Progress slow in improving hospitals' patient safety systems

December 13, 2005

While there has been some improvement in patient safety systems at hospitals, progress has been slow and the current systems are not close to meeting certain recommendations, according to a study in the December 14 issue of JAMA.

The 1998 Institute of Medicine (IOM) National Roundtable on Health Care Quality and subsequent reports ushered in a period of extensive research about the quality of the U.S. health care system, according to background information in the article. The IOM report, To Err Is Human, provided in-depth analyses of a wide range of patient safety problems and underscored the need for improvement. Subsequently, the IOM has called for "fundamental change ... to close the quality gap and save lives," and proposed a national initiative to "provide a strategic direction for redesigning the health care system of the 21st century." These documents indicate that successful implementation of change in the nation's overall health care system requires change in specific patient safety systems at the hospital level.

Daniel R. Longo, Obl.S.B., Sc.D., and colleagues from the University of Missouri-Columbia, conducted a study to assess the status of patient safety systems and examine changes from 2002 to 2004. The study included a survey of all acute care hospitals in Missouri and Utah at 2 points in time, in 2002 and 2004, using a 91-item comprehensive questionnaire (n = 126 for survey 1 and n = 128 for survey 2). The researchers analyzed the responses of the 107 hospitals that responded to both surveys to assess the changes over time.

Seven variables were constructed to represent the most important patient safety constructs studied: computerized physician order entry systems, computerized test results, and assessments of adverse events; specific patient safety policies; use of data in patient safety programs; drug storage, administration, and safety procedures; manner of handling adverse event/error reporting; prevention policies; and root cause analysis. For each hospital, the 7 variables were summed to give an overall measure of the patient safety status of the hospital.

The researchers found that development and implementation of patient safety systems is at best modest. "Self-reported regression in patient safety systems was also found. While 74 percent of hospitals reported full implementation of a written patient safety plan, nearly 9 percent reported no plan. The area of surgery appears to have the greatest level of patient safety systems. Other areas, such as medications, with a long history of efforts in patient safety and error prevention, showed improvements, but the percentage of hospitals with various safety systems was already high at baseline for many systems. Some findings are surprising, given the overall trends; for example, while a substantial percentage of hospitals have medication safety systems, only 3 percent reported full implementation at survey 2 of computerized physician order entry systems for medications, despite the growth of computer technology in general and in hospital billing systems in particular."

"Response from within the health care system clearly has been slow. In part, this is because of the complexities involved in implementing systems and changing cultures; however, complexity can also be an excuse," the authors write.

"Based on our findings, we recommend that individual hospitals, including their boards of directors, medical staffs, administration, and staff, review the list of patient safety systems our expert focus groups identified as needed in all hospitals. They can conduct their own survey of where they stand with regard to development and implementation of each of these and report where they stand to the community. While the list may seem long, it is very manageable when viewed by individual hospital departments to which given system characteristics apply. We concur with the larger recommendations of others that nationally there must be a far more aggressive agenda," the researchers write.
(JAMA.2005; 294:2858-2865. Available pre-embargo to the media at

Editor's Note: Funding for this study was provided by a grant from the Agency for Healthcare Research and Quality and through subcontracts with the Utah Department of Health and the Missouri Department of Health and Senior Services.

Editorial: Creating a Safer Health Care System - Finding the Constraint

In an accompanying editorial, Stephen G. Pauker, M.D., Ellen M. Zane, B.A., M.A., and Deeb N. Salem, M.D., of the Tufts-New England Medical Center, Boston, comment on the study by Longo et al.

"To produce sustained change, it is essential to understand root causes of current problems, establish policies to induce and maintain change, create measurements at all levels that shape safer behaviors, and properly measure progress toward the goal of having a safer health care system. Longo et al provide data about the introduction of safety systems, but better measurement systems and better data are also needed about the incidence of adverse events."

"Rewarding safety will surely help. Some clinicians might consider being paid to perform as being unprofessional, but few could object to creating a safer and higher-quality health care system. Rather than labeling such initiatives as pay-for-performance programs, it may be preferable to think of them as paying for quality and paying for safety. The time has come to take bold action and to embrace change, but first it is time to understand the constraints to accomplishing that change," they write. (JAMA.2005; 294:2906-2908. Available pre-embargo to the media at

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