Analysis and measurement are crucial to understanding, monitoring, targeting and evaluating patient safety improvement.
A wide range of approaches are used to measure and analyse patient safety. Some of these are backward looking and retrospective, analysing and quantifying past adverse events and tracking levels of harm. Others are more forward looking, aiming to predict and anticipate potential harmful events or establish the current and future safety state of an organisation.
Both approaches play an important role in providing an overall picture of patient safety, and both need to be regularly and routinely conducted to ensure the current state of patient safety is understood and emerging problems are addressed.
Healthcare organisations have a responsibility to analyse and investigate patient safety incidents. When done effectively, this can provide important and valuable insights into patient safety issues.
Root Cause Analysis
Root Cause Analysis is a widely used approach to analysing and investigating incidents, and can bring together a range of different professionals, experts and patients to develop a detailed picture of why things went wrong and what can be done to address those problems and improve.
Levels of harm
Levels of harm can be established and measured through case note reviews to identify 'triggers' that indicate that harmful events may have taken place, or through performing regular and brief checks on wards to count the number of patients suffering from harmful events at any time. Both the Global Trigger Tool and the Patient Safety Thermometer provide relatively simple and straightforward methods to measure and analyse patient safety.
More proactive and future-oriented approaches to measuring and analysing patient safety include different risk assessment methods and the use of safety cases. Risk assessment methods aim to analyse and measure potential future problems and harmful events. A range of specific techniques support this, ranging from a simple risk assessment matrix to rank the severity and likelihood of future adverse events, through to sophisticated methods of modelling and quantifying the types and effects of potential failures throughout a healthcare system.
The overall safety state of a unit, department or organisation can be understood in detail by preparing a safety case. Safety cases are widely used in other industries, and involve a structured, systematic and evidence-based analysis of the current safety arrangements across a specific area. They offer healthcare a new approach to bringing healthcare professionals together to analyse and measure safety, and identify and address gaps in current systems and practices.