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As the last post in our four-part patient safety series, this blog summarizes the lessons from throughout the series and explains how to use frameworks to help healthcare organizations finally push forward their patient safety programs.

Lesson #1: A shared problem requires a unified approach

The first piece in the series, The rise and stall of patient safety: Why 22 Years of Industry Effort Has Flatlined, highlights the industry’s struggle with making large-scale progress toward improving patient safety. While several contributing factors are identified, a few were highlighted:

  • Siloed, fragmented approaches (each unit focuses on one “slice” of the problem)
  • Lack of comprehensive data (including near-miss incident data)
  • Inability to define exactly what a “high-reliability organization” looks like (despite the popularity of the term)

Given that patient safety involves a coordinated effort from so many different parts of the organization, it is no surprise that a series of individual tactics may not be enough to generate meaningful results. 


“Better data, collected from unified sources of information, can help capture and connect risk data in a way that surfaces the most critical information, so all stakeholders know precisely where to focus. A comprehensive healthcare risk technology suite that includes patient safety and quality, risk management information systems and software (known as ‘RMIS’), and environment, health, and safety (EHS) solutions is ideal for addressing systemic problems because it helps an organization shift away from responding reactively and toward more holistic approaches”

Lesson #2: Understanding the challenges of the human factor

The second piece, The Human Factor: How to Align Patient Safety Technology with Healthcare’s Largest Complexity, examines why reaching zero harm in the healthcare industry is more challenging than other industries, such as aerospace and manufacturing. One key difference is that, unlike aircraft or machinery, patients require empathy and compassion, and the enormous number of variables involved with the human body make standardization extremely difficult. These additional factors also explain the lag in zero harm efforts:

  • A tradition of highly segmented organizations (starting with training & onboarding)
  • Culture can limit progress (especially between management and staff)
  • Expecting technology to be a “silver bullet” (and forcing workarounds to technical challenges)

Recognizing the cultural challenges involved, and the interconnected nature of healthcare organizations, we offer a six-point model to link together disparate efforts. The configurability of technology solutions plays a critical role in implementing this strategy.


“Compared to current fragmented approaches, the difference in this coordinated six-point approach is that it recognizes each solution, alone, does not deliver sustainable and organization-wide change. In this sense, for instance, remaining data silos prevent technology from enabling safety culture, which in turn limits the open communication necessary to close the loop on safety events and create transparency.”

Lesson #3: Communication is key

In the third piece, Breaking Down Barriers: How to Improve Communication and Build a Sustainable Patient Safety Culture, we discuss how communication can amplify or hinder patient safety efforts. Examples include:

  • The hierarchical nature of healthcare organizations (with power differences between physicians and other professionals)
  • Development of a “silo mentality” (contributing to employee stress and job dissatisfaction)
  • Difficulty “closing the loop” on patient safety reporting (starting with challenging intake systems)

Even the strongest program will struggle if the entire team doesn’t fully understand the goals and responsibilities, or if they fail to see how their participation ultimately makes a difference. Successful programs not only communicate effectively upward and downward but also make the intake process streamlined to avoid non-reporting issues.


“A single-platform healthcare risk management solution like Origami Risk can help to improve communication and contribute to a strong patient safety culture by breaking down silos, getting more people throughout the organization involved in adverse event intake, promoting data-sharing, and triggering follow-ups.”

What next?

Even if your organization manages to break down silos and unify the approach to patient safety, understands and adapts to the challenges of the human factor, and creates a non-punitive culture that embraces change, the path forward may still not be clear. At this stage, leaning on frameworks may help point the way.

The ASHRM ERM Framework

The American Society for Health Care Risk Management (ASHRM) published ENTERPRISE RISK MANAGEMENT: Implementing ERM, which includes a framework for healthcare organizations to follow. The framework focuses on eight interrelated domains:

  • Operational 
  • Human Capital
  • Clinical/Patient Safety
  • Legal / Regulatory
  • Strategic 
  • Technology
  • Financial
  • Hazard

One way to connect the takeaways from the articles with the domains from the framework is to place the Clinical/Patient Safety domain at the center, and then examine how each other domain interacts with it. Applying the takeaways to those overlaps can help illuminate what the challenges are that need to be resolved, and how to steer clear of traps that have hindered patient safety programs in the past.

Connecting Domains

Looking at the overlaps between the Operational domain and Clinical/Patient Safety, while keeping in mind the challenges of siloed systems, cultural resistance, and a lack of communication, it becomes clearer how the right technology may be able to help. For example, delivering timely reporting on key patient safety metrics (especially right after changes have been made to operations in an attempt to improve patient safety) gives every unit insight into what is working and what is not, which provides a more comprehensive view that helps attack silos. 

Empowering all levels of staff to report incidents in a streamlined way (Operational) and then closing the loop with a root cause analysis (Technology) can have a positive impact on employee morale and turnover (Human Capital) thereby improving the culture, and avoiding the “workaround” reflex. If that improved process is easy to document, compliance risk is lowered (Legal/Regulatory) which improves the bottom line (Financial).

Leveraging the interconnected nature of ASHRM’s eight domains avoids the fragmented, piecemeal approach that has contributed to the lack of progress in key patient safety measures. Using the framework as a starting point, and then looking for ways to address the three takeaways can ensure your organization finds ways to innovate and improve patient safety operations in a way that finally creates real progress.

To learn more about how your organization can make a lasting impact on its patient safety culture, start a conversation with us or download our latest healthcare white paper, Improving Patient Safety: 6 Ways to Move Beyond the Status Quo. In it, you'll learn about a six-point approach to patient safety and how the components are mutually beneficial.