1. Risks of dismissing patient, family, and caregiver concerns.
2. Insufficient governance of Artificial Intelligence in healthcare
3. The wide availability and viral spread of medical misinformation: Empowering patients through health literacy.
4. Medical error and delay in care resulting from cybersecurity breaches.
5. Unique healthcare challenges in caring for veterans.
6. The growing threat of substandard and falsified drugs.
7. Diagnostic error: The big three—cancers, major vascular events and infections.
8. Persistence of healthcare-associated infections in long-term care facilities.
9. Inadequate communication and coordination during discharge.
10. Deteriorating community pharmacy working conditions contribute to medication errors and compromise patient and staff safety.

• 30 years after Betsy Lehman’s death, preventable harm happens every day in health care settings across Massachusetts 
• The consequences of unsafe care strike patients and families first before rippling across the system, impacting cost, capacity and equity 
• Information about patient safety outcomes in Massachusetts falls far short of what everyone needs to know 
• Game-changing action is necessary…and is now possible 
• From paper to impact: Initial Roadmap action steps 
• Looking ahead: Momentum is building for new thinking and approaches  

1. Tell your healthcare provider about any recent care.

2. Tell your healthcare provider if you think you have an infection or if your infection is getting worse.

3. Take antibiotics exactly as prescribed and tell your healthcare provider if you have any side effects, such as diarrhoea.

4. Remind staff and visitors to keep their hands clean.

5. Allow people to clean your room.

The vision of the Strategy is to build a health care system where quality is a daily commitment, ensuring that all individuals trust that health care will be safe, respectful, equitable and efficient.

The Strategy aims to achieve the following key objectives:

• To nurture an efficient, accountable and data-driven health system: strong leadership and governance are essential for ensuring operational efficiency and evidence-based decision-making. Effective governance structures set clear policies, enforce accountability and ensure transparent oversight. By systematically collecting and analysing data, the country can continuously improve health care performance and decision-making. This approach fosters a culture of accountability and enables timely, informed responses to health care challenges.
• To foster trust in an effective and safe health system: building public trust requires a focus on patient safety, clinical outcomes and the reliability of health care services. Evidence-based practices, integrated with innovative solutions, are key to enhancing safety, accessibility and overall patient outcomes. This will help to ensure that the health care system operates reliably, fairly, and efficiently, increasing trust among patients, health care workers and the wider public.
• To create patient partnerships in health care provision: empowering patients to take an active role in managing their own health care is essential for developing a high-performing and cost-effective health care system. This approach leads to better resource allocation, enhanced satisfaction for both patients and providers, greater utilization of preventive services and improved health outcomes. Patients must understand their health conditions, treatment options and care processes if they are to make informed decisions. Health literacy, especially digital health literacy, equips individuals to engage effectively with health care providers. The Strategy aims to ensure that patients, families and providers collaborate to personalize care, respecting individual values and preferences and thereby improving the overall quality of care.

The Strategy is structured using three strategic directions.

1. Leadership and governance: this direction focuses on building a strong foundation for the health system through effective leadership, transparent governance and the integration of evidence-based practices. When the system operates efficiently and responsibly, it can better address the needs of the population.
2. Evidence and innovation: this direction emphasizes the importance of continuous innovation and the integration of evidence-based practices and focuses on improving safety, effectiveness and equity in health care. By embracing new technologies and approaches, the country can enhance the reliability of its health system.
3. Literacy and engagement: this direction emphasizes patient empowerment through improved health literacy and engagement of patients in care decisions. Ensuring that patients are well informed and fully involved in their care leads to better outcomes and strengthens the patient–provider relationship.

 The least developed dimensions of the care safety culture are mainly related to the role of managers and relate to human resources (32%), non-punitive response to error (35%), teamwork between the institution's departments (40%) and management support for the safety of care (45%). These results do not differ from what has been observed in previous regional measurements.

*Please note this paper is in French.

• Massachusetts, Hawaii, and New Hampshire top the 2023 State Scorecard rankings for health system performance, based on 58 measures of health care access, quality, use of services, costs, health disparities, reproductive care and women’s health, and health outcomes. The lowest-performing states were Oklahoma, West Virginia, and Mississippi.
• Deaths from Covid-19 — as well as premature, avoidable deaths from causes like drug overdoses, firearms, and certain treatable chronic conditions — rose dramatically during the first two years of the pandemic, lowering life expectancy across the United States.
• There was wide state variation on the Scorecard’s new measures of health outcomes and access to care for women, mothers, and infants. Maternal mortality and deaths related to substance use rose quickly among women of reproductive age during the pandemic — a particular concern given new state policies limiting reproductive care access.
• Temporary federal policies during the Covid-19 pandemic drove uninsured rates to record lows, with nearly all states realising gains in health coverage. But some of those policies have ended, and high health costs still saddle millions of Americans with medical debt.
• There are ways the nation could improve health outcomes and lessen variation from state to state. Federal and state governments could: close the coverage gaps that remain and enrol uninsured people who are eligible for subsidized coverage; improve the cost protections of insurance plans; and lower barriers to reproductive health, preventive health, and behavioural healthcare, particularly for the most vulnerable.

1. Process of implementation.
2. Process of evaluation.
3. Change in health professional’s behaviour.
4. Change in patient behaviour.
5. Future recommendations.

The authors conclude that ‘significant improvement is needed in adopting evidence-based and carefully considered approaches to implementing and evaluating Cultural Safety initiatives in hospital settings. Specifically, implementation should be underpinned by a validated theoretical framework and consider and address potential practical barriers in engaging health practitioners.’

There were four key phases in the development of our LHS: build a Community of Practice; facilitate iterative change; develop supportive organisational infrastructure; and establish a sustainable, ongoing LHS. In total, the Community of Practice supported 83 unique Covid-19 ECHO sessions involving 3192 h of clinician participation and over 10 000 h of organisational commitment. Six larger sessions were run between March 2020 and September 2022 with 3192 attendances.

New models of care and care pathways were codeveloped in sessions and network leaders contributed to the development of guidelines and policy advice. These innovations enabled WVPHN to lead the Australian state of Victoria on rates of COVID vaccine uptake and GP antiviral prescribing.

The Covid-19 pandemic created a sense of urgency that helped stimulate a regional primary care-based Community of Practice and LHS. A robust theoretical framework and established change management theory supported the purposeful implementation of the LHS. Reflection on challenges and successes may provide insights to support the implementation of LHS models in other primary care settings.

• Preterm birth: The national preterm birth rate remains at 10.4% with Black moms facing a preterm birth rate of 14.7%, almost 1.5 times higher than the national average.
• Inadequate prenatal care: Rates of inadequate prenatal care reached 15.7%, the highest in a decade with disparities most pronounced in Black and American Indian/Alaska Native communities.
• Maternal mortality: Rates have returned to pre-pandemic levels with over 800 maternal deaths in 2022, a national rate of 22 deaths per 100,000 live births, with Black and American Indian/Alaska Native mothers experiencing rates 2-3 times higher than White mothers.
• Infant mortality: Preterm birth remains the leading cause of infant mortality, which rose by 3% in 2023—the largest increase in over 20 years. Black infants are nearly twice as likely to die in their first year than the national average.
• Environmental exposure: Nearly 40% of birthing individuals are at risk of exposure to extreme heat, while almost three in four birthing people are at risk of exposure to poor air quality.

• Despite being sicker and more complex, hospitalised patients in the first quarter of 2024 were on average over 20% more likely to survive than expected given the severity of their illnesses compared to the fourth quarter of 2019.
• Based on Vizient’s analysis, the AHA using national hospitalisation data projects that while caring for sicker patients, hospitals’ efforts to improve safety led to 200,000 Americans hospitalised between April 2023 and March 2024 surviving episodes of care they wouldn’t have in 2019.
• Hospitals cared for more patients overall in the first quarter of 2024 than in the last quarter of 2019, including providing care to a sicker, more complex patient population.
• Hospitals’ central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) in the first quarter of 2024 were at rates lower than those recorded in the fourth quarter of 2019.
• Not only did multiple key preventive health screenings rapidly rebound to pre-pandemic levels, but ongoing improvement has led to a 60%-to-80% increase in breast, colon and cervical cancer screenings in the first quarter of 2024 compared to the fourth quarter 2019. 

The Act seeks to strengthen openness and transparency throughout the Irish health care system. It applies to public and private health services and must be followed by all staff. A key focus of the Act is on open disclosure.

Open disclosure is defined as an open, honest, compassionate and timely approach to communicating with patients and, where appropriate their relevant person, following patient safety incidents. The Act introduces a legal requirement to disclose a list of specific incidents called notifiable incidents. The notifiable incidents are described in the Act.

The Act requires health services providers to be open and transparent with patients, their families, or both depending on the patient's wishes. For most of the notifiable incidents the patient has sadly died.

The Act outlines a process for open disclosure, ensuring that patients, their families, or both, receive truthful and timely information in any healthcare setting when a notifiable incident happens. The Act also requires mandatory notification of the notifiable incidents to the appropriate regulatory body.

Summary of the Act

The Act provides a legal framework for:

• Mandating a health services provider to disclose notifiable incidents when providing a health service to a patient. There are currently 13 notifiable incidents but the Minister of Health may add to this list in the future - Notifiable incidents 1.10 and 1.11, which relate to incidents in maternity and neonatal care, use terminology that has been defined by regulation. This regulation has now been published as ‘Statutory Instrument 501/2024’ and is available on the Patient Safety (Notifiable Incidents and Open Disclosure) Regulations 2024 - irishstatutebook.ie.
• Mandating health services providers to communicate reviews of cancer screenings they have carried out at the patient's request (breast, bowel and cervical screening).
• Information shared, as well as an apology made, as part of an open disclosure of a notifiable incident and communication of patient-requested cancer screening reviews, cannot be used for certain legal or regulatory purposes
• Procedures for clinical audits and protections for the data gathered.
• A health services provider must inform the relevant regulator (Mental Health Commission, Chief Inspector of Social Services, and the Health Information and Quality Authority) of a notifiable incident within 7 calendar days using the National Incident Management System (NIMS). It is important to note that reporting notifiable incidents through NIMS does not remove the need to report such incidents through other reporting channels.
• The law outlines the requirement of the designated person, who is a support person for the patient or their relevant person and is an employee of the health services provider. The designated person is essential for open disclosure
• The Act specifies what should be discussed at the open disclosure meeting and cancer review meetings, in the written follow-up, and how important it is to keep accurate records.
• Open disclosure is recognised as a process, and the Act specifies what must be covered at an open disclosure meeting, written follow-up of such meetings, the need for additional open disclosure meetings, as well as how a patient or their representative can seek clarification on what was discussed.
• Once the incident has been logged on NIMS, in line with local governance processes, the health services provider (HSE or S38) can notify the relevant regulator on this digital platform. Private providers and independent practitioners will report a notifiable incident through a portal on the regulator's website.
• The Act amends Part 4 of the Civil Liability (Amendment) Act 2017 to align the process with that of the Patient Safety Act. It applies to all patient safety incidents but is not mandated in law. It is an option for staff to use it if they would like similar protections that apply to the Patient Safety Act for all other patient safety incidents.
• Amendments to the Health Act 2007 that modify the threshold for HIQA to carry out statutory investigations and expansion of monitoring into private hospitals.
• The Chief Inspector of Social Services' discretionary power to carry out a review of specified incidents that may have resulted in death or serious injury where some or all of the care was delivered in a designated centre, such as a nursing home. This part of the Act is not commencing on 26 September 2024. It will commence once an essential technical update has been made to the Act. Commencement of this part of the Act will be communicated by the Department of Health in due course.

There are 2 circumstances recognised in the Act where open disclosure may not happen:

• if the patient or their relevant person declines open disclosure. In this scenario, they must be provided with the information on how to contact the health services at any time within the next 5 years to request open disclosure
• when the patient or their relevant person cannot be contacted despite reasonable attempts to do so.

Clinical audit

The Act encourages staff to carry out clinical audits to continuously improve our patient care standards.

The Act offers significant legal protections to clinicians undertaking clinical audit . Information created during a clinical audit cannot be used as:

• admission of fault by a healthcare professional or organisation
• evidence in legal cases (civil proceedings) against healthcare professionals or healthcare organisations
• evidence to cancel a healthcare professionals’ indemnity insurance
• evidence of fault, professional misconduct, poor professional performance or any other failure or omission
• evidence in disciplinary or fitness to practice procedures against healthcare professionals.