Circulation 76,548 • Volume 20, No. 3 • Fall 2005   Issue PDF

Insights from a Patient Safety Officer

Kenneth J. Abrams, MD, MBA

The Role

Five years ago the safety officer was a member of the health care team with knowledge, expertise, and experience in fire and environmental safety. Today, that has changed significantly. The role of the Patient Safety Officer (PSO) has emerged as a new frontier for the development of critical work needed to improve the likelihood of a successful health care experience for patients. The Institute of Medicine’s (IOM) report, “To Err is Human,” brought to light the breadth and depth of harm that was being experienced in American health care and called for action to be taken to address these important patient care issues.1 As the public is seeking greater accountability, payers are seeking improved performance, and the health care community is seeking ways to regain trust, the role of the PSO is developing into a pivotal component for transformational change.

Patient safety requires high level leadership and systems thinking. As such, the PSO is usually a senior level position within the organization, working with both administrative and clinical leaders. While reporting relationships may differ from organization to organization, it is imperative that the PSO have a strong partnership with the CEO to successfully develop and deploy a comprehensive patient safety program.

Many critical initiatives in the health care domain affect the daily work of a PSO. Two of these are the JCAHO’s National Patient Safety Goals and the Institute for Healthcare Improvement’s 100K Lives Campaign. While these are goals and initiatives, they are not a recipe for transformation and implementation. The PSO needs to create a program of change around the following key areas:

  1. The culture of safety
  2. Adverse event analysis
  3. National initiatives
    a. Operational process change
    b. Health information technology

Although a detailed explanation of these facets of safety is beyond the scope of this article, I will attempt to define key objectives of each element.

A culture of safety can be defined as an integrated pattern of individual and organizational behavior based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from processes of care delivery.2 A strategy to develop a just culture employs 2 complementary ideas. First, it creates a system that encourages reporting of injuries and near misses and keeps individuals safe from blame, shame, and retaliation.3 Next, the value imparted by open reporting promotes the creation of reliable care processes, which goes beyond vigilance.

Adverse event systems have 2 major components: methods of detecting adverse events and methods of analyzing adverse events. Since most current systems of adverse event detection rely on voluntary reporting, the vast majority of adverse events go undetected.4 Unfortunately, much of the current assessment of adverse events is retrospective. One hopes, as information technology continues to penetrate the health care delivery system, automated detection of potential events will help eliminate harm. Implementation of automatic detection systems requires the emergence of precise terminology in order to be effective.

One of the most recognized national initiatives aimed at operational process change is the 100K Lives Campaign, launched on December 16, 2004, at the IHI National Forum.5 The campaign employs 6 changes in care aimed at preventing avoidable deaths. For additional information, visit The IOM has made several recommendations focused on improved information systems to support patient safety as a standard of care in hospitals, doctors’ offices, and every other health care setting (IOM, 2004).

Bringing these initiatives to life is the role of the PSO and his or her team. Leading patient safety initiatives takes fortitude and leadership. A PSO will be asked to work on all of the previously mentioned initiatives and integrate them into a comprehensive plan of action. In order to do so, a number of critical skills are required. Fundamentally, a PSO needs to be a change agent, working through a plethora of competing and sometimes conflicting agendas. Transformation, execution, and people skills represent the 3 broad categories of leadership competencies needed to be a successful PSO. The technical and behavioral characteristics that comprise these categories cover the spectrum of leadership skills, including communication, initiative, performance management, innovative and strategic thinking, talent development, and professionalism, to name a few.

The Opportunity

Anesthesiologists and nurse anesthetists are uniquely suited to serve as PSOs. Many already are leading national efforts to enhance patient safety. As anesthesia providers, we possess a broad understanding of the complexities of delivering care in a wide variety of environments. We deal with medical management, technical procedures, the young and old, the sick and well, as well as the critically ill and injured. We understand the value of team approaches in the provision of care. We understand the value of equipment checks before providing care.

We have led the development of patient safety, and have dramatically reduced perioperative mortality through systematic analysis, program development, and widespread deployment. Our leaders have developed standards, guidelines, and practice parameters to provide anesthesiologists and nurse anesthetists with the fundamental elements needed to deliver safe care. We have raised the bar, by choice. In doing so, we have become the benchmark for safety-first medical care, as evidenced by the recent article in the Wall Street Journal.6

Now we need to further develop our leadership by cultivating the interdisciplinary relationships and partnerships needed to promote the development of a safety agenda across all specialties. I would ask you to consider the following:

  • Could a pre-procedural safety check of all procedural equipment eliminate device-related injuries?
  • How can we use our knowledge and understanding of the closed claims project to promote knowledge creation within other specialties?
  • What would the impact on patient safety be if we could engage all specialties to adopt our commitment to safe care?

We have been criticized for developing key components of clinical care and then leaving them for others. Notably, anesthesiologists helped to develop critical care units, yet, over time, we have become progressively less involved in critical care medicine. We cannot allow this to happen with patient safety. We must demonstrate the commitment and leadership needed to sustain anesthesiology leadership in safety development. We must create the infrastructure to enable process development, systems technology, cross-fertilization, and interdisciplinary collaboration. In short, we must continue to build upon our strengths, for the benefit of all patients.

Dr. Abrams is Chairman of Anesthesiology and Perioperative Medicine, and Patient Safety Officer at AtlantiCare in Pomona, NJ.


  1. Kohn, LT, Corrigan, JM, and Donaldson, MS, editors; Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press, 2000.
  2. Kizer, KW. Large system changer and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago: National Patient Safety Foundation, 1999.
  3. O’Leary DS. Perspectives and Insights. Council on Teaching Hospitals, Spring Meeting. Joint Commission on Accreditation of Healthcare Organizations. Phoenix, AZ, 2003.
  4. Bates DW, et al. Detecting adverse events using information technology. J Am Med Inform Assoc. 10(2):115-128, 2003.
  5. Institute for Healthcare Improvement. 100k lives campaign. IHI National Forum. Orlando, FL., 2004.
  6. Hallinan JT. Once seen as risky, one group of doctors changes its ways. Wall Street Journal, June 21, 2005.