Chapter 3 reviewed the overwhelming evidence that healthcare today is neither safe nor high quality. We learned that the best available data indicate that in any given healthcare encounter we receive only about half of the right care,1 and that patients are also injured by care at an alarming frequency, resulting in tens or hundreds of thousands of preventable deaths per year.2,3 Fortunately, significant practical and scholarly work has created a set of tools that can help you improve both the safety and quality of care. In this chapter, we focus on standard healthcare improvement tools. Then, Chapter 9 will cover tools derived from Lean production.
PREVENTING ADVERSE EVENTS AND IMPROVING PATIENT SAFETY
Sometimes things do not go as expected, and patients are harmed by the process of care. These adverse events are patient safety events. They happen because of the care process, not because of the underlying disease (Table 8-1). Many tools for the healthcare improvement practitioner revolve around responding to and preventing these kinds of events.
Table 8-1QUALITY AND PATIENT SAFETY ||Download (.pdf) Table 8-1 QUALITY AND PATIENT SAFETY
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Questions to Ask
Examples of Problems in Each Domain
Did something bad happen to a patient that is not caused by the disease?
A patient admitted for a knee replacement gets pneumonia.
A patient admitted for pneumonia gets deep venous thrombosis (DVT).
A patient in clinic is prescribed a medication to which she is allergic, resulting in anaphylaxis.
Did we do everything that we should have to give this patient the best chance of the best outcome?
A patient's hypertension is poorly controlled, increasing her risk of stroke.
A patient is not offered age-appropriate colon cancer screening.
A patient hospitalized with sepsis from pneumonia does not receive the right antibiotics.
Some terms are commonly used by patient safety practitioners, and healthcare delivery scientists should be familiar with them.4
An adverse event is one that results in patient harm. A near miss does not reach a patient, but it still represents an error that we can learn from.
Adverse event: Often defined as an injury caused by care, not by the underlying disease. This injury results either in increased care (e.g., more monitoring) or a worse outcome (including death) for the patient. By definition, an adverse event results in harm to a patient.
Preventable adverse event: Preventability is difficult to define. The core idea is that an error in care occurred, ...