Safety – what to measure

Reading comments to a blog entry prompts me to comment. For discussion purposes, consider the following four box table.

  Patient suffers harm Patient doesn’t suffer harm
Preventable medical error made  XXXXXXXXXXXXXXX  
No preventable medical error made    


As an example, consider placing a central line, with the medical error being failure to wash hands, and the harm being an infection. One could focus on the “Patient suffers harm” column and try to find cases where a preventable medical error was made (red X’s). But, there are two problems.

  1. Failure to wash hands may not have caused the infection
  2. The infection may be unrelated to a preventable medical error.

The problem is focusing on outcomes, especially since bad outcomes are common in hospitals (patients die).

One should focus on errors not outcomes. In the case of central line infections, this is rather easy if one is following the checklist recommended by Pronovost, because the process of placing a central line is monitored for errors.

Also, note that in the original use of the checklist for central line infections, for the “before” case, about 30% of the time one of the 5 checklist items was not carried out and the central line infection rate was about 10%.

To focus on errors, one must describe the process, say what is and is not an error, and observe the process each time. Each of these steps has a spectrum of difficulty and since there are so many processes, the overall program of improving safety is challenging. But it has been done before – the rate of anesthesiology errors (and bad outcomes) was improved in the 70s and 80s.

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