Three Reasons Why Patient Safety Is Difficult to Improve

Updated: Sep 12

By Paul Gallese, PT, MBA

A new book written by Johns Hopkins University professor and a physician colleague sharply criticizes the patient safety movement for failing to deliver the improvements promised over two decades of research, funding and policymaking (Cruickshank, 2019).

Still Not Safe: Patient Safety and the Middle-Managing of American Medicine,” by professor Kathleen Sutcliffe and the late physician Robert L. Wears, points to two flaws in how patient safety has been studied since the 1999 publication of “To Err is Human: Building a Safer Health System” by the Institute of Medicine (now the National Academy of Medicine).

The first flaw is the absence of consensus about what is being studied, and the second is data collection methods the authors view as being subject to hindsight bias. The Vitalacy team’s experience observing patient safety initiatives in many hospitals is consistent with the book’s point of view, and we offer the following three reasons why patient safety improvement has been disappointing.

1. Patient safety initiatives not guided by credible baseline data

We have found that many hospitals do not have sufficient baseline data to help them determine how patient safety efforts should be prioritized and implemented for best results. Our first order of business is usually working with hospital clients to gather credible, unbiased data that serve as this baseline.

The data serving as the foundation of a patient safety improvement process must be viewed as credible by clinicians. To achieve credibility, the data must be robust, descriptive and replicable – meaning that the data must reflect a true representation of what is happening, not only a sampling, and the data must be consistently gathered in the same fashion over time, so that improvements to baseline can be seen and believed.

Data credible enough to guide and drive patient safety improvement cannot be gained by direct observation, only by automated electronic compliance monitoring. The data gained through automated technology is more accurate and more grounded in reality than what is gained through direct observation of caregivers, which up until recently was considered the gold standard of hand hygiene compliance measurement. That changed when the Leapfrog Group announced recently that it was adding electronic compliance monitoring to its hand hygiene practice standards for 2019.

2. Many hospitals overestimate their compliance with patient safety protocols

Many hospitals overestimate their hand hygiene compliance, for example, due to the Hawthorne effect, the alteration of behavior by the subjects of a study due to their awareness of being observed. Hand hygiene compliance measured through direct observation is affected by the Hawthorne effect – compliance is high when care providers know they are being observed, but drops off when they are not. For this reason, a study of direct observation found compliance rates to be overstated by up to 300 percent (Srigley et al., 2014).

In addition, because of the considerable time and expense hospitals must invest in the direct observation of caregivers, direct observation captures only 1.2 percent to 3.5 percent of all hand hygiene events, according to the Electronic Hand Hygiene Compliance Organization.

Vitalacy’s Patient Safety Platform electronically monitors hand hygiene compliance 24/7, thereby capturing 100 percent of all hand hygiene events and giving a hospital a true and credible measure. Electronic monitoring also can spot signs of nurse fatigue and measure the true effectiveness of nurse rounding and workflow in preventing healthcare-acquired conditions such as falls, bedsores and deep vein thrombosis.

3. Frontline workers discouraged from reporting mistakes and system flaws

Sutcliffe also writes that many hospital cultures still tend to place blame for adverse events on frontline workers closest to the problem. Workers within these cultures are therefore discouraged from reporting mistakes or flaws within systems.

Our team has found that care providers become more invested and engaged in patient safety efforts when they see their actions contributing to better patient safety results.

The data gathered by the Vitalacy Patient Safety Platform creates a real-time map that measures hand hygiene compliance, the consistency and effectiveness of nurse rounding, and the likelihood of nurse fatigue. By collecting and analyzing these data, unit managers can make adjustments to workflow to improve performance on these quality measures and enhance patient safety.

Care providers receive personalized reports on their individual performance; the reports provide feedback and engage the providers in the patient safety effort. Once they realize how the technology contributes to patient safety by lowering infection rates or the incidence of healthcare-acquired conditions, their engagement increases even more.

Feedback from care providers has helped Vitalacy to refine its patient safety platform, and the work groups we conduct with our clients are designed to explore the data we gather for insights into how to improve the effectiveness of patient care and assure patient safety.

Using this approach, we are confident the future gains made in patient safety will be much greater than they’ve been over the past 20 years.



Cruickshank, S. A critical history of America’s failed push for patient safety. HUB, Johns Hopkins University, Dec. 3, 2019.

Srigley JA, et al: Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system,: a retrospective cohort study, BMJ Quality & Safety, Dec. 2014;23(12):974-980.

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