JKF Journal

Friday, August 29, 2008

"Don't think that you are more safe in a place just because they don't talk about their errors. "

With Labor Day right around the corner, I'm catching up on some healthcare blog reading that I've missed out on while enjoying the summer. Earlier this month on "Running a Hospital" Beth Israel Deaconess Medical Center CEO Paul Levy discusses transparency in the patient safety realm. BIDMC took the bold step to report the incidence of preventable harm events on their very public website. You can take a look at the report here.

For each of the Joint Commission's preventable harm events, BIDMC lists the number of times such an event happened at the hospital within a quarter. Levy's discussion on the motivation and concerns surrounding such a public forum is insightful. The emphasis on reporting the raw number of harm events- and not obscuring them by reporting them as percentages of total patient population- shows a real understanding that patients are people whose lives are truly impacted by preventable errors.

It also sets up a clear standard of comparison; the goal is to have zero preventable events, and anything above zero signals continued room for improvement. What's the bottom line? Big thinking in a simple framework that patients, nurses, doctors and hospital administrators alike can use to chart progress and identify ways to change the status quo and improve patient safety.

The line from Levy's post that struck me the most is the quote used for the title of this post: "Don't think that you are more safe in a place just because they don't talk about their errors." I think this succinctly sums up an important aspect of patient safety today. For years, it was commonly assumed that there was an acceptable threshold for errors in medicine. Then came the realization that harm events could be prevented by analyzing and reworking broken systems. It's a huge change in philosophy, and the exciting part is that as patients and healthcare providers, we are all in the middle of a true zeitgeist shift. The language and tools to move medicine into a new, safer phase are right now being developed at a quick clip, and it will take some time and thought to figure out how we can best use these new resources to improve patient safety.

Surprising news about the incidence of harm events at one institution doesn't necessarily mean that a hospital isn't safe or actively trying to become safer; instead, it's a new way to bring healthcare providers and consumers on the same safety page.



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