“To Err is Human”: Uniformly Reporting Medical Errors and Near Misses, a Naïve, Costly, and Misdirected Goal

Andrus, Charles H.; Villasenor, Eduardo G; Kettelle, John B.; Roth, Randolph; Sweeney, Allison M.; Matolo, Nathaniel M.

doi:10.1016/s1072-7515(03)00236-9

Cited by 18 publications

(11 citation statements)

References 26 publications

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“…Incident data are biased, primarily comprising errors of commission (rarely including errors of omission) and mainly reported by nursing staff. [14][15][16] For all of these reasons, reported incident data are not suitable for measuring safety performance. The true value in incident reporting lies not in counting incident reports, but in the analysis and understanding of causation and the subsequent actions to prevent patient harm through "error proofing" the system.…”

Section: The Measurement Problem In Patient Safetymentioning

confidence: 99%

Patient safety — a balanced measurement framework

Wakefield¹,

Jorm²

2009

Aust. Health Review

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Evidence of the unacceptably high incidence of patient harm associated with health care has resulted in patient safety becoming a major reform agenda. Despite significant investment by governments on strategies to reduce patient harm, confusion still exists on how to measure patient safety.While the goal of patient safety is harm prevention, most of the measurement focus has been on counting incident reports. The (ab)use of reported incident data to measure both technical safety performance (injury rates) and evaluate the effectiveness of safety improvement initiatives continues to confuse and mislead consumers, funders and providers of health care. This paper proposes a simple measurement framework for patient safety which balances the elements of: learning, action, performance, patient experience, and staff attitudes and behaviour. Application of this framework to current priority areas should be used as a basis for patient safety improvement at clinical unit, hospital, state and national levels.OVER THE PAST fifteen years, patient safety has become the focus of significant national and international health reform activity. Despite this, the measurement of patient safety has remained a challenge, particularly at jurisdictional level. This paper seeks to address this issue by proposing a simple patient safety measurement framework involving five measurement domains. All have limited scope, each being best for a specific purpose, but used together can assist an organisation in measuring and improving patient safety.Multiple patient safety measures have been proposed and combined; however, very few assess patient safety performance (true rate of patient harm). It has recently been suggested that "while most hospitals measure some aspect of patient safety, there may not be comprehensive measurement in up to 44% of hospitals", 1 (p. 39) yet these authors did not define or justify a set of measures that would constitute comprehensive measurement for safety. The practical framework outlined in this paper, while pragmatic in its scope, represents a comprehensive view of patient safety measurement. What is known about the topic? It is hard to measure safety performance, that is, the true adverse event or injury rate. Incident reports are often incorrectly used for this purpose. Measures of harm alone are not sufficient to help us determine how to improve safety (ie, for harm prevention). What does this paper add? This paper introduces a comprehensive measurement framework for patient safety. Measures are suggested for the complementary elements of: safety learning, safety performance, patient experience, and staff attitudes and behaviour. Use of measures for all these elements tells us why incidents occur, whether corrective action is being undertaken, the quanta of harm, whether patients feel safe and about the organisational safety culture. What are the implications for practitioners? Application of this measurement framework produces a comprehensive assessment of patient safety. Use of the framework will ens...

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Section: The Measurement Problem In Patient Safetymentioning

confidence: 99%

Patient safety — a balanced measurement framework

Wakefield¹,

Jorm²

2009

Aust. Health Review

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“…While such systems have their skeptics [12], the allure of improving patient care through a blame-free health delivery system has led to the development of a patchwork quilt of reporting systems based upon these principles. A lack of standardization among these systems has significantly hindered their usefulness in developing generalizable knowledge about the nature of medical errors or data upon which to established evidence-based medical practices [13].…”

Section: Confidential Error and Near-miss Reportingmentioning

confidence: 99%

Patient Safety and Patients' Rights

Silverman

2004

AMA Journal of Ethics

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Adopting a uniform system that enhances patient safety.Upon initial examination, efforts toward achieving these 2 goals appear philosophically complementary. For example, both tout as a primary benefit improvement of access to health care services. However, closer inspection of these initiatives' more prominent features reveals seemingly irreconcilable demands. As described below, the push toward consumer-driven health plans as a way to offer affordable employer-based health coverage (and, hence, advance the first goal) requires that comprehensive information be available about individual physicians. The patient safety movement's advocacy for the creation of a confidential medical error reporting system (that would serve the second goal) requires safeguarding individual physician information from the public. Consumer-Driven Health CareWith more than 43 million Americans lacking health insurance and health insurance premiums for the insured rising by double digits year after year, we appear to be approaching the demise of the current structure of the employment-based health insurance system [1]. Employers, seeking both new ways to offer employees the valuable benefit of health insurance coverage and, at the same time, better ways to contain the financial risk they shoulder when providing such benefits, are increasingly turning to consumer-driven health benefit plans as a possible solution [2][3][4]. Recently approved by the Internal Revenue Service, consumer-driven (or consumer-directed) health plans continue the economic trend toward turning passive patients who may overutilize health services into savvy, frugal consumers of health services [5][6][7] by "putting patients in a position to say 'no' to themselves" [4]. While there are several different ways to structure a "consumer-driven" health plan [2-4], they generally offer individual employees an increased role in the design of their benefit package, including choice of physician and the opportunity to set the level of their financial risk. In a consumer-directed plan, patients shoulder a greater burden of the cost of health services.In addition to making cost-benefit analyses of particular interventions, individual patients will have a greater responsibility to research and analyze the quality of their clinicians and to weigh the relative merits of these providers' expertise in the particular interventions. There are grave concerns that patients are being moved into these plans with neither the requisite training to expertly assess quality data, nor even an adequate level of available data from which to base quality comparisons. Meanwhile, hundreds of thousands, if not millions, of consumers are already joining such plans, and they will need access to sophisticated data on the quality of

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“…Expenditures for health care continue to rise at an alarming pace, and the movement toward evidencebased medicine and outcomes research are more pervasive. [1][2][3][4][5] New restrictions on the medical workforce include limiting work hours for physicians in training, [2][3][4][5] and aging of health care workers and the population 3-4 amid growing concerns about professional liability, life style change, and other concerns.…”

mentioning

confidence: 99%

“…The effort to practice evidence-based care and to improve outcomes has promulgated a number of studies and initiatives, including leapfrog and other initiatives subsequent to the Institute of Medicine's "To Err Is Human Report." [5][6][7][8][9] A growing body of literature began to suggest that outcomes were improved at high volume centers. 1,2,9,10 The data were often based on mortality data or length of stay criteria.…”

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Innovation and Competence in an Era of Medical Workforce Flux

Lanzafame

2003

Journal of Clinical Laser Medicine & Surgery

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“To Err is Human”: Uniformly Reporting Medical Errors and Near Misses, a Naïve, Costly, and Misdirected Goal

Cited by 18 publications

References 26 publications

Patient safety — a balanced measurement framework

Patient safety — a balanced measurement framework

Patient Safety and Patients' Rights

Innovation and Competence in an Era of Medical Workforce Flux

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“To Err is Human”: Uniformly Reporting Medical Errors and Near Misses, a Naïve, Costly, and Misdirected Goal

Cited by 18 publications

References 26 publications

Patient safety &mdash; a balanced measurement framework

Patient safety &mdash; a balanced measurement framework

Patient Safety and Patients' Rights

Innovation and Competence in an Era of Medical Workforce Flux

Contact Info

Product

Resources

About

Patient safety — a balanced measurement framework

Patient safety — a balanced measurement framework