from the editor
It ’ s valuable to know how much harm there is and for every institution to be aware of trends in adverse events so that they can take steps to mitigate and address issues within their walls .”
Patient Safety is Everyone ’ s Business
This year ’ s Patient Safety Week observance is
March 12-18 , a good time to review the findings from the recent SafeCare Study , led by investigators from Mass General Brigham . The study provides an estimate of progress toward enhancing patient safety and highlighting the need for continued improvement .
“ The study clearly demonstrates a need for better tools , increased measurement of patient harm , and better implementation systems ,” says David Westfall Bates , MD , medical director of clinical and quality analysis for Mass General Brigham and chief of general internal medicine at Brigham and Women ’ s Hospital . “ While we looked at hospitals in Massachusetts , improving the delivery of safe care is a national issue , not one that is specific to one hospital , system , state , or region . It ’ s valuable to know how much harm there is and for every institution to be aware of trends in adverse events so that they can take steps to mitigate and address issues within their walls .”
“ Our work is a call to action for those from board to bedside to ensure reducing preventable patient harm is a top priority ,” says Elizabeth Mort , MD , senior vice president of quality and safety at Massachusetts General Hospital and a co-author of the study . “ Keep in mind that our study looked at patient safety before the COVID-19 pandemic . We know that our industry is now facing economic , workforce and wellness challenges nationally . Given these pressures , remaining focused and committed to patient safety is more important than ever .”
The SafeCare study reviewed 2,800 inpatient charts from patient visits in 2018 to hospitals ranging from large to small , the research team identified at least one adverse event in 23.6 percent of admissions . Overall , 23 percent of these adverse events were judged to be preventable given what is known today , and 32 percent had serious or higher clinical severity . The leading causes of harm were medication related ( 39 percent of adverse events ); surgery / procedural ( 30 percent ); patient care , including falls and pressure ulcers ( 15 percent ); and healthcare-associated infections ( 12 percent ).
Bates and co-authors recommend that healthcare providers improve tracking of adverse drug effects , increase reliable and routine collection of data , deliver consistent and reliable care for healthcare-associated infections and work toward a culture that prioritizes safe , high-quality care .
“ It ’ s important to do the work to identify adverse events if we ’ re going to work to improve them ,” says Bates . “ All organizations should have approaches for monitoring these things on a regular basis .”
In this issue we examine healthcare technology-related hazards that can jeopardize patient and healthcare personnel safety , and strategies to mitigate these preventable adverse events . As Rob Schluth , principal project officer in ECRI ’ s Device Evaluation group , notes , safety is everyone ’ s business : “ In the healthcare environment , everyone plays a role in patient safety . That includes the frontline healthcare workers who use medical devices and the clinical engineers who install , service , and maintain them ; but it also includes IT professionals , purchasers , administrators , and others .” Our coverage begins on page 14 .
Until next month , bust those bugs ! Kelly M . Pyrek Editor & Publisher kelly @ healthcarehygienemagazine . com
Reference : Bates , DW et al . The Safety of Inpatient Health Care . NEJM . DOI : 10.1056 / NEJMsa2206117 healthcarehygienemagazine
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