Beyond Individual Harms: A Total Systems Approach to Patient Safety

Patient safety work is often organized around individual types of harm. We focus on falls, medication errors, healthcare-associated infections, diagnostic errors, and other important safety priorities. When a new risk emerges, we develop programming, tools, and interventions to address it.

This harm-by-harm approach to patient safety can lead us to address individual risks independently, even when they share many of the same underlying contributing factors. While focused efforts to reduce specific types of harm remain important, meaningful and sustainable improvement also requires us to look within and outside of our healthcare organizations to address the broader issues that impact safety.

The causes of many seemingly different safety events could each be influenced by similar factors: How was the work designed? Did technology support the people using it, or did it make their jobs harder? Were staff working around a process that did not reflect how care is actually delivered? Did they have the skills, resources, time, and psychological safety needed to identify and respond to risk? Were patients and families involved? Were vendors, manufacturers, or other partners outside of the healthcare organization part of the solution?

These questions point to a broader opportunity for patient safety: addressing not only individual harms, but the organizational and extra-organizational factors that influence whether safe care can reliably be delivered.

Moving Toward Cross-Cutting Themes

MPSC’s approach to programming has continued to evolve. 

Beginning this year, rather than organizing our programming around a specific service line or safety issue, we are focusing on building capacity and awareness around three cross-cutting themes that are critical to patient safety, regardless of the specific harm being discussed. Whether we are talking about falls, medication safety events, healthcare-associated infections, diagnostic safety, or an emerging risk, the same fundamental questions about systems, organizational capability, and technology apply.

These themes are:

• Total Systems Safety

• Building Capacity for Safe and Equitable Care 

• Technology as a Safety Tool—and a Risk

These themes do not replace focused attention on specific patient safety issues. Reducing individual types of harm remains important, but it cannot be our only strategy. If we address falls, medication errors, infections, and other safety events independently without also addressing the organizational and system factors that contribute to them, we risk solving the same underlying problems repeatedly in different, and potentially conflicting forms.

Total Systems Safety

Safety should not be the result of individual vigilance alone because it emerges from interactions among people, processes, technology, the physical environment, leadership, organizational culture, and policy.

Total Systems Safety asks us to look beyond the actions of an individual and examine how the design and conditions of the system shape the ability to deliver safe care. Why was the task difficult to perform safely? How did workflow, staffing, technology, cognitive load, or the environment influence what happened? Is there a difference between how we expect work to occur and how it is actually performed in practice?

This perspective also changes how we learn. Patient safety has traditionally focused heavily on understanding what went wrong after harm occurs. We also need to learn from everyday work, including how healthcare teams routinely adapt to variability and keep patients safe despite competing demands and imperfect systems.

A systems approach shifts our focus from asking people to be more careful to designing conditions that make safe care easier to deliver.

Building Capacity for Safe and Equitable Care

Knowing what needs to improve does not necessarily mean an organization has the capacity to improve it.

Sustainable patient safety requires investment in people, leadership, culture, skills, and infrastructure. Healthcare organizations need staff who understand improvement and patient safety methods, leaders who make safety a strategic priority, reliable processes for learning from risk, assessment of harm and outcomes with a health equity lens, and cultures where people can raise concerns without fear.

This is why workforce well-being, psychological safety, leadership, equity, training, and organizational capability are not separate from patient safety. They are among the conditions that determine whether improvement can be achieved and sustained.

This theme also reflects an important role for MPSC. Building regional patient safety capability means making practical tools and training available not only to quality and safety professionals, but to the broader healthcare workforce and ecosystem. Anyone who designs, leads, or participates in a workflow that affects patient care has a role in creating safer systems.

Technology as a Safety Tool—and a Risk

Technology is now inseparable from the way healthcare is delivered. Electronic health records, medical devices, clinical decision support, automation, artificial intelligence, and other technologies can reduce cognitive burden, standardize processes, identify risk, and prevent harm. However, they can also create new risks.

Poorly designed or implemented technology can increase workload, create unintended consequences, and widen the gap between how a process was designed and how work actually occurs. Technology should therefore not automatically be viewed as a solution to a safety problem simply because it removes a manual step.

Safe implementation requires understanding both benefits and risks, involving frontline users in design and implementation, monitoring for unintended consequences, and working with technology developers, manufacturers, vendors, and other industry partners when the source of risk extends beyond the healthcare organization.

Our work through the Consortium for Safe AI in Healthcare is one example of this approach, but the principle extends well beyond AI. Modern patient safety requires healthcare organizations to understand technology as both an important safety tool and an increasingly important source of risk.

Creating a Common Framework for Patient Safety

These three themes are not separate areas of work as they are interconnected and reinforce one another.

A technology-related safety event may reveal a human factors issue, but it may also expose gaps in organizational governance, workforce training, psychological safety, or vendor oversight. A medication error may appear to be a clinical issue but ultimately reflect technology design, workflow, staffing, communication, or competing demands. A fall may lead to a new policy, when the more important question is whether the organization has the culture and improvement capability to understand why the existing process was not working.

Looking at these issues through a common framework helps us move beyond treating every safety problem as an isolated event.

It also helps us expand the ecosystem of people responsible for patient safety. Clinicians and patient safety professionals cannot solve every problem from within healthcare organizations. Safer systems will increasingly require collaboration with patients and families, human factors experts, technology developers, manufacturers, engineers, designers, policymakers, and others who influence how healthcare is designed and delivered.

MPSC is positioned to bring these perspectives together. As a regional patient safety center and learning network, our role is not simply to provide programming on the safety issue of the month. It is to help organizations learn from one another, build shared capability, engage partners who can address upstream contributors to harm, and translate that learning into practical approaches that can be used across the region.

We will continue to address the individual patient safety issues that matter to our members and the healthcare community. But rather than focusing harm-by-harm as each new issue emerges, our goal is to continually connect those issues back to the systems, capabilities, and technologies that shape safety across healthcare.

Safer care should not depend on people working harder to overcome imperfect systems. We need to design systems that make it easier to do the right thing and more difficult for them to cause harm that reaches patients.