Shifts in safety: Trends shaping 2024 from Press Ganey’s PSO

Coauthored by Heather Reed, Senior Director, Patient Safety Organization Clinical and Reliability.

The patient is at the heart of everything we do. Every day, those of us in the healthcare industry strive to reach the ultimate objectives: Compassionate, high-quality care. Optimal health outcomes. And the best possible patient experience at every point in their journey. 

But safety is a baseline patient expectation that underpins all of healthcare. High-quality care, optimal outcomes, and 5-star experiences are all, inherently, safe. If the goal is zero harm, we must never settle for good intentions when real action is needed. Only through ongoing measurement, analysis, benchmarking, and improvements can we accelerate toward this goal and deliver on our promise of patient safety for all.

What is the Press Ganey PSO?

The Press Ganey Patient Safety Organization (PSO), the largest PSO in the country, is a confidential, legally protected forum where members can share safety best practices, learn from each other, and analyze reported safety data.

To date, 124 health systems and 3,965 facilities have joined Press Ganey's PSO. Members have submitted 5.1 million safety event records since its inception in 2016. With national patient safety initiatives gaining momentum, the Press Ganey PSO is uniquely positioned to empower organizations like yours to make true progress toward zero harm.

United by a common mission, the Press Ganey PSO fosters collaboration among healthcare leaders. Together, we identify national patient safety risks and develop solutions for the most critical issues.

Continue reading to explore national safety trends in healthcare.

Patient safety 2024: Trends shaping the road ahead

An analysis of 568,505 events discovered between December 2022 and November 2023 reveals that care management, environmental, and procedural events comprise over 82% of all classified incidents.

Most frequent events

Diving deeper, the care management category, which encompasses things like medication errors, pressure injuries, diagnosis delays, and general coordination issues, emerged as the most frequently reported event type.

Serious safety events

A serious safety event happens when a deviation from generally accepted performance standards reaches a patient and results in moderate to severe harm—or even death.

In 2023, the most common serious safety events fell into three categories: other care management, pressure ulcers, and other procedural (e.g., accidental puncture or laceration, or other issues in technique like puncture/laceration or mislabeled/lost specimen).

1. Other care management events had the highest percentage of deaths. As other care management can be a catchall event type, Press Ganey’s machine learning team is building AI techniques to harvest data from events with this event type classification.
2. Pressure ulcers had the highest percentage of severe permanent harm.  
3. Other procedural had the highest percentage of severe temporary harm.

Based on a 2023 data analysis, the Press Ganey PSO has identified three critical calls to action:

1. Perform root cause analysis quality checks. When there isn’t a proper structure and governance for the cause analysis process, events reoccur.
2. Improve ambulatory medication safety. Press Ganey PSO members in 2023 highlight a greater percentage of medication serious safety events in the ambulatory setting (3%), vs. the inpatient (1%) or outpatient (<1%) care settings. 
3. Integrate equity and safety. There's no such thing as safe, high-quality care that's also inequitable. Health systems can leverage patient safety programs to advance equity.

Press Ganey PSO: Driving national safety initiatives forward

Recent reports and initiatives reinforce the importance of PSOs. These include:

• National Action Plan to Advance Patient Safety: This plan advocates for a total systems approach to safety, encompassing culture, leadership, patient engagement, workforce safety, and learning systems. The Press Ganey PSO’s learning system supports the intra- and interorganizational learning outlined by this plan. For example, the Press Ganey PSO’s Safety Alerts and Safe Table program operationalizes interorganizational learning by identifying and warning others about potential safety risks and sharing best practices to prevent harm. 
• President's Council of Advisors on Science and Technology (PCAST) report: This report outlines a forward-looking approach to advance the safe and effective use of AI in healthcare. The Press Ganey PSO’s collaboration with the Agency for Healthcare Research and Quality’s AI program will support the development of standards and regulations for the use and oversight of AI in healthcare. Additionally, our PSO’s use of AI will follow the guidance of these efforts to ensure the safe and effective use of large language models to harvest key findings from event descriptions submitted to Press Ganey's national database.
• CMS Patient Safety Structural Measures (PSSMs): These attestation measures focus on leadership, governance, and safety culture and will likely be required for hospitals to report in 2025. The Press Ganey PSO's learning forums, analytics, and health equity offerings will support members’ attestations for the proposed measures. For example, domain 4.3: Accountability & Transparency in the proposed measures ask hospitals to attest by saying, “Our hospital reports serious safety events, near misses, and precursor events to a Patient Safety Organization (PSO) listed by the Agency for Healthcare Research and Quality (AHRQ) that participates in voluntary reporting to AHRQ’s Network of Patient Safety Databases.”

The Press Ganey PSO offers a range of resources to help healthcare organizations achieve their safety goals. These include:

• High Reliability Learning Series: Equip healthcare leaders with strategies for building a strong safety culture. Listen to our webinars featuring top experts in the field. 
• Safety Event Classification Advisory Panel: Press Ganey PSO members may submit safety event cases to an expert panel for feedback on deviation, event type, harm classification, and general safety event classification considerations to drive inter-rater reliability within the organization and to advance the skills of safety event review teams.
• Cause Analysis Grand Rounds: Press Ganey PSO members submit root cause analysis cases for feedback on the structure and quality of the cause analysis to optimize the organization’s overall cause analysis program.
• Office hours: Spend time with Press Ganey safety and high reliability experts and our safety support team each month. With no formal agenda, this is an opportunity for members to ask questions about everything, from integrating safety and equity to the cause analysis data submission processes.
• Data analysis and national collaboration: The Press Ganey PSO maintains the largest safety event database in the country. We study our data set to identify trends on a national level as well as uncover insights to shape a safety improvement strategy. Press Ganey PSO dashboards translate national insights into actionable data at the local level for members.

By working together—as healthcare leaders, government agencies, patients, and safety experts—we can achieve significant progress in creating a safer healthcare environment for everyone.

For access to the full report, contact Press Ganey PSO Senior Director Heather Reed at hreed@pressganey.com. For more information, or to join the PSO, reach out to a safety expert.