8 Strategies for improving and measuring patient safety

For facility administrators, patient safety has become inseparable from regulatory risk.

Decisions made on staffing levels, workflow design, and resource allocation now show up directly in CMS Star Ratings, Joint Commission findings, reimbursement outcomes, and public reporting. A single safety lapse can trigger survey citations, payment penalties, or a downgrade that takes years to reverse.

This pressure exists alongside familiar constraints: persistent staffing shortages, rising patient acuity, limited operating margins, and constant change in regulatory expectations. Administrators are asked to maintain compliance, protect staff, and deliver safe care without the luxury of excess capacity. 

When safety systems strain under that weight, leadership is held responsible regardless of intent or effort.

Facilities that perform well under this scrutiny share a common trait. Safety is treated as an operational requirement, not a clinical side project. Leaders invest in standardization, staffing resilience, and reporting systems that surface risk early. They spend time in care environments, understand where processes break down, and respond before regulators or patients are the first to notice.

In this article, we will examine why patient safety is important, what may cause its deterioration, and explore the strategies mentioned above to help you improve and measure it.

What is patient safety, & why is it so important?

The best practices for patient safety in healthcare facilities should focus on preventing and mitigating errors and adverse effects in healthcare. It’s about building a sustainable system that does 3 things exceptionally well:

1. Prevents errors from occurring in the first place
2. Catches errors before they reach the patient
3. Mitigates the impact of errors that are not caught in time

In 2026, safety standards reached an all-time high. With the overhaul of the CMS Five-Star Rating system, safety performance now acts as a "measuring stick." 

If a facility fails to meet its safety benchmarks, it can trigger an automatic 1-star drop in future cycles, regardless of how "fancy" its amenities may be, or how other patient outcomes are. In short, if you aren't practicing safety, you aren't going to be successful.

The impact of poor patient safety

The cost of failing your patients is staggering. Beyond the financial aspect, the human toll is devastating; medical errors remain a leading cause of death in the United States.

• Financial erosion: Poor patient safety costs the U.S. healthcare system billions of dollars annually in lost productivity, litigation, and non-reimbursable readmissions.
• Loss of reputation: Low safety scores from organizations such as The Leapfrog Group or Healthgrades directly influence where patients choose to seek care, potentially leading to a measurable decline in your facility's market share.
• Workforce moral injury: When a patient is unintentionally harmed, the second wave of victims is the clinicians themselves, leading to staff burnout and a high turnover rate.
• Joint Commission penalties:  The Joint Commission patient safety goals are put in place to establish guidelines to help facilities navigate the turbulent waters of patient safety, which, if not followed, result in penalties in more than one category.

Failure in patient safety can have a domino effect, with one mishap leading to another. Paying attention to the details is key to preventing unwanted harm to those you seek to help.

4 Causes of poor patient safety

Errors rarely happen because of one "bad" apple. Errors occur when multiple layers of safeguards fail in succession.

1. Communication breakdowns

Communication is key to the procurement of good patient outcomes. The most common cause of harm occurs during the transition of care between clinicians (shift handoffs). 

When vital information is missed on a nurse's note or a surgeon isn't briefed on a patient's change in condition, the system breaks down.

2. Work & cognitive overload

Poor nurse-to-patient ratios or excessive overtime can fatigue clinicians, and a tired medical professional is statistically more likely to make a mistake. 

When your staff are stretched too thin, unfortunately, "shortcut culture" begins to take hold of team members as a survival mechanism.

3. Lack of standardization

When different departments coexist in the same work environment, using different names for the same procedure creates a situation ripe for miscommunication. 

This inconsistency can be a breeding ground for confusion and errors; taking the time to coordinate between departments and standardize protocols will be a huge step forward in patient safety.

4. Fear of being reprimanded 

In what can be called "blame culture," staff sometimes hide their mistakes to avoid punishment or reprimands. Regrettably, this ensures that the system in place never learns from the error, only prolonging a vicious cycle.

Administrative leadership role in patient safety

Leadership has to be the "thermostat" of a facility's safety culture. They have to set the temperature for the entire setting. To move the needle, leaders must:

• Allocate capital: Invest in technology that takes some of the weight off of your staff, and invest in flexible staffing options to ensure your staff is rested and focused on their next shift.
• Practice rounding for outcomes: Administrative leaders should be a constant presence on the floor, asking questions, listening, and ensuring staff have the resources they need to accomplish their goals.
• Psychological safety: Management must ensure a work environment where a junior tech feels safe speaking up if they notice a problem with a technique or situation.

8 Strategies to help improve patient safety

There is no one-size-fits-all solution to improving patient safety and quality in nursing; it is a combination of strategic ideas being put into practice.

1. Verify clinical protocols are standardized across the board

Consistency and repetition are the enemies of error. Facilities must maintain proper and constant audit processes and enforce uniform safety protocols across:

• Medication administration (The "Five Rights")
• Hand hygiene compliance (the most basic yet vital defense)
• Transitions of care (using standardized tools like SBAR)

2. Strengthen your team's communication & teamwork

Treat safety as a team sport. Deploy a structured communication network and ensure that everyone, from your janitorial staff to the most specialized of specialists, is on the same page regarding protocols and clinical risk management.

3. Adopt an evidence-based safety culture 

You don't have to reinvent the wheel. Use proven frameworks such as:

• High-Reliability Organization (HRO): Emphasizes a zero-harm mindset and system-level safeguards borrowed from high-risk industries such as aviation and nuclear power.
• Just Culture: Emphasizes fair and consistent accountability by differentiating between human error (console), risky behavior (coach), and reckless behavior (punish).

These frameworks support the development of systems that make it easier to report errors, learn from near-misses, and respond consistently when safety events occur.

4. Create a system for incident reporting & learning

Encourage and create an environment where medical staff feel comfortable reporting errors in real time or anonymously reporting near misses. 

Use a team-based retrospective process, such as Root Cause Analysis (RCA), to dig past the "who did it?" to find the "why the system let it happen?"

5. Engage with patients & their families

Patients are some of the best "safety checks" available. 

Use the “Teach-Back” model to ensure patients, before leaving your facility, understand their discharge instructions. By interacting with your patients, you may uncover information that will help improve patient safety and healthcare operations management.

6. Invest in staff training

Continued education should be a staple in your facility; information will keep your staff safe. Sim-lab training for emergency response protocols keeps your core team's skills sharp when under pressure. 

7. Give your care team the proper support

There is safety in numbers; with proper staffing ratios, the chances of errors drop substantially. 

When staffing gaps arise, medical facilities should have a flexible, fast staffing solution, such as Nursa, to find qualified clinicians who can step in and ensure their permanent team isn't overwhelmed or prone to error. Explore how flexible staffing can help you cover sudden gaps or spikes in patient census.

8. Prepare for these common barriers

• Change resistance: Clinicians often rely on established routines; prepare by involving them early and clearly communicating the purpose of change.
• Initiative fatigue: Too many new policies at once can overwhelm staff; prepare by pacing rollouts and prioritizing high-impact initiatives.
• Staffing shortages: Chronic understaffing increases fatigue and error risk; prepare by planning coverage buffers and monitoring workload strain.
• Lack of psychological safety: When speaking up is discouraged or punished, reporting suffers; prepare by reinforcing non-punitive reporting and leadership follow-through.
• Technology resistance: New digital tools can disrupt clinical workflows; prepare by aligning technology with real workflows and providing hands-on training.
• Data overload without insight: Excess data without clear answers frustrates clinicians; prepare by translating data into actionable feedback and visible improvements.

Measurement frameworks for monitoring patient safety

How can you improve something that isn’t measured? 

In patient safety, measurement has shifted beyond tracking harm after it occurs to identifying signals that predict risk earlier. As a result, high-performing facilities balance lagging indicators with leading indicators to monitor safety more effectively.

• Leading indicators: Measures that signal future risk or system weakness, such as near-miss reporting rates, hand hygiene compliance, and staff safety culture surveys.
• Lagging indicators: Measures that reflect harm after it has occurred, including hospital-acquired infections (HAIs), readmission rates, and PSI-90 scores.

To turn measurement into meaningful improvement, many facilities rely on structured improvement frameworks. One widely used framework is the Plan-Do-Study-Act (PDSA) Cycle, which remains the gold standard for testing small safety changes before having them rolled out facility-wide. 

Furthermore, comparing your facility's numbers against national databases, such as the National Healthcare Safety Network (NHSN) or the Centers for Medicare & Medicaid Services (CMS), ensures your facility isn't operating in a vacuum and can track its progress.

Bottom line: Patient care & safety start with leadership

Patient safety is a relentless, daily commitment. 

While using the latest technology and employing the strictest protocols are vital, they can be ineffective without a leadership team that takes control and prioritizes the humanity of its staff and patients alike.

Are you ready to elevate your facility's safety standards? 

Start by examining your current adverse-event reporting culture and exploring how flexible staffing support can help protect your team from stress, exhaustion, and the dangers of burnout.

Sources:

• Patient Safety Standards & 2026 Quality Rating System
• Patient Safety Indicators (PSI) Technical Specifications v2025/2026
• Patient Safety and Quality Improvement Act (PSQIA) Oversight
• National Patient Safety Goals (NPSGs) | Joint Commission ‍
• H.R. 3415 - Nurse Staffing Standards for Patient Safety‍
• Impact of Chevron Deference Overturn on Health Regulation‍
• 2026 Advocacy Agenda for Quality & Safety‍
• CMS Elevates Patient Safety in 2026 Star Ratings‍
• Tools and Strategies for Quality Improvement and Patient Safety