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How Do We Measure Safety

Over recent years, two national reports published by the Institute of Medicine focus on the need for patient safety programs in hospitals. The reports are entitled "To Err is Human: Building a Safer Healthcare System" and, more recently, "Crossing the Quality Chasm: A New Healthcare System for the 21st Century". Both reports place a spotlight on healthcare errors and identify the need to evaluate and rebuild systems that decrease risk to patients.

This involves a need to report errors that occur as well as "near misses" and utilize information to identify risk points and build systems that reduce these risks. Systems is a keyword when talking about patient safety programs.

Over many decades healthcare has focused on ensuring that those providing the care are well trained and practice safely. It is important to continually assess the capabilities of those that provide healthcare. However, it is increasingly important to realize that those delivering healthcare are part of complex health delivery systems that need to be retooled and strengthened to support the provision of safe care.

The success of such efforts requires us to change the culture in which healthcare is provided. Creating a culture of safety is truly a team effort involving hospitals, caregivers, physicians, and patients. At CVPH, our patient safety program has several functions:

  1. We encourage reporting of errors and near-errors by all healthcare providers;
  2. We analyze the information provided in reports to identify system weaknesses;
  3. We identify root causes (of errors and near-errors) and implement changes to reduce risks;
  4. We monitor the results of system changes to evaluate their effectiveness.