Patient Safety - a Balanced Measurement Framework

By Wakefield, John G.; Jorm, Christine M. | Australian Health Review, August 2009 | Go to article overview

Patient Safety - a Balanced Measurement Framework

Wakefield, John G., Jorm, Christine M., Australian Health Review


Evidence of the unacceptably high incidence of patient harm associated with health care has resulted in patient safety becoming a major reform agenda. Despite significant investment by governments on strategies to reduce patient harm, confusion still exists on how to measure patient safety.

While the goal of patient safety is harm prevention, most of the measurement focus has been on counting incident reports. The (ab)use of reported incident data to measure both technical safety performance (injury rates) and evaluate the effectiveness of safety improvement initiatives continues to confuse and mislead consumers, funders and providers of health care.

This paper proposes a simple measurement framework for patient safety which balances the elements of: learning, action, performance, patient experience, and staff attitudes and behaviour. Application of this framework to current priority areas should be used as a basis for patient safety improvement at clinical unit, hospital, state and national levels.

Aust Health Rev 2009: 33(3): 382-389

OVER THE PAST fifteen years, patient safety has become the focus of significant national and international health reform activity. Despite this, the measurement of patient safety has remained a challenge, particularly at jurisdictional level. This paper seeks to address this issue by proposing a simple patient safety measurement framework involving five measurement domains. All have limited scope, each being best for a specific purpose, but used together can assist an organisation in measuring and improving patient safety.

Multiple patient safety measures have been proposed and combined; however, very few assess patient safety performance (true rate of patient harm). It has recently been suggested that "while most hospitals measure some aspect of patient safety, there may not be comprehensive measurement in up to 44% of hospitals",1 (p. 39) yet these authors did not define or justify a set of measures that would constitute comprehensive measurement for safety. The practical framework outlined in this paper, while pragmatic in its scope, represents a comprehensive view of patient safety measurement.

The measurement problem in patient safety

There has been an increasing worldwide emphasis on accountability and governance in the health system.2 This has led to an increased organisational and public focus on measurement of patient safety.

Despite this, patient safety is an elusive concept to both understand and measure. What does it mean to be safe? - a system where no errors occur, or a system in which patient harm as a consequence of error is minimised? Measurement of patient safety is difficult, mainly due to our inability to define and accurately quantify patient harm, and an inappropriate focus on individual error. Particular problems include distinguishing safety from quality,3 the negative connotations of error,4 the poor linkage of error with patient harm,5 and the emotion that surrounds preventable patient harm.

At the heart of confusion over patient safety measurement has been the misuse of reported clinical incident data as a measure of patient safety performance. Counting reported incidents is a futile exercise. Probably due to an absence of true safety performance data, this practice continues at facility, state6"9 and national levels.10 The figures are often misinterpreted as safety performance data, causing community and political concern.

Under-reporting of incidents is the norm, with as few as 1% of incidents being reported.11 Reported incidents thus provide "only a very incomplete reflection of actual incidents".12 (p. 71) Some authors suggest that while there is likely to be greater accuracy about counts of more serious incidents,13 staff still have considerable discretion in regard to reporting. Incident data are biased, primarily comprising errors of commission (rarely including errors of omission) and mainly reported by nursing staff. …

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