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Become an Engaged Consumer of Health Care.

Medical errors are one of the leading causes of death in this country:
More than motor vehicle accidents. More than breast cancer. More than AIDS.
More than all of them combined.

People who care about their health care have a responsibility to learn about patient safety and quality improvement. This section is designed to provide knowledge, tools and resources to help you learn more about the issue and become an engaged, prepared consumer of Health Care.

The Relationship between Patient Safety and Quality Improvement

Patient safety and quality improvement are perceived by most people in healthcare to be distinct but related concepts. Most agree that patient safety and quality improvement overlap and have a common goal of improving the outcomes (results) that patients experience when they undergo medical treatment. Many describe patient safety as a component of quality improvement or the foundation of quality improvement. The portion of the Hippocratic Oath that states, First do no harm, is widely cited in quality improvement circles, both in medicine and other sectors.

In some healthcare organizations, patient safety and quality improvement are in the same department or perhaps even done by the same persons. In other organizations, the two functions are seen as distinct and therefore are conducted by different people working in different parts of the organization.

Patient Safety Definitions

What do we mean by medical errors? The term medical error is used to describe two things: First, when something that was planned as a part of medical care is not done right, or second, when the wrong plan was used in the first place.

For example, giving a patient a dose of medication ten times more than what was ordered is a medical error. Giving a patient the exactly the right dose as ordered is an error if the wrong medication was ordered to begin with, due to a misdiagnosis for example or confusing one patient with another.

Medical errors do not happen just in hospitals. They can occur anywhere in the health care system, including:

• Hospitals
• Clinics
• Outpatient surgery centers
• Doctors’ offices
• Nursing homes
• Pharmacies
• Patients’ homes

Medical errors are not just problems with medications they can involve:

• Medications
• Complications during or after surgery
• Misdiagnosis
• Equipment failure
• Laboratory reports that are wrong or that get lost
• Delays in care
• Documentation errors, including abbreviations in the medical record that are not understood by everyone, or a misplaced decimal point
• Getting one patient confused with another, or getting their records confused

Other terms used by patient safety researchers and advocates are:

Patient safety event—an event that causes an injury to the patient or presents a risk of harm. Patient safety events can also include the following:

• Near-miss event—an event when the unwanted consequences were prevented or corrected. That is, an error happened during medical care that could have caused injury or harm to the patient, but steps were taken to prevent the harm or injury from happening.
• No-harm event—an event occurred but it did not result in harm to the patient.

Unsafe conditions—circumstances that increase the probability of a patient safety event.

Healthcare Quality Definitions

The Institute of Medicine defines quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

The IOM further defines the elements of quality care are as follows:

1. Recognize patients at risk for diseases
2. Do appropriate evaluation
3. Make the appropriate diagnosis
4. Start the appropriate treatment
5. Schedule the appropriate follow-up
6. Stimulate the appropriate compliance/adherence to treatment

The goal of quality improvement is to decrease complications caused by healthcare treatment, morbidity (loss of bodily function), mortality (death) and cost of care.