Defining and measuring patient safety.
Despite the growing demand for improved safety in health care, debate remains regarding the magnitude of the problem and the degree to which harm is preventable. To a great extent, this debate stems from variation in the definition and methods for measuring safety, its "shadow" error, and the degree of preventability. This article reviews the definition of safety and error, discusses approaches to measuring safety, and provides a framework for investigating incidents that unveils how the systems under which care is delivered may contribute to adverse incidents.
Pronovost
Peter J
PJ
Department of Anesthesiology & Critical Care Medicine, Surgery and Health Policy & Management, The Johns Hopkins University School of Medicine, 901 South Bond Street, Suite 318, Baltimore, MD 21231, USA. ppronovo@jhmi.edu
Thompson
David A
DA
Holzmueller
Christine G
CG
Lubomski
Lisa H
LH
Morlock
Laura L
LL
D000328:Adult; D003142:Communication; D003422:Critical Care / Q000379:methods* / Q000458:organization & administration; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008508:Medication Errors / Q000517:prevention & control*; D011787:Quality of Health Care; D012308:Risk Management; D012449:Safety