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Sharing Lessons Learned and Improvements Achieved - Causes for Celebration

Improving patient safety encompasses a number of significant elements.

Causes For Celebration

Improving patient safety encompasses a number of significant elements. 

It is about learning from the lessons related to causality and contributing factors arising from patient safety incident investigations. It includes designing and implementing improvement projects to enhance the processes of healthcare and to address the human factors that often impede performance. It is also about adjusting the strategies of such projects in accordance with quality improvement techniques and measurable performance parameters to incrementally improve performance. Most important, improving patient safety includes sustaining these improvements and sharing the lessons. The same continuous improvement logic applies to learning from incidents of excellence discussed previously in this series.

In order to be successful in these noble endeavors, we must engage with all stakeholders during the formative stages of process improvement projects. That begins with robust, succinct investigations and analysis of the numerous factors contributing to patient safety incidents and/or incidents of excellence. The next step is to address the lessons learned with rigorous planning and implementation of improvement strategies. Failure to engage with front-line stakeholders, and in healthcare this means clinical staff and patients, runs the risk of leading to lack of buy-in to new initiatives. Leadership must encourage, nurture and value front-line contributions and support these efforts. As a result of these efforts, short-term returns on investments may be realized. But in terms of improving overall health and healthcare outcomes, a longer-term perspective on return on investment must be appreciated, endorsed and implemented.

Yet even if leadership and culture are aligned and key stakeholders are engaged, the impact of quality and safety improvement initiatives will remain limited unless shared between work-centers within institutions and, more broadly, between institutions. After all, the processes for providing healthcare services and factors affecting human performance should be the same or similar between work-centers and institutions. At the same time, some pragmatic local issues may prevail that will necessitate the accommodation of variations. Not sharing what has been learned between work-centers and between institutions represents a failure to appreciate the broader construct that what matters most to patients is a universal paradigm, not an approach limited to one work-center or one institution.

None of this represents modern thinking about healthcare. More than 150 years ago, Florence Nightingale, my favorite hero of patient safety, demonstrated that simple improvements in hygiene and nutrition could dramatically reduce morbidity and mortality in hospitalized patients in a war zone1, and she used statistics to support her conclusions. By the way, Nightingale had never heard about PDSA cycles. Today, basic hygiene and provision of adequate nutrition are worldwide mainstays of inpatient care. Simple solutions, adopted locally but spread internationally, resulted in dramatic, universal improvements in healthcare and patient safety.

Case Studies:

The framework for shared learning between institutions and in a national and/or international framework has been strongly advocated. Two examples of shared learning are worth mentioning because of the impact they have had worldwide.

  1. Central Line Associated Blood Stream Infection (CLABSI) prevention – In 2006,  Pronovost, et al, published the first report of a multi-center, systematic attempt to reduce the incidence of central line infections in intensive care unit settings (CLABSI)2. At the time of the study, the US was experiencing over 80,000 CLABSI and approximately 28,000 related deaths per year, e.g., 28,000 lethal patient safety incidents. The cost of care associated with these infections was approximately $28,000,000,000 per annum. The strategy behind this study was simply to treat the insertion of central catheters in a fashion similar to a surgical procedure. “The recommended procedures were hand washing, using full-barrier precautions during the insertion of central venous catheters, cleansing the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters.” Within three months, the rate of infections decreased to zero. Since this early publication, numerous other studies have reported similar results and today many institutions worldwide continue to report the sustained impact of this intervention3.

    A simple process improvement strategy was implemented, studied, improved, analyzed, reported locally, then nationally and now adopted internationally, thus benefiting thousands of patients, dramatically reducing preventable deaths and also substantially reducing healthcare costs. 
  2. The World Health Association Safe Surgery Checklist – In 2009, Hayes, et al, reported the results of an international trial of a simple surgical checklist designed to assure proper identification of patients and surgical sites, and to enhance staff coordination and communication in operating theaters4. The results, now confirmed in additional studies, were dramatic, with 36 – 40% reductions in operative/post-operative complications and mortality5. Initially the results of this study were treated with skepticism by some surgeons. However, subsequent studies and the international adoption of the Safe Surgery Checklist as the standard for surgical care by the World Health Organization and many national healthcare organizations have led to dramatic and sustained improvements in healthcare, reductions in mortality and enormous cost-savings6.

    Once again, implementing a simple strategy has resulted in dramatic improvements in care for patients and has been adopted internationally.

Shared learning, shared learning! Time to Celebrate!


  1. Nightingale, F. Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army. Founded Chiefly on the Experience of the Late War, London: Harrison and Sons, 1858.
  2. Pronovost, P, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006;355:2725-2732, DOI: 10.1056/NEJMoa061115.
  3. Marshall J, et al. Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology, 2014;35:753- 771.
  4. Hayes A, et al. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med 2009;360:491-499, DOI: 10.1056/NEJMsa0810119.
  5. Treadwell JR, Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf 2014;23:299-318, doi:10.1136/bmjqs-2012-001797.
  6. The WHO Safe Surgery Checklist and Implementation Manual – accessed at

Daniel Cohen

Leading Patient Safety & Quality Consultant

03 May 2017