Seeing the Whole Picture

April 1, 2011 | Health System Risk Management


Studies have shown that hospital care continues to harm and kill patients, yet many healthcare organizations still do not see the whole picture of patient safety in their facilities or look to other facilities for lessons learned. Assessing patient safety data is like considering a work of abstract art—you don't always recognize what you're seeing. With abstract art, perception and understanding may be strongly influenced by the quality and characteristics of the materials and by how the artist interacted with the paint, canvas, and tools. An abstract work may cause you to reexamine your thinking about the subject before you.

Likewise, a portrait of hospital patient safety is influenced by the quality and performance of the tools and methods a hospital uses to identify and understand adverse events. Consider the provocative findings of a study by the U.S. Department of Human Services' Office of Inspector General (OIG): hospital adverse event reporting systems, a data-gathering tool used by risk managers to gauge patient safety, failed to capture 93% of serious adverse events that were identified with other tools and methods. Thus, OIG questioned the usefulness of reporting systems as a reliable way to count adverse events. Although hospital reporting systems may be a weaker surveillance tool, the information they garner...

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