Patient Safety and Quality Improvement: Terminology.

Abstract

1. Lucy Pereira-Argenziano, MD* 2. Fiona H. Levy, MD* 1. *Department of Pediatrics, NYU School of Medicine, New York, New York. Medical errors and unintended harm continue to occur, despite preventive strategies. Understanding terminology and key attributes of improving safety can lead to creation of systems to reduce medical errors and preventable harm. After completing the article, the reader should be able to: 1. Understand and apply common terms used during discussions of safety and quality. 2. Describe common types of error and harm in pediatrics. 3. Describe the pediatric response to Institute of Medicine recommendations. 4. Understand attributes of high-reliability organizations and how their principles can be used to improve patient safety. The patient safety movement was galvanized by publication of To Err is Human by the Institute of Medicine (IOM) in 1999. (1) The report estimated that 44,000 to 98,000 people die in US hospitals each year as a result of medical errors. Equally interesting and perhaps as important to the magnitude of preventable injury occurring to patients in the United States is the fact that much of the data used as the basis for these estimates had been published and available in 1991. (2) The economic impact of medical errors has equally alarming implications for both health systems and consumers. Researchers analyzed clinical and billing data from a hospital database containing information from 600 hospitals and ambulatory surgery centers within the United States for visits in which injury occurred as a result of medical error. (3) A cost analysis was performed for each injury visit. Extrapolation of the data to the broader US population estimated the cost of medical errors to the US health-care system to have been $1 billion in 2009. Because the study focused solely on inpatient costs of medical …