3 Steps to Address Underlying Causes of Adverse Events

While employing tools to prevent individual adverse events can be effective in the short term, addressing the underlying factors of medical errors is necessary for sustainable improvement, according to a commentary on the Agency for Healthcare Research and Quality's National Quality Measures Clearinghouse website.

The author discusses how to effectively implement evidence-based best practices to improve safety, such as those delineated in AHRQ's "Making Health Care Safer II" report. He says that while simply adopting the report's 22 practices that are "encouraged" or "strongly encouraged" can benefit patient safety, long-term improvement depends on understanding the underlying factors.



He provides three steps healthcare leaders should follow to address the root cause of safety and quality deficiencies:
•    Incorporate human factors engineering, systems engineering and expertise from other fields to design a safer healthcare system.
•    Study and disseminate safety culture improvement strategies.
•    Establish "standardized, reliable and reproducible measurements for common safety problems," the author states.

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