July 25, 2010
Measuring and Assessing Patient Safety
Patient safety is such an essential part of our health care system and it helps describe quality health care. Keeping the patients safe is a challenging issue because errors and mistakes can and do happen every day. Error occurs “when a process does not proceed the way that it was intended by its designers and managers” (McLaughlin & Kaluzny 2006). According to the Institute of Medicine, medical error resulted in as many as 98,000 preventable deaths per year. Someone has to ensure methods are taken to help reduce the possibility that errors occur, but who is responsible for taking these proper measurers? Is it society, patients themselves, physicians, nurses, nursing professors, administrators, researchers, physicians, or professional associations? Consequence, all of these entities are responsible for making sure the patient has the safest environment possible. This is a nationwide and worldwide problem that will never be completely resolved because there is always a chance that medical errors happen. Patient safety is a sensitive concept to both understand and measure. What does it mean to be safe? a system where no errors occur, or a system in which patient harm as a consequence of error is minimized? Measurement of patient safety is difficult, due to our inability to define patient harm, and an inappropriate focus on individual error. Particular issues involves distinguishing safety from quality, the negative connotations of error, the poor relation of error with patient harm, and the emotion that surrounds preventable patient harm. Patient safety measurement has been the misuse of reported clinical incident data as a measure of patient safety performance. According to France, Greevy, Liu, Burgess, Dittus, Weinger, & Speroff in their article Measuring and Comparing Safety Climate in Intensive Care Units, “To measure safety climate in intensive care units (ICU) owned by a large for-profit integrated health delivery systems; identify specific provider, ICU, and hospital factors that influence safety climate; and improve the reporting of safety climate data for comparison and benchmarking. We administered the Safety Attitudes Questionnaire (SAQ) to clinicians, staff, and administrators in 110 ICUs from 61 hospitals. A total of 1502 surveys (43% response) from physicians, nurses, respiratory therapists, pharmacists, mangers, and other ancillary providers” The responses of this questionnaire help the hospital decision making to improve patient safety.
Clinicians, researches and administrators implementing quality improvement programs are encouraged to take more comprehensive view of the environment, procedures and processes, practitioners associate with care delivery, and the interactions of those factors with the patient population served. ”(McLaughlin & Kaluzny 2006) describe that “challenges in implementing and reporting patient safety practices reflect issues around the decision to adopt, prioritization of select practices, and methodological difficulties encountered in the identification process.” Event monitoring systems have the purpose to recognize important events based on clinical rules. Clinical triggers are flags to clinicians to point out the possibility for error. An adverse event is a unfavorable medical change that happens after beginning the study that may or may not be in relationship to or caused by study drug treatments. A medical event is a clinically important change in physical and mental health status. Any medical event that causes clinically relevant interference with functioning, for example, headache that causes school absence or causes clinically important activity restriction. Is also any event that requires medical attention, for example a URI with visit to a doctor. Failure Mode and Effects...