Patient Safety: Let's Measure What Matters
Authors: Eric J. Thomas, David C. Classen
Journal: Annals of Internal Medicine (2014)

Ideas and Opinions6 May 2014Patient Safety: Let's Measure What MattersEric J. Thomas, MD, MPH and David C. Classen, MD, MSEric J. Thomas, MD, MPHFrom University of Texas at Houston–Memorial Center for Healthcare Quality and Safety, Houston, Texas, and University of Utah School of Medicine, Salt Lake City, Utah. and David C. Classen, MD, MSFrom University of Texas at Houston–Memorial Center for Healthcare Quality and Safety, Houston, Texas, and University of Utah School of Medicine, Salt Lake City, Utah.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M13-2528 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Recent studies in the United States and Europe suggest that despite some success at individual hospitals and reduced harm for 2 conditions (1), patient safety is not improving (2, 3) and remains a major public health problem (4). We have studied patient safety for 20 years, and these findings prompted one of us (Dr. Thomas) to review the case summaries of the 265 preventable deaths from the Utah and Colorado Medical Practice Study (5). The Institute of Medicine used these cases to estimate the number of preventable deaths due to medical errors for its landmark report, "To Err is Human" ...References1. Wang Y, Eldridge N, Metersky ML, Verzier NR, Meehan TP, Pandolfi MM, et al. National trends in patient safety for four common conditions, 2005-2011. N Engl J Med. 2014;370:341-51. [PMID: 24450892] CrossrefMedlineGoogle Scholar2. 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 Scholar3. 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 Scholar4. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013;9:122-8. [PMID: 23860193] CrossrefMedlineGoogle Scholar5. Thomas EJ, Studdert DM, Newhouse JP, Zbar BI, Howard KM, Williams EJ, et al. Costs of medical injuries in Utah and Colorado. Inquiry. 1999;36:255-64. [PMID: 10570659] MedlineGoogle Scholar6. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Pr; 2000. Google Scholar7. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA. The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery. 1999;126:66-75. [PMID: 10418594] CrossrefMedlineGoogle Scholar8. Levinson DR. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. OEI-06-09-00090. Washington, DC: Department of Health and Human Services; 2010. Accessed at http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf on 20 March 2014. Google Scholar9. Meyer GS, Nelson EC, Pryor DB, James B, Swensen SJ, Kaplan GS, et al. More quality measures versus measuring what matters: a call for balance and parsimony. BMJ Qual Saf. 2012;21:964-8. [PMID: 22893696] CrossrefMedlineGoogle Scholar10. Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC: National Academies Pr; 2011. Accessed at www.iom.edu/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx on 28 October 2013. Google Scholar Author, Article, and Disclosure InformationAffiliations: From University of Texas at Houston–Memorial Center for Healthcare Quality and Safety, Houston, Texas, and University of Utah School of Medicine, Salt Lake City, Utah.Disclosures: Dr. Thomas helped to develop a commonly used safety culture survey and conducts research on safety culture. Dr. Classen is employed by a federally certified patient safety organization, which advises health care organizations about measuring and improving patient safety. Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2528.Corresponding Author: Eric J. Thomas, MD, MPH, University of Texas at Houston–Memorial Hermann Center for Healthcare Quality and Safety, 6410 Fannin Street, UTPB 1100, Houston, TX 77030; e-mail, eric.[email protected]tmc.edu.Current Author Addresses: Dr. Thomas: University of Texas at Houston–Memorial Hermann Center for Healthcare Quality and Safety, 6410 Fannin Street, UTPB 1100, Houston, TX 77030.Dr. Classen: University of Utah School of Medicine, Veterans Administration Medical Center, 500 South Foothill Boulevard, Salt Lake City, UT 84149.Author Contributions: Conception and design: E.J. Thomas, D.C. Classen.Drafting of the article: E.J. Thomas, D.C. Classen.Critical revision of the article for important intellectual content: E.J. Thomas, D.C. Classen.Final approval of the article: E.J. Thomas, D.C. Classen.Administrative, technical, or logistic support: E.J. Thomas. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited ByCompelled Disclosure of Confidential Information in Patient Safety ResearchOperational measurement of diagnostic safety: state of the scienceThe Impact of Performing Medical/Nursing Tasks at Home Among Caregivers of Individuals With Cognitive ImpairmentThe harms of promoting 'Zero Harm'Measures to Improve Diagnostic Safety in Clinical PracticeCreating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unitDevelopment of the Surgical Patient safety Observation Tool (SPOT)Exploring the roots of unintended safety threats associated with the introduction of hospital ePrescribing systems and candidate avoidance and/or mitigation strategies: a qualitative studyAccuracy of interpreting vital signs in simulation: An empirical study of conformity between medical and nursing studentsMeasuring What Really Matters in Patient SafetyDevelopment of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional LearningHow safe are your patients?Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine wardThe future of measuring patient safety: prospective clinical surveillanceAdvancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework 6 May 2014Volume 160, Issue 9Page: 642-643KeywordsAdverse eventsCaregiversDisclosureHealth careHealth care qualityMedicarePrevention, policy, and public healthResearch quality assessmentSafetySafety studies ePublished: 6 May 2014 Issue Published: 6 May 2014 CopyrightCopyright © 2014 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...