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Florence Nightingale once quipped, "The first duty of a hospital is that it should do the sick no harm." Yet the 1998 Institute of Medicine report, "To Err is Human," revealed that hospitalized patients all too frequently suffer the consequences of mishaps; some 44,000-98,000 patients every year die from medical mistakes.
Despite this troubling revelation and the subsequent flourishing field of patient safety (which can be defined as the prevention, avoidance, and amelioration of adverse outcomes originating from the processes of care delivery), little measurable progress has been made in patient safety in the United States during the past 15 years.
Certainly, success stories exist, such as the actualization that central line infection rates can be reduced to near zero with proper processes, procedures, and culture. Yet demonstration of broad-based impact of the patient safety field has been lacking and the cause is multifactorial: Patient safety is a relatively infant field, and suboptimal safety culture and team-based care, lack of knowledge and competency in safety science, and inadequate (or even perverse) incentives all likely play a role.
However, a more important contributing factor may be the inadequacy of routine safety measurement.
After all, measurement is the first step toward gaining the knowledge and control, which in turn leads to improvement. For many, safety measurement is simply defined by benchmarked metrics of harm occurrence (e.g. infection rates, falls, etc.). Assessing safety by these reactive measures, although informative, does not by itself tell us how dangerous it is now or will be in the future. The narrow view of defining safety based upon these lagging indicators –indicators that define safety just by those events that have already reached a patient – would be analogous to the nuclear power industry defining safety solely by the frequency of catastrophic events. To more meaningfully understand the safety in our hospitals, these rear-view metrics should be balanced with proactive measures of prevention and reliability, i.e., leading indicators. The essence of leading indicators (such as the results of a safety culture survey, information obtained during safety walk rounds, and system audits) is that they are proactive. They measure variables that are believed to be indicators or precursors of safety performance so that safety is achieved and maintained before harm actually occurs.
A proposed minimum safety measurement set for a hospital or care delivery unit is as follows:
Leading indicators of safety:
• Safety culture survey results.
• Safety walk rounds.
• Clinical care audits.
Lagging indicators of safety:
• Mortality.
• Hospital-acquired conditions.
• Incident reporting.
• Medication errors.
• Malpractice claims/patient complaints.
• Diagnostic errors.
• Appropriateness of care.
To truly know if our hospital (or clinic, or inpatient unit, or health care system) is safe, we need to be able to understand not only if safety has been demonstrated in the past, but also if it is being demonstrated in the present, and will be in the future; if care delivery is reliable; and if the system is learning from harm or errors in process.
Only through such a multiperspective measurement dashboard to shape culture and drive performance will health care truly achieve the performance that our patients deserve and that will allow us to uphold our moral and professional obligation of primum non nocere.
What safety measurements are you and your hospital using to achieve this goal?
Dr. Pendleton is chief medical quality officer for University of Utah Health Care, Salt Lake City, and a member of the Hospitalist News advisory board.
Florence Nightingale once quipped, "The first duty of a hospital is that it should do the sick no harm." Yet the 1998 Institute of Medicine report, "To Err is Human," revealed that hospitalized patients all too frequently suffer the consequences of mishaps; some 44,000-98,000 patients every year die from medical mistakes.
Despite this troubling revelation and the subsequent flourishing field of patient safety (which can be defined as the prevention, avoidance, and amelioration of adverse outcomes originating from the processes of care delivery), little measurable progress has been made in patient safety in the United States during the past 15 years.
Certainly, success stories exist, such as the actualization that central line infection rates can be reduced to near zero with proper processes, procedures, and culture. Yet demonstration of broad-based impact of the patient safety field has been lacking and the cause is multifactorial: Patient safety is a relatively infant field, and suboptimal safety culture and team-based care, lack of knowledge and competency in safety science, and inadequate (or even perverse) incentives all likely play a role.
However, a more important contributing factor may be the inadequacy of routine safety measurement.
After all, measurement is the first step toward gaining the knowledge and control, which in turn leads to improvement. For many, safety measurement is simply defined by benchmarked metrics of harm occurrence (e.g. infection rates, falls, etc.). Assessing safety by these reactive measures, although informative, does not by itself tell us how dangerous it is now or will be in the future. The narrow view of defining safety based upon these lagging indicators –indicators that define safety just by those events that have already reached a patient – would be analogous to the nuclear power industry defining safety solely by the frequency of catastrophic events. To more meaningfully understand the safety in our hospitals, these rear-view metrics should be balanced with proactive measures of prevention and reliability, i.e., leading indicators. The essence of leading indicators (such as the results of a safety culture survey, information obtained during safety walk rounds, and system audits) is that they are proactive. They measure variables that are believed to be indicators or precursors of safety performance so that safety is achieved and maintained before harm actually occurs.
A proposed minimum safety measurement set for a hospital or care delivery unit is as follows:
Leading indicators of safety:
• Safety culture survey results.
• Safety walk rounds.
• Clinical care audits.
Lagging indicators of safety:
• Mortality.
• Hospital-acquired conditions.
• Incident reporting.
• Medication errors.
• Malpractice claims/patient complaints.
• Diagnostic errors.
• Appropriateness of care.
To truly know if our hospital (or clinic, or inpatient unit, or health care system) is safe, we need to be able to understand not only if safety has been demonstrated in the past, but also if it is being demonstrated in the present, and will be in the future; if care delivery is reliable; and if the system is learning from harm or errors in process.
Only through such a multiperspective measurement dashboard to shape culture and drive performance will health care truly achieve the performance that our patients deserve and that will allow us to uphold our moral and professional obligation of primum non nocere.
What safety measurements are you and your hospital using to achieve this goal?
Dr. Pendleton is chief medical quality officer for University of Utah Health Care, Salt Lake City, and a member of the Hospitalist News advisory board.
Florence Nightingale once quipped, "The first duty of a hospital is that it should do the sick no harm." Yet the 1998 Institute of Medicine report, "To Err is Human," revealed that hospitalized patients all too frequently suffer the consequences of mishaps; some 44,000-98,000 patients every year die from medical mistakes.
Despite this troubling revelation and the subsequent flourishing field of patient safety (which can be defined as the prevention, avoidance, and amelioration of adverse outcomes originating from the processes of care delivery), little measurable progress has been made in patient safety in the United States during the past 15 years.
Certainly, success stories exist, such as the actualization that central line infection rates can be reduced to near zero with proper processes, procedures, and culture. Yet demonstration of broad-based impact of the patient safety field has been lacking and the cause is multifactorial: Patient safety is a relatively infant field, and suboptimal safety culture and team-based care, lack of knowledge and competency in safety science, and inadequate (or even perverse) incentives all likely play a role.
However, a more important contributing factor may be the inadequacy of routine safety measurement.
After all, measurement is the first step toward gaining the knowledge and control, which in turn leads to improvement. For many, safety measurement is simply defined by benchmarked metrics of harm occurrence (e.g. infection rates, falls, etc.). Assessing safety by these reactive measures, although informative, does not by itself tell us how dangerous it is now or will be in the future. The narrow view of defining safety based upon these lagging indicators –indicators that define safety just by those events that have already reached a patient – would be analogous to the nuclear power industry defining safety solely by the frequency of catastrophic events. To more meaningfully understand the safety in our hospitals, these rear-view metrics should be balanced with proactive measures of prevention and reliability, i.e., leading indicators. The essence of leading indicators (such as the results of a safety culture survey, information obtained during safety walk rounds, and system audits) is that they are proactive. They measure variables that are believed to be indicators or precursors of safety performance so that safety is achieved and maintained before harm actually occurs.
A proposed minimum safety measurement set for a hospital or care delivery unit is as follows:
Leading indicators of safety:
• Safety culture survey results.
• Safety walk rounds.
• Clinical care audits.
Lagging indicators of safety:
• Mortality.
• Hospital-acquired conditions.
• Incident reporting.
• Medication errors.
• Malpractice claims/patient complaints.
• Diagnostic errors.
• Appropriateness of care.
To truly know if our hospital (or clinic, or inpatient unit, or health care system) is safe, we need to be able to understand not only if safety has been demonstrated in the past, but also if it is being demonstrated in the present, and will be in the future; if care delivery is reliable; and if the system is learning from harm or errors in process.
Only through such a multiperspective measurement dashboard to shape culture and drive performance will health care truly achieve the performance that our patients deserve and that will allow us to uphold our moral and professional obligation of primum non nocere.
What safety measurements are you and your hospital using to achieve this goal?
Dr. Pendleton is chief medical quality officer for University of Utah Health Care, Salt Lake City, and a member of the Hospitalist News advisory board.
