Overview For decades healthcare organizations have relied almost exclusively on voluntary event reporting to identify adverse events, or patient harm. No longer. The evidence overwhelmingly shows the cost in injury & death as well as dollars (e.g. excessive length of stay) is not sustainable or credible.
“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.”
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 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.”
There is no magic bullet but, rather, what is required is an optimally tuned set of triggers and a comprehensive operating model.
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