Assessment and evaluation of patient safety reports: When should we intervene?

Abstract

Objective

The impact of medical errors on patient outcomes has been well-described. Multiple avenues for documenting and addressing patient safety events have been created, including quality outcome registries and adverse event databases.

Methods

This paper summarizes key data and definitions related to medical errors, as well as systems for monitoring them. We also offer considerations for how to interpret and act on these reports, at the hospital- or vascular surgery division-specific level.

Results

Several methods and systems exist for characterizing, cataloging, and addressing medical errors and quality of care.

Conclusions

Safety report review and adjudication should be timely and conducted according to principles of root cause analysis. Strategies to address systems-level factors should follow a defined improvement model. Division-level quality officers should meet as a group with hospital-level safety officers on a routine basis to discuss themes of safety that may resonate across the institution.