Dr. Don Berwick Responds to NEJM-published Harvard Trigger Study by Renewing Call for Automated Harm Detection
“They may not welcome the duty to push patient safety back to strategic prominence. Nevertheless, ‘first do no harm’ remains a sacred obligation for all in health care, and success requires ‘constancy of purpose for improvement.’ Without renewed board and executive leadership and accountability for safety and without concerted, persistent investment in and monitoring of change, a summary study 34 years from now may again look all too familiar, with millions upon millions of patients, families, and health care staff paying the price for inaction.”
Trigger-based Patient Safety Method Finds High Rate of Preventable Harm in Hospitals – New Harvard Study Reveals
Dr. David Bates, Dr. Elizabeth Mort, and co-authors from Mass Gen Brigham and affiliates sought to evaluate the current state of patient safety using a trigger-based method across 11 Massachusetts hospitals using 2018 data. To summarize the remarkable findings, the study identified one adverse event in every four admissions, and approximately a quarter of those were preventable.
Patient Safety and Risk Management 1: The Problem
Patient safety generally relies on software portals to report events. The idea is that, if a “culture of safety” is positive, clinicians and staff will report patient safety events. For its part, risk management generally relies on claims management software. The idea is that, once a lawsuit is on the books, a risk management team will manage that case until its conclusion. These two workflows are not only occurring at different time frames along the journey of a patient and her family but they also are addressing very different needs and, as a result, reflect very different requirements for “success.”
Outcomes-based Patient Safety and Risk Management, Part II: The Top 3 Misconceptions
There is no magic bullet but, rather, what is required is an optimally tuned set of triggers and a comprehensive operating model.
Outcomes-driven Patient Safety and Risk, Part I: The Primary Pitfall
"The culture of Culture" is holding back the field from following the evidence demonstrating the new method of identifying and reducing patient harm and preventable risk.
Who Killed Patient Safety?
today Pascal wishes to comment on a recent article by Hemmelgarn et al in which the authors posed a question: “Who Killed Patient Safety?”