17 Learning together to be ‘Safer together’: implementing a learning network to advance patient safety

<h3>Background</h3> Despite high hopes for shared learning in safety, it remains unrealized. Harm from medical errors is still underreported, and findings from investigations are often not shared beyond the originating facility or even widely within a facility or health system. <h3>Objective</h3> The ‘Safer Together: National Action Plan to Advance Patient Safety’ (NAP) advocates for enhancing patient safety by facilitating intra- and inter-organizational learning, accelerating safety learning networks, initiating systems for interprofessional education on safety, and expediting industry-wide collaboration on safety initiatives. <h3>Methods</h3> Aligning with one of the four foundational areas in NAP, the Learning System, we explore solutions for widespread learning from safety events across 17 states in various healthcare settings. We discuss the challenges of culture, technology, measurement, and barriers to learning from errors. We present insights from our NAP self-assessments, ambulatory safety huddles, and national-level Safe Tables. We also discuss our solutions for learning from causal analyses, storytelling through a ‘Good Catch’ program, and the importance of data and breaking down silos. Our focus is also on communication breakdowns that cause patient harm in ambulatory care settings, fortifying the need for safety huddles and a platform for office staff to flag unsafe conditions and proactively address risks to patient safety. <h3>Results</h3> Our safety culture survey and the observations from NAP self-assessments have highlighted opportunities to improve our culture, awareness, and collaborative learning across several states in the US. The Key Driver Diagram outlines our approach (figure 1). Although it is still early, our statistical analyses indicate positive trends in increased reporting of incidents and near-misses and improved patient safety (figures 2–5). <h3>Conclusions and Implications</h3> Learning systems can be compelling in improving the culture of safety, fortifying our healthcare processes, and improving patient and workforce safety.