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1 Work together to drive greater urgency to prevent harm to patients and those who care for them in all settings across the care continuum.

2 Strengthen the foundation for eliminating harm by ensuring that leaders actively promote a culture of safety, the spread of learning systems, patient and family engagement, and workforce safety.

3 Partner with patients, families, and care partners and commit to open, honest, and respectful communication to create safe, person‐centered health care.

4 Coordinate and collaborate to achieve large‐scale, sustainable improvement in safety.

5 Transparently share successes and failures within and across organizations and industries to promote learning and improve outcomes for all.

6 Advance health equity so that everyone has the safest care, and no one is disadvantaged due to demographic characteristics or social determinants.

7 Support policies and regulations that will improve patient safety.

Source: Institute for Healthcare Improvement, 2020.

Figure 1.3 National Action Plan for Patient Safety: four foundational themes.

Source: Institute for Healthcare Improvement, 2020.

The action plan (Figure 1.3) is organized into four major themes: Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning Systems (Table 1.1). Seventeen recommendations accompany the four interdependent foundational themes to create total systems safety; no theme stands alone—improvement in one will reflect improvement in another.

Three further cross‐cutting themes relate to each theme and specify how each should be enacted:

 Person‐centered care.

 Care across the continuum.

 Relationship between patient safety and health equity.

Systemic biases in health care show concentrated harm to certain populations specific to race, ethnicity, sex, gender, age, and socioeconomics. All organizations are urged to apply the recommendations as the way forward to eliminate patient harm.