1. Key issues for the next decade:
Assessing Safety
The Measurement and Monitoring of Safety in Healthcare
Susan Burnett
Centre for Patient Safety and Service Quality,
Imperial College London

2. Fig 2 Changes in rates of 9 AHRQ derived patient safety indicators.
Hospital Episode Statistics 1996-7 to 2005-6, England
Is Healthcare
Getting Safer?
Vincent, C. et al.
BMJ
2008;337:a2426
Vincent, C. et al. BMJ
2008;337:a2426
Copyright ©2008 BMJ Publishing Group Ltd.

3. Charles
Vincent
Jane
Carthey
Susan
Burnett

4. Methods
1.
Reviews of research literature and reports from organisations:




Safety relevant industries
Conceptual approaches and models of systems safety
Measurement and monitoring in healthcare
The role of patients and families
2.
Interviews with senior staff in national organisations
3.
Case studies in healthcare organisations in the UK and USA





Acute & specialist trusts
Mental Health
Primary care
Combined organisations
Clinical services: maternity care, care of the elderly,
anaesthesia

5. Five key questions:
1.
Has patient care been safe in the past?
2.
Are our clinical systems and processes
reliable?
3.
Is care safe today?
4.
Will care be safe in the future?
5.
Are we responding and improving?

7. Has care been safe in the past?
Many different categories of harm:• General harm from healthcare (e.g. HCAI)
• Treatment-specific harm (complications)
• Overtreatment (falls – sedatives)
• Delayed or inadequate diagnosis
• Failure of appropriate treatment
• Harm from error
• Psychological harm and feeling unsafe

8. And there are many different
measures of harm:• Mortality statistics
• Record review
• Global Trigger Tool
• Staff reporting
• Routine databases
Each gives a partial assessment of the underlying broad issue of harm

10. “Without the letter, the patient's perception of why
they're in clinic may be different to the reasons that
the GP stated or there may be pertinent facts which the
patient doesn't describe....”

11. Overall results: missing clinical information
in

12. ‘We always need a
colposcope with that list
and time and time again it
isn’t there or it’s broken or
it isn’t back or nobody
knows where it is’
Surgeon 3 Organisation A

13. ‘We always need a colposcope with that list and
time and time again it isn’t there or it’s broken or it
isn’t back or nobody knows where it is’
Surgeon 3 Organisation A

14. Overall Results
in

15. Sensitivity to Operations:
Is care safe today?
What might change safety today?
• Staffing levels
• Volume of patients
• Patient dependency/acuity on the wards
Examples
• Routine monitoring in Anaesthesia
• Safety Walkrounds
• Briefings and Checklists
• Safety Huddles and Handovers
• Patient interviews

16. Anticipation and Preparedness:
Will care be safe in the future?
Examples:
• Safety in surgery
• Falls risk assessments
• Pressure ulcer risk assessments
• Risk registers
• FMEA
• Safety culture assessments
• Safety cases

19. Day of week of procedure and 30 day mortality for elective surgery:
retrospective analysis of hospital episode statistics
Paul Aylin et al, BMJ 2013;346:f2424 (Published 28 May 2013)
Results There were 27 582 deaths within 30 days after 4 133 346 inpatient admissions
for elective operating room procedures (overall crude mortality rate 6.7 per 1000). The
number of weekday and weekend procedures decreased over the three years (by 4.5%
and 26.8%, respectively). The adjusted odds of death were 44% and
82% higher, respectively, if the procedures were carried out on
Friday (odds ratio 1.44, 95% confidence interval 1.39 to 1.50) or
a weekend (1.82, 1.71 to 1.94) compared with Monday.

20. Hospital Nurse Staffing and Quality of Care
Research in Action, Issue 14 (2004)
Hospitals with low nurse staffing levels tend to have
higher rates of poor patient outcomes such as
pneumonia, shock, cardiac arrest, and urinary tract
infections, according to research funded by the Agency for
Healthcare Research and Quality (AHRQ) and others.
http://www.ahrq.gov/research/findings/factsheets/services/nursestaffing/index.html

21. The Working Hours Of Hospital Staff Nurses And Patient Safety
Both errors and near errors are more likely to occur when
hospital staff nurses work twelve or more hours at a
stretch.
Ann E. Rogers, Wei-Ting Hwang, Linda D. Scott, Linda H. Aiken, and
David F. Dinges
DOI 10.1377/hlthaff.23.4.202 ©2004
Project HOPE–The People-to-People Health
Foundation, Inc.

22. Are we responding and improving?
• Integrating safety information
across the organisation
• Providing information at the
level for interpretation and
action
• Building learning into
organisational development –
not just a clinical issue

23. Key Issues
1. Developing ways to anticipate and be proactive
2. Safety monitoring should receive more attention
3. Safety information is fragmented in healthcare
organisations – integration and learning needs
investment in technology and data analysis
4. Safety information needs to be customised to the
different levels
5. Improving safety is an organisational development issue,
not just a clinical issue

24. CPSSQ:
http://www1.imperial.ac.uk/medicine/about/institutes/pa
tientsafetyservicequality/
The report:
http://www.health.org.uk/publications/the-measurementand-monitoring-of-safety/