SIQuAS VRQ

Symposium

From perceived quality to perception of medical error - For an integrated methodology to detect medical errors
Saturday October 15, 2005
Arturo Pinna Pintor Foundation Hall
Via Vespucci 61 – Torino, Italy

Multiple Approaches to Identify Medical Errors

James B. Battles

Senior Service Fellow for Patient Safety, Center for Quality Improvement & Patient Safety. Agency for Healthcare Research & Quality (AHRQ). Rockville-USA.

Patient safety has become an international priority with major research programs being carried out throughout the world. There is a good deal of concern that the research approaches that have been associated with health services research and the study of medical outcomes maybe inadequate to meet the needs and problems associated with patient safety. A significant question is just what are the appropriate approaches to this new field of research? While many aspects of the study of patient safety are is relatively new, they should build on the rich heritage of safety science that has existed outside of medicine for years. Is it possible to build upon traditional approaches from health services research and add the strengths of research approaches from safety science and other disciplines to learn lessons for patient safety research?

A model for patient safety identification and risk has been developed that provides a conceptual framework for a variety of research approaches to identify risks and hazards associated with medical error. Approaches that have proven effective include the use of medical records and administrative record review, event reporting, direct observation, process mapping, focus groups, probabilistic risk assessment, and safety culture assessment. There is no single research method that can be universally applied to identify risks and hazards in patient safety. Rather we must look to multiple approaches to the identification process. We should apply a principle of maritime navigation which states that you can never truly know where you are without a three point fix of your position. In the process of identifying risks and hazards we need to employ multiple research methods to truly understand or fix our position as to where we are in patient safety.

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last update: 2005/11/06