The Science of Safety Improvement: Learning While Doing
Authors: Carolyn M. Clancy, Donald M. Berwick
Journal: Annals of Internal Medicine (2011)

Editorials17 May 2011The Science of Safety Improvement: Learning While DoingCarolyn M. Clancy, MD and Donald M. Berwick, MD, MPPCarolyn M. Clancy, MDFrom Agency for Healthcare Research and Quality, Rockville, MD 20850, and Centers for Medicare & Medicaid Services, Washington, DC 20201.Search for more papers by this author and Donald M. Berwick, MD, MPPFrom Agency for Healthcare Research and Quality, Rockville, MD 20850, and Centers for Medicare & Medicaid Services, Washington, DC 20201.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-154-10-201105170-00013 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Dr. Jane Jones is the chief quality officer for a hospital where the chief executive officer has repeatedly emphasized the need to reduce readmission rates. Dr. Jones found an article (1) about an innovative program called “reengineered discharge” (RED) that dramatically reduced the rates of readmissions and emergency department visits within the first 30 days after hospital discharge. This program was tested in a block randomized trial and involved using a nurse discharge advocate to arrange follow-up appointments and medications and a pharmacist to follow up with patients several days after discharge.Dr. Jones was impressed by the abstract but ...References1. Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150:178-87. [PMID: 19189907] LinkGoogle Scholar2. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy SM, Foy R, et al. Advancing the science of patient safety. Ann Intern Med. 2011;154:693-6. LinkGoogle Scholar3. Foy R, Ovretveit J, Shekelle PG, Pronovost PJ, Taylor SL, Dy S, et al. The role of theory in research to develop and evaluate the implementation of patient safety practices. Qual Saf Health Care. 11 February 2011. [Epub ahead of print.] Google Scholar4. Davidoff F. Heterogeneity is not always noise: lessons from improvement. JAMA. 2009;302:2580-6. [PMID: 20009058] CrossrefMedlineGoogle Scholar5. Shekelle PG, Pronovost PJ, Wachter RM, Taylor SL, Dy S, Foy R, et al. Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria. Contract Final Report. AHRQ publication no. 11-0006-EF. (Prepared by RAND Health under contract HHSA-290-2009-10001C with the Agency for Healthcare Research and Quality.) Rockville, MD: Agency for Healthcare Research and Quality; 2010. Accessed at www.ahrq.gov/qual/contextsensitive/ on 15 March 2011. Google Scholar6. Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NK, et al. 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A research framework for reducing preventable patient harm. Clin Infect Dis. 2011;52:507-13. [PMID: 21258104] CrossrefMedlineGoogle Scholar16. Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: a review of surveys. Qual Saf Health Care. 2005;14:364-6. [PMID: 16195571] CrossrefMedlineGoogle Scholar17. Sullivan P, Goldmann D. The promise of comparative effectiveness research. JAMA. 2011;305:400-1. [PMID: 21266687] CrossrefMedlineGoogle Scholar18. Fisher ES, Shortell SM. Accountable care organizations: accountable for what, to whom, and how. JAMA. 2010;304:1715-6. [PMID: 20959584] CrossrefMedlineGoogle Scholar19. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124-34. [PMID: 21105794] CrossrefMedlineGoogle Scholar20. U.S. Department of Health and Human Services. Adverse events in hospitals: national incidence among Medicare beneficiaries. 2010. Accessed at oig.hhs.gov/oei/reports/oei-06-09-00090.pdf on 7 April 2011. Google Scholar21. Classen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al. ‘Global trigger tool’ shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff (Millwood). 2011;30:581-9. [PMID: 21471476] CrossrefMedlineGoogle Scholar22. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219. [PMID: 21282262] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Agency for Healthcare Research and Quality, Rockville, MD 20850, and Centers for Medicare & Medicaid Services, Washington, DC 20201.Acknowledgment: The authors thank Denise Dougherty, PhD, and Gail Makulowich, BA.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0629.Corresponding Author: Gail Makulowich, Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850; e-mail, [email protected]hhs.gov.Current Author Addresses: Dr. Clancy: Agency for Healthcare Research and Quality, 540 Gaither Road, Rockville, MD 20850.Dr. Berwick: Centers for Medicare & Medicaid Services, 200 Independence Avenue SW, Mailstop 314G, Washington, DC 20201. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAdvancing the Science of Patient Safety Paul G. Shekelle , Peter J. Pronovost , Robert M. Wachter , Stephanie L. Taylor , Sydney M. Dy , Robbie Foy , Susanne Hempel , Kathryn M. McDonald , John Ovretveit , Lisa V. Rubenstein , Alyce S. Adams , Peter B. Angood , David W. Bates , Leonard Bickman , Pascale Carayon , Sir Liam Donaldson , Naihua Duan , Donna O. Farley , Trisha Greenhalgh , John Haughom , Eileen T. Lake , Richard Lilford , Kathleen N. Lohr , Gregg S. Meyer , Marlene R. Miller , Duncan V. Neuhauser , Gery Ryan , Sanjay Saint , Kaveh G. Shojania , Stephen M. Shortell , David P. 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