebM&M project—is how much progress has been made in preventing patient harm and how much work remains to be done. Content from the site's early days reveals areas of significant advancement—such as handoffs and health care–associated infections—but also illustrates areas (such as diagnostic error) where the science is relatively immature and errors still persist. A persistent theme throughout the sites' existence has been "the tension between needing to improve care and knowing how to do it." Although rigorous research has led to major accomplishments in many areas of safety, the field still struggles with how to respond to emerging threats (such as the need to reduce inappropriate opioid prescribing) in the face of incomplete evidence, measurement challenges, and the potential for unintended consequences with mistargeted interventions.

Ultimately, however, the patient safety movement has helped forge a fundamental cultural shift within health care. Traditional medical culture largely consisted of a "blame and shame" atmosphere—one in which errors were ignored whenever possible and solutions focused on punitive approaches to individual clinicians. In large part due to the patient safety movement, the last 20 years have seen a shift toward understanding adverse events (and, by extension, many quality problems) as primarily due to flawed systems. To improve systems, it is now clear that clinicians deserve support, patients deserve transparency, and both deserve to be part of organizations dedicated to reducing harm. This transformation has required the dedicated efforts of frontline staff, safety professionals, researchers, organizational leaders, and engaged patients and their advocates.

From their beginning, AHRQ WebM&M and PSNet have worked to support these leaders by providing the knowledge needed to advance the patient safety field across all its dimensions. As we hand over the reins of AHRQ PSNet to new technical and editorial teams, we are proud to have influenced the development of the field and played a role in keeping patients safe.

We are grateful to our team of editors and staff, who have worked tirelessly to produce all of this content with the highest standards of quality and integrity, while also achieving the highest satisfaction ratings of any government website. Our UCSF-based staff are project and editorial director Erin Hartman (who has been with us from the start) and project analysts Tiffany Lee and Vida Lynum (who have both worked on the project for more than a decade). Lorri Zipperer is our development editor and cybrarian, responsible for culling the literature each week to find and prioritize the 20 key resources. Our PSNet clinician editors are Sumant Ranji, Kiran Gupta, Urmimala Sarkar, Audrey Lyndon, and Rachel Stern. Our WebM&M clinician editors are Brad Sharpe, Sumant Ranji, Kiran Gupta, Linda Franck, and Tiffany Pon. Kaveh Shojania, now editor of BMJ Quality and Safety, has been a vital partner in this and many other safety efforts. Russ Cucina and Sara Murray helped guide us in the area of informatics. Our technology partner, Silverchair of Charlottesville, VA, has produced and maintained a highly functional, innovative site that has evolved as our user needs have expanded and the technological capabilities of the web have mushroomed. We are also grateful to our superb editorial board and to our colleagues at AHRQ, who have supported us generously and whose input has made the site better.

We thank our readers for your support of and enthusiasm for AHRQ Patient Safety Network—producing it has been a pleasure and a privilege. We hope we have made a significant contribution to our shared goal of reducing the number and toll of medical errors and eliminating patient harm, and that the site would have made Dr. Eisenberg, who was a role model and a medical school professor of one of ours (RMW), proud.

Sumant Ranji, MD
Chief, Division of Hospital Medicine
Zuckerberg San Francisco General Hospital
Professor of Clinical Medicine
University of California, San Francisco

Robert M. Wachter, MD
Professor and Chair, Department of Medicine
Holly Smith Distinguished Professor in Science and Medicine
Marc and Lynne Benioff Endowed Chair
University of California, San Francisco