Year: 2015
Type: editorial
Abstract: Large numbers of patients are injured annually by care that is intended to help them, and while many strides have been made in improving our understanding of patient safety considerations, it is not clear that this is translating into improvements in clinical outcomes. We now know that a small number of causes of harm appear to account for most of the injuries in hospitals, specifically hospital-acquired infections, adverse drug events, surgical injuries, deep venous thromboses and pulmonary emboli, falls and pressure ulcers.1 Some types of harm, though, such as harm caused by failure to make a correct diagnosis or harm caused by failure to intervene quickly enough in a decompensating patient, are more elusive and not so readily counted, and thus, the true toll from iatrogenic harm is certainly substantially higher than current estimates suggest. Moreover, many of the safety issues that have the greatest cognitive component may be relatively hard to count. In addition, cognitive safety issues may be even more important outside the hospital than in it because care is so much more fragmented and patients interact with the system much less often, which may increase the impact of errors.
Another factor is the relationship between errors and harm. Although few studies have attempted to quantify this directly, it is clear that a relatively low proportion of errors result in harm—just one in a hundred in one study.2 Errors are frequent, but they vary in their likelihood of causing harm; among harm, it is considered preventable if it associated with an error that likely caused the harm, while other cases involving harm are not preventable given what is known. In the accompanying paper, Patel et al 3 make a strong case that attempting to achieve a zero error rate is not feasible in most areas and …
Source: BMJ Quality & Safety
Authors: David W Bates, Aziz Sheikh
Institutions: Brigham and Women's Hospital, University of Edinburgh
Language: English
Subfield: Emergency Medical Services
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2266335658