Paul Levy, former CEO of Beth Israel Deaconess Medical Center in Boston, wrote in a recent blog post that event reporting systems should include near-misses and that hospital leaders need to prioritize continuous process improvement as a strategic objective to improve patient safety.
Mr. Levy responded to a recent report by the Office of Inspector General revealing that the majority of adverse events are not reported. The OIG recommended CMS and the Agency for Healthcare Research and Quality create a list of potentially reportable events and assist hospitals in using the list; and that CMS guide accreditors who assess hospitals' efforts to track and analyze events.
Mr. Levy says the real issue, however, is the design of adverse event reporting systems, which do not document near-misses. "Virtually all adverse event reporting systems are 'bolt-on' additions to hospital clinical information systems," Mr. Levy says. "They do not result from a thorough analysis of how work is done on the floors and units of hospitals. […] They are certainly not designed to capture near-misses, which occur 100 to 1000 times more often than actual adverse events, but which are a huge source of information about systemic problems. Filling them out is often considered 'extra work' by busy clinicians, not as part of a process of continuous, front-line driven process improvement. Thus the recommendations offered in the report will not, I predict, make a significant difference in the future."
Mr. Levy also commented on a study in Health Services Research that found patient safety has likely not improved significantly from 1998-2007. He says the main reason for a lack of improvement is "the fact that most hospitals still do not have in place clinical, administrative, and governance leaders who seriously and consistently put process improvement at the top of their strategic objectives."
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Mr. Levy responded to a recent report by the Office of Inspector General revealing that the majority of adverse events are not reported. The OIG recommended CMS and the Agency for Healthcare Research and Quality create a list of potentially reportable events and assist hospitals in using the list; and that CMS guide accreditors who assess hospitals' efforts to track and analyze events.
Mr. Levy says the real issue, however, is the design of adverse event reporting systems, which do not document near-misses. "Virtually all adverse event reporting systems are 'bolt-on' additions to hospital clinical information systems," Mr. Levy says. "They do not result from a thorough analysis of how work is done on the floors and units of hospitals. […] They are certainly not designed to capture near-misses, which occur 100 to 1000 times more often than actual adverse events, but which are a huge source of information about systemic problems. Filling them out is often considered 'extra work' by busy clinicians, not as part of a process of continuous, front-line driven process improvement. Thus the recommendations offered in the report will not, I predict, make a significant difference in the future."
Mr. Levy also commented on a study in Health Services Research that found patient safety has likely not improved significantly from 1998-2007. He says the main reason for a lack of improvement is "the fact that most hospitals still do not have in place clinical, administrative, and governance leaders who seriously and consistently put process improvement at the top of their strategic objectives."
Related Articles on Patient Safety:
Study: Hospitals Report Only 1 in 7 Medical ErrorsHHS Finalizes Core Set of 26 Medicaid Quality Measures
AHRQ: Some Healthcare Experts Find Quality Reporting Websites Difficult to Use