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illuminates the collective insights of the 27 member organizations of the National Steering Committee for Patient Safety (NSC), convened in 2018 by the Institute for Healthcare Improvement and committed to achieving safer care and reducing harm to patients and caregivers.

Though U.S. researchers have identified many evidence-based, effective best practices for harm reduction over the past 20 years, they are seldom shared nationally and implemented effectively across multiple organizations. Reducing preventable harm requires a total systems approach: a coordinated, proactive strategy in which risks are anticipated and systemwide safety processes are applied across the entire healthcare continuum through robust collaboration among all stakeholders.

The National Action Plan includes 17 recommendations to advance patient safety, with a focus on eliminating inequities at the point of care. Supplemented by both a Self-Assessment Tool and an Implementation Resource Guide, the Plan centers on four foundational and interdependent priority areas:  

• Culture, Leadership, and Governance: to demonstrate and foster commitments to safety as a core value and promote the development of safety cultures.
• Patient and Family Engagement: to instill the practice of co-designing and co-producing care with patients, families, and care partners to ensure their meaningful partnership in all aspects of care design, delivery, and operations.
• Workforce Safety: to ensure the safety and resiliency of organizations and workforces as a precondition to advancing patient safety with a unified, total systems-based approach to eliminate harm to both patients and the workforce.
• Learning System: to foster networked and continuous learning within and across health care organizations at all levels to encourage widespread sharing, learning, and improvement.

The NSC considers these areas to be foundational because they create the fertile soil that allows broader safety initiatives to take root and be cultivated. They are also interdependent because advancing in one area alone is difficult without advancing in all of them. And they each benefit from widespread collaboration and coordination. The resulting recommendations in these four areas build on the substantial body of experience, evidence, and lessons learned that the NSC has gathered and will test and implement together to allow for future refinements as our understanding, experience, and evidence evolve over time. 

The NSC was originally co-chaired by Jeffrey Brady, M.D., M.P.H., former director of AHRQ's Center for Quality Improvement and Patient Safety (CQuIPS), and Tejal K. Gandhi, M.D., M.P.H., CPPS, senior fellow, Institute for Healthcare Improvement (IHI); chief safety and transformation officer, Press Ganey Associates. The NSC is currently co-chaired by CQuIPS Director Craig Umscheid, M.D., M.S., and Patrician McGaffigan, R.N., M.S., CPPS, vice president, safety programs, IHI, and president, Certification Board for Professionals in Patient Safety. about the NSC and the National Action Plan.