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Review article: Biomedical intelligence

Vol. 142 No. 2930 (2012)

Patient safety – who cares?

  • David L B Schwappach
  • Dieter Conen
DOI
https://doi.org/10.4414/smw.2012.13634
Cite this as:
Swiss Med Wkly. 2012;142:w13634
Published
15.07.2012

Summary

Medical errors and adverse events are a serious threat to patients worldwide. In recent years methodologically sound studies have demonstrated that interventions exist, can be implemented and can have sustainable, measurable positive effects on patient safety.

Nonetheless, system-wide progress and adoption of safety practices is slow and evidence of improvements on the organisational and systems level is scarce and ambiguous. This paper reports on the Swiss Patient Safety Conference in 2011 and addresses emerging issues for patient safety and future challenges.

References

  1. Zwaan L, de Bruijne M, Wagner C, Thijs A, Smits M, van der Wal G, et al. Patient record review of the incidence, consequences, and causes of diagnostic adverse events. Arch Intern Med. 2010;170(12):1015–21.
  2. Shojania KG, Burton EC, McDonald KM, Goldman L. Changes in rates of autopsy-detected diagnostic errors over time. JAMA: The Journal of the American Medical Association 2003;289(21):2849–56.
  3. Sonderegger-Iseli K, Burger S, Muntwyler J, Salomon F. Diagnostic errors in three medical eras: a necropsy study. Lancet. 2000;355(9220):2027–31.
  4. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377–84.
  5. Gandhi TK, Kachalia A, Thomas EJ, Puopolo AL, Yoon C, Brennan TA, et al. Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims. Ann Intern Med. 2006;145(7):488–96.
  6. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881–7.
  7. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493–9.
  8. Wachter RM. Why diagnostic errors don’t get any respect – and what can be done about them. Health Aff. 2010;29(9):1605–10.
  9. Gandhi TK, Lee TH. Patient Safety beyond the Hospital. N Engl J Med. 2010;363(11):1001–3.
  10. Zwaan L, Thijs A, Wagner C, van der Wal G, Timmermans DRM. Relating faults in diagnostic reasoning with diagnostic errors and patient harm. Acad Med. 2012;87(2).
  11. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. The American Journal of Medicine 2008;121(5, Supplement):S2-S23.
  12. Singh H, Graber ML, Kissam SM, Sorensen AV, Lenfestey NF, Tant EM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Quality & Safety 2011;doi: 10.1136/bmjqs-2011-000150.
  13. Nendaz MR, Gut AM, Louis-Simonet M, Perrier A, Vu NV. Bringing explicit insight into cognitive psychology features during clinical reasoning seminars: a prospective, controlled study. Education for health (Abingdon, England) 2011;24(1):496.
  14. Ely JW, Graber ML, Croskerry P. Checklists to Reduce Diagnostic Errors. Acad Med. 2011;86(3):307–13.
  15. Sawyer D. Do it by Design. An introduction to human factors in medical devices. Rockville: US Department of Health and Human Services; 1996.
  16. Birnbach DJ, Nevo I, Scheinman SR, Fitzpatrick M, Shekhter I, Lombard JL. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care. 2010;19(5):462–5.
  17. Boyce N. War on error. Lancet. 2012;379(9816):605.
  18. Anderson O, Davey G, West J. Make it better. Designing out medical error. London: Helen Hamlyn Centre, Royal College of Art; 2011.
  19. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An Intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–32.
  20. Sawyer M, Weeks K, Goeschel CA, Thompson DA, Berenholtz SM, Marsteller JA, et al. Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. Crit Care Med. 2010;38(S8):S292–S298.
  21. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:doi: 10.1136/bmj.d219.
  22. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.
  23. Weiser TG, Haynes AB, Dziekan G, Berry WR, Lipsitz SR, Gawande AA, et al. Effect of a 19-item surgical safety checklist during urgent operations in A Global Patient Population. Ann Surg. 2010;251(5).
  24. de Vries EN, Prins HA, Crolla RMPH, den Outer AJ, van Andel G, van Helden SH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928–37.
  25. Borchard A, Schwappach DLB, Barbir A, Bezzola P. A Systematic review of the effectiveness, compliance, and critical factors for implementation of safety checklists in surgery. Ann Surg. 2012; in press.
  26. van Klei WA, Hoff RG, van Aarnhem EEHL, Simmermacher RKJ, Regli LPE, Kappen TH, et al. Effects of the Introduction of the WHO “surgical safety checklist” on in-hospital mortality: a cohort study. Ann Surg. 2012;255(1):44–9.
  27. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–700.
  28. Kliger J, Blegen MA, Gootee D, O’Neil E. Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy. Jt Comm J Quality Safety. 2009;35(12):604–12.
  29. Kliger J, Singer S, Hoffman F, O’Neil E. Spreading a medication administration intervention organizationwide in six hospitals. Jt Comm J Quality Safety. 2012;38(2):51–60.
  30. Kwan Y. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med. 2007;167(10):1034–40.
  31. Kaboli PJ HAMBSJ. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955–64.
  32. Hug B, Witkowski D, Sox C, Keohane C, Seger D, Yoon C, et al. Adverse drug event rates in six community hospitals and the potential impact of computerized physician order entry for prevention. J Gen Intern Med. 2010;25(1):31–8.
  33. van Rosse F, Maat B, Rademaker CMA, van Vught AJ, Egberts ACG, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics. 2009;123(4):1184–90.
  34. Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, Lo C, et al. Effects of two commercial electronic prescribing systems on prescribing error rates in hospital in-patients: a before and after study. PLoS Med. 2012;9(1):e1001164.
  35. Institute of Medicine. To err is human. Building a safer health system. Washington, DC: National Academy Press; 2000.
  36. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124–34.
  37. Langelaan M, Baines R, de Bruijne M, Broekens M, van de Steeg L, Siemerink K, et al. Monitoring adverse events in hospitals. Paper presented at the Swiss Patient Safety Conference, Basel November 29th 2011. 2011.
  38. Zegers M, de Bruijne MC, Wagner C, Hoonhout LHF, Waaijman R, Smits M, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Health Care. 2009;18(4):297–302.
  39. Vincent C. Patient safety past and future. Paper presented at the Swiss Patient Safety Conference, Basel November 29th 2011. 2011.
  40. Benning A, Ghaleb M, Suokas A, Dixon-Woods M, Dawson J, Barber N, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ. 2011;342:doi:10.1136/bmj.d195.
  41. Benning A, Dixon-Woods M, Nwulu U, Ghaleb M, Dawson J, Barber N, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011;342:doi:10.1136/bmj.d199.
  42. Needham DM, Sinopoli DJ, Dinglas VD, Berenholtz SM, Korupolu R, Watson SR, et al. Improving data quality control in quality improvement projects. Int J Qual Health Care. 2009;21(2):145–50.
  43. Pronovost PJ, Berenholtz SM, Morlock L. Is quality of care improving in the UK? BMJ. 2011;342:doi:10.1136/bmj.c6646.
  44. Pronovost PJ, Goeschel CA. Viewing health care delivery as science: challenges, benefits, and policy implications. Health Serv Res. 2010;45(5p2):1508–22.
  45. Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA, Pronovost PJ. Explaining Michigan: ceveloping an ex post theory of a quality improvement ürogram. Milbank Q. 2011;89(2):167–205.
  46. Longo DR, Hewett JE, Ge B, Schubert S. The long road to patient safety. JAMA: The Journal of the American Medical Association. 2005;294(22):2858–65.
  47. Schwappach DLB. Risk factors for patient-reported medical errors in eleven countries. Health Expect. 2012;doi:10.1111/j.1369-7625.2011.00755.x.
  48. Vincent C, Aylin P, Franklin BD, Holmes A, Iskander S, Jacklin A, et al. Is health care getting safer? BMJ. 2008;337:doi:10.1136/bmj.a2426.
  49. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361(14):1401–6.