Review Article| Volume 23, ISSUE 3, P659-673, July 2007

Monitoring Patient Safety

      The opportunity to improve patient safety is significant and the pressure to improve it is increasing. An approach to evaluate an organization's progress with patient safety efforts has not been clearly articulated, and existing efforts to monitor safety are likely inadequate. We present a framework to monitor patient safety, combining valid rate-based measures to evaluate outcomes and processes of care, and non–rate-based measures to evaluate structure and context of care. We present an example of how the safety scorecard from this framework is used to monitor patient safety at The Johns Hopkins Hospital and in over 150 ICUs in Michigan, New Jersey, and Rhode Island.
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      1. Kohn L. Corrigan J. Donaldson M. To err is human: building a safer health system, Report from the Committee on Quality of Health Care in America, Institute of Medicine. National Academy Press, Washington, DC1999
        • Institute of Medicine
        Crossing the quality chasm: a new health system for the 21st century.
        National Academy Press, Washington, DC2001
        • Brennan T.
        • Gawande A.
        • Thomas E.
        • et al.
        Accidental deaths, saved lives, and improved quality.
        N Engl J Med. 2005; 353: 1405-1409
        • Leape L.L.
        • Berwick D.M.
        Five years after To Err Is Human: what have we learned?.
        JAMA. 2005; 293: 2384-2390
        • Wachter R.
        The end of the beginning: patient safety five years after “To Err Is Human”.
        Health Aff (Millwood). 2004; (Suppl Web Exclusives (W4):534–45)
        • Lilford R.
        • Mohammed M.
        • Spiegelhalter D.
        • et al.
        Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma.
        Lancet. 2004; 363: 1147-1154
        • Hayward R.
        • Hofer T.
        Estimating hospital deaths due to medical errors; preventability is in the eye of the reviewer.
        JAMA. 2004; 286: 415-420
        • Thomas J.
        • Hofer T.
        Accuracy of risk-adjusted mortality rate as a measure of hospital quality of care.
        Med Care. 1999; 37: 83-92
        • Jha A.
        • Li Z.
        • Orav E.
        • et al.
        Care in U.S. hospitals—the Hospital Quality Alliance program.
        N Engl J Med. 2005; 353: 265-274
        • Brook R.H.
        • McGlynn E.A.
        • Cleary P.D.
        Quality of health care. Part 2: measuring quality of care.
        N Engl J Med. 1996; 335: 966-970
        • Zimmerman J.E.
        • Draper E.
        • Wagner D.
        Comparing ICU populations: background and current methods.
        in: Sibbald W.J. Bion J. Evaluating critical care: using health services research to improve quality. Springer, New York2000: 121-139
        • Clermont G.
        • Angus D.C.
        • DiRusso S.M.
        • et al.
        Predicting hospital mortality for patients in the intensive care unit: a comparison of artificial neural networks with logistic regression models.
        Crit Care Med. 2001; 29: 291-296
        • Donabedian A.
        Evaluating the quality of medical care.
        Milbank Mem Fund Q. 1966; 44: 166-206
        • Pronovost P.J.
        • Berenholtz S.M.
        • Goeschel C.A.
        • et al.
        Creating high reliability in healthcare organizations.
        Health Serv Res. 2006; 41: 1599-1617
        • Arispe I.
        • Holmes J.
        • Moy E.
        Measurement challenges in developing the National Healthcare Quality Report and the National Healthcare Disparities Report.
        Med Care. 2005; 43: I17-I23
        • Kelley E.
        • Moy E.
        • Stryer D.
        • et al.
        The national healthcare quality and disparities reports: an overview.
        Med Care. 2005; 43: I3-I8
        • Zhan C.
        • Miller M.R.
        Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
        JAMA. 2003; 290: 1868-1874
        • McGlynn E.A.
        An evidence-based national quality measurement and reporting system.
        Med Care. 2003; 41: I8-I15
        • Gordis L.
        Saunders, Philadelphia2004
        • Pronovost P.J.
        • Holzmueller C.G.
        • Sexton J.B.
        • et al.
        How will we know if patients are safer? An organization-wide approach to measuring and improving patient safety.
        Crit Care Med. 2006; 34: 1988-1995
        • Sexton J.B.
        • Thomas E.
        Measurement: assessing a safety culture. Achieving safe and reliable healthcare strategies and solutions.
        Health Administration Press, Chicago2004 (p. 115–27)
      2. Sexton JB, Helmreich RL. Using language in the cockpit: relationships with workload and performance. In: Dietrich R, editor. Communication in High Risk Environments. Humboldt Universitat zu Berlin, Germany; 2003. p. 57–73.

        • Lilford R.
        • Mohammed M.
        • Braunholtz D.
        • et al.
        The measurement of active errors: methodological issues.
        Qual Saf Health Care. 2004; 12: ii8-ii12
        • Pronovost P.J.
        • Thompson D.A.
        • Holzmueller C.G.
        • et al.
        Defining and measuring patient safety.
        Crit Care Clin. 2005; 21 (vii): 1-19
        • Pronovost P.J.
        • Nolan T.
        • Zeger S.
        • et al.
        How can clinicians measure safety and quality in acute care?.
        Lancet. 2004; 363: 1061-1067
        • Berenholtz S.M.
        • Pronovost P.J.
        • Lipsett P.A.
        • et al.
        Eliminating catheter-related bloodstream infections in the intensive care unit.
        Crit Care Med. 2004; 32: 2014-2020
        • Pronovost P.
        • Needham D.
        • Berenholtz S.
        • et al.
        An intervention to decrease catheter-related bloodstream infections in the ICU.
        N Engl J Med. 2006; 355: 2725-2732
        • Martinez E.
        • Pronovost P.
        • Kim L.
        • et al.
        Sensitivity of routine intensive care unit surveillance for detecting myocardial ischemia.
        Crit Care Med. 2003; 31: 2302-2308
        • Kim Y.
        • Oh S.
        • Kim J.
        Incidence and natural history of deep-vein thrombosis after total hip arthroplasty. A prospective and randomized clinical study.
        J Bone Joint Surg Br. 2003; 85: 661-665
        • Needham D.
        • Dowdy D.
        • Mendez-Tellez P.
        • et al.
        Studying outcomes of intensive care unit survivors: measuring exposures and outcomes.
        Intensive Care Med. 2005; 31: 1153-1160
        • Gerberding J.
        Hospital-onset infections: a patient safety issue.
        Ann Intern Med. 2002; 137: 665-670
        • Woolf S.
        Patient safety is not enough: targeting quality improvements to optimize the health of the population.
        Ann Intern Med. 2004; 140: 33-36
        • Drakulovic M.
        • Torres A.
        • Bauer T.
        • et al.
        Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial.
        Lancet. 1999; 354: 1851-1858
        • Cook D.
        • Guyatt G.
        • Marshall J.
        • et al.
        A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation. Canadian Critical Care Trials Group.
        N Engl J Med. 1998; 338: 791-797
        • Attia J.
        • Ray J.G.
        • Cook D.J.
        • et al.
        Deep vein thrombosis and its prevention in critically ill adults.
        Arch Intern Med. 2001; 161: 1268-1279
        • Kress J.P.
        • Pohlman A.S.
        • O'Connor M.F.
        • et al.
        Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation.
        N Engl J Med. 2000; 342: 1471-1477
        • Ely E.W.
        • Baker A.M.
        • Dunagan D.P.
        • et al.
        Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously.
        N Engl J Med. 1996; 335: 1864-1869
        • Resar R.
        • Pronovost P.
        • Haraden C.
        • et al.
        Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.
        Jt Comm J Qual Patient Saf. 2005; 31: 243-248
        • Needleman J.
        • Buerhaus P.
        • Mattke S.
        • et al.
        Nurse-staffing levels and the quality of care in hospitals.
        N Engl J Med. 2002; 346: 1715-1722
        • Leape L.L.
        • Cullen D.J.
        • Clapp M.D.
        • et al.
        Pharmacist participation on physician rounds and adverse drug events in the intensive care unit.
        JAMA. 1999; 282: 267-270
        • Pronovost P.
        • Weast B.
        • Rosenstein B.
        • et al.
        Implementing and validating a comprehensive unit-based safety program.
        Journal of Patient Safety. 2005; 1: 33-40
        • Bates D.W.
        • Teich J.M.
        • Lee J.
        • et al.
        The impact of computerized physician order entry on medication error prevention.
        JAMA. 1999; 6: 313-321
        • Koppel R.
        • Metley J.
        • Cohen A.
        • et al.
        Role of Computerized physician order entry systems in facilitating medication errors.
        JAMA. 2005; 293: 1197-1203
        • Han Y.
        • Carcillo J.
        • Venkataraman S.
        • et al.
        Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.
        Pediatrics. 2005; 116: 1506-1512
        • Angus D.C.
        • Kelley M.A.
        • Schmitz R.J.
        • et al.
        Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?.
        JAMA. 2000; 284: 2762-2770
        • Institute of Medicine
        Patient safety: achieving a new standard of care.
        National Academies Press, Washington, DC2004
      3. Patient Safety and Quality Improvement Act of 2005, Public Law 109–41.

        • Barach P.
        • Small S.D.
        Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.
        BMJ. 2000; 320: 759-763
        • Holzmueller C.G.
        • Pronovost P.J.
        • Dickman F.
        • et al.
        Creating the web-based intensive care unit safety reporting system.
        JAMA. 2005; 12: 130-139
        • Lubomski L.
        • Pronovost P.J.
        • Thompson D.
        • et al.
        Building a better incident reporting system: perspectives from a multisite project.
        J Clin Outcomes Mgmt. 2004; 11: 275-280
        • Needham D.
        • Sinopoli D.
        • Thompson D.
        • et al.
        A system factors analysis of “line, tube, and drain” incidents in the intensive care unit.
        Crit Care Med. 2005; 33: 1701-1707
        • Cullen D.
        • Bates D.
        • Small S.
        • et al.
        The incident reporting system does not detect adverse drug events: a problem for quality improvement.
        Jt Comm J Qual Improv. 1995; 21: 541-548
        • Vincent C.
        Understanding and responding to adverse events.
        New Eng J Med. 2003; 348: 1051-1056
        • Pronovost P.J.
        • Holzmueller C.G.
        • Martinez E.
        • et al.
        A practical tool to learn from defects in patient care.
        Jt Comm J Qual Saf. 2006; 32: 102-108
        • Ammerman M.
        The root cause analysis handbook.
        Productivity Inc, Portland (OR)1998
        • Colla J.
        • Bracken A.
        • Kinney L.
        • et al.
        Measuring patient safety climate: a review of surveys.
        Qual Saf Health Care. 2005; 14: 364-366
        • Pronovost P.J.
        • Goeschel C.
        Improving ICU care: it takes a team.
        Healthc Exec. 2005; 20: 14-22
        • Berenholtz S.M.
        • Milanovich S.
        • Faircloth A.
        • et al.
        Improving care for the ventilated patient.
        Jt Comm J Qual Saf. 2004; 30: 195-204
        • Rubin H.
        • Pronovost P.
        • Diette G.
        The advantages and disadvantages of process-based measures of health care quality.
        Int J Qual Health Care. 2001; 13: 469-474
        • McGlynn E.A.
        Choosing and evaluating clinical performance measures.
        Jt Comm J Qual Improv. 1998; 24: 470-479
        • Berenholtz S.M.
        • Dorman T.
        • Ngo K.
        • et al.
        Qualitative review of intensive care unit quality indicators.
        J Crit Care. 2002; 17: 1-12
        • Van Den Berghe G.
        • Wouters P.
        • Weekers F.
        • et al.
        Intensive insulin therapy in critically ill patients.
        N Engl J Med. 2001; 345: 1359-1367
        • Bernard G.
        • Vincent J.
        • Laterre P.
        • et al.
        Efficacy and safety of recombinant human activated protein C for severe sepsis.
        N Engl J Med. 2001; 344: 699-709
        • McGlynn E.A.
        • Asch S.M.
        Developing a clinical performance measure.
        Am J Prev Med. 1998; 14: 14-21
        • Guyatt G.
        • Sackett D.
        • Cook D.
        Users' guides to the medical literature. II. How to use an article about therapy or prevention. A. Are the results of the study valid?.
        JAMA. 1993; 270: 2598-2601