Never events: Better measures needed to eliminate medical mistakes

To achieve meaningful patient safety reform and reduce preventable "never events," the healthcare industry must reassess the way it measures medical mistakes to get a more accurate picture of the extent of the errors, according to a Harvard Business Review blog post.

Patient safety is an ongoing concern in hospitals and health systems, especially with the revelation that medical errors are the nation's third-leading cause of death. However, rates of never events have seen little apparent progress, due in large part to flawed measurement processes, wrote Timothy Morgenthaler, M.D., chief patient safety officer at the Mayo Clinic, and Charles M. Harper, M.D., the clinic's executive dean for practice.

Even in states that require reporting, such as Minnesota, several factors distort data on never events, the authors explained. Not only has the precise definition of the term changed over time, but the average inpatient's condition is also more severe and complex than ever, while numerous procedures and treatments that were unheard of a decade ago are now common. The flaws in patient safety measurement mean different providers have widely disparate ideas of how much progress they have made.

Mayo has taken several steps to monitor patient safety in a way that sidesteps these flaws, according to the authors. For example, the clinic analyzes every step in the care process for patients who die under its care, even in cases when death was the expected outcome, creating quarterly metrics for recurring care issues or opportunities for improvement.

Moreover, the clinic reviews every incident involving serious harm to determine whether it was caused by a deviation from the clinic's standards of care; any such harms caused by deviations are counted as preventable harms. "This is a meaningful way to measure progress in patient safety, because it measures something we feel we can influence--i.e., how reliably we follow our best practices to prevent harm," they wrote.

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