Hospital mortality: when failure is not a good measure of success.

Kaveh G Shojania; Alan J Forster

Commentary

Hospital mortality: when failure is not a good measure of success.

July 30, 2008

Shojania KG, Forster AJ. CMAJ. 2008;179(2):153-7.

View more articles from the same authors.

This commentary discusses the limitations of using hospital standardized mortality ratios as a measure of the quality of care, as illustrated in a recent study of preventable deaths after cardiac surgery.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Improving patient safety: moving beyond the "hype" of medical errors.

October 26, 2005

Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification.

August 29, 2007

Adverse events detected by clinical surveillance on an obstetric service.

November 15, 2006

Using prospective clinical surveillance to identify adverse events in hospital.

March 30, 2011

Deaths due to medical error: jumbo jets or just small propeller planes?

August 8, 2012

The frustrating case of incident-reporting systems.

May 20, 2009

Incident reporting systems: what will it take to make them less frustrating and achieve anything useful?

December 1, 2021

The elephant of patient safety: what you see depends on how you look.

August 25, 2010

Can you prevent adverse drug events after hospital discharge?

April 12, 2006

Evidence-based medicine: a cornerstone for clinical care but not for quality improvement.

May 15, 2019

Clinicians in quality improvement: a new career pathway in academic medicine.

February 25, 2009

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety.

March 6, 2005

Using Medical Emergency Teams to detect preventable adverse events.

September 9, 2009

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

March 22, 2017

A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.

February 15, 2017

Estimating deaths due to medical error: the ongoing controversy and why it matters.

October 26, 2016

Trends in adverse events over time: why are we not improving?

March 27, 2013

'Bad apples': time to redefine as a type of systems problem?

June 26, 2013

Implementing patient safety interventions in your hospital: what to try and what to avoid.

March 12, 2008

The vanishing nonforensic autopsy.

March 12, 2008

Using an interactive voice response system to improve patient safety following hospital discharge.

August 1, 2007

'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds.

March 12, 2014

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.

January 12, 2022

Double checking: a second look.

May 18, 2016

Sociocultural factors influencing incident reporting among physicians and nurses: understanding frames underlying self- and peer-reporting practices.

October 15, 2014

Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system.

July 23, 2014

Quality improvement in medical education: current state and future directions.

January 18, 2012

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

November 1, 2006

The tension between needing to improve care and knowing how to do it.

August 15, 2007

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

July 18, 2007

Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research.

March 25, 2020

Patient safety at the crossroads.

May 4, 2016

Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric?

August 5, 2015

Creating a just culture: the Ottawa Hospital's experience.

August 21, 2019

Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care.

March 27, 2013

Improving patient safety through the systematic evaluation of patient outcomes.

February 13, 2013

Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.

March 20, 2013

Usability evaluation of order sets in a computerized provider order entry system.

August 24, 2011

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

May 4, 2011

Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited.

October 5, 2011

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

November 25, 2020

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals.

July 10, 2019

Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

March 27, 2005

Clinical problem-solving. Lost in transcription.

October 18, 2006

Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study.

November 12, 2014

Teaching quality improvement and patient safety to trainees: a systematic review.

June 30, 2010

Safe but sound: patient safety meets evidence-based medicine.

April 12, 2006

Does full disclosure of medical errors affect malpractice liability? The jury is still out.

March 6, 2005

A systematic review to evaluate the accuracy of electronic adverse drug event detection.

January 4, 2012

Adverse events following an emergency department visit.

February 28, 2007

The uptake of technologies designed to influence medication safety in Canadian hospitals.

February 20, 2008

Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory.

September 11, 2013

Effect of point-of-care computer reminders on physician behaviour: a systematic review.

March 24, 2010

Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis.

January 2, 2008

Study of a multisite prospective adverse event surveillance system.

July 31, 2019

The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality.

November 17, 2010

Do physicians clean their hands? Insights from a covert observational study.

July 27, 2016

Introducing the patient safety professional: why, what, who, how, and where?

September 28, 2011

A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors.

September 24, 2014

The incidence and severity of adverse events affecting patients after discharge from the hospital.

March 6, 2005

The effects of on-screen, point of care computer reminders on processes and outcomes of care.

September 2, 2009

Quality gaps identified through mortality review.

February 1, 2017

Computerised provider order entry and residency education in an academic medical centre.

August 1, 2012

Patient safety in emergency medical services: a systematic review of the literature.

December 21, 2011

Adverse events in patients with return emergency department visits.

January 14, 2015

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme.

June 22, 2022

Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients.

April 16, 2008

Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis.

April 19, 2023

Information exchange among physicians caring for the same patient in the community.

December 3, 2008

Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward.

March 18, 2015

The many faces of error disclosure: a common set of elements and a definition.

April 4, 2007

A framework to assess patient-reported adverse outcomes arising during hospitalization.

August 24, 2016

Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy.

September 11, 2019

Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort.

July 15, 2015

Temporal clustering of critical illness events on medical wards.

July 26, 2023

Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care

October 2, 2019

Validation of a discharge summary term search method to detect adverse events.

April 21, 2005

What is the value and impact of quality and safety teams? A scoping review.

November 16, 2011

A randomised controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death or hospital readmission.

December 6, 2017

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

March 6, 2005

Safe medication prescribing and monitoring in the outpatient setting.

May 17, 2006

Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data.

October 12, 2016

The MedSafer Study: a controlled trial of an electronic decision support tool for deprescribing in acute care.

July 31, 2019

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

November 15, 2017

Adverse events among emergency department patients with cardiovascular conditions: a multicenter study.

March 10, 2021

The problem with the '5 whys.'

September 14, 2016

Patient safety: this is public health.

August 20, 2014

Burnout and sources of stress among health care risk managers and patient safety personnel during the COVID-19 pandemic: a pilot study.

July 7, 2021

Patient safety 2.0: slaying dragons, not just investigating them.

July 19, 2023

Adverse events after transition from ICU to hospital ward: a multicenter cohort study.

May 20, 2020

Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial

October 16, 2019

Patient safety professionals as the third victims of adverse events.

June 26, 2019

The problem with Plan-Do-Study-Act cycles.

February 3, 2016

A new frontier in healthcare risk management: working to reduce avoidable patient suffering.

February 24, 2016

ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group.

January 29, 2014

Overestimation of clinical diagnostic performance caused by low necropsy rates.

December 14, 2005

Beyond FMEA: the structured what-if technique (SWIFT).

September 26, 2012

Using pharmacists to optimize patient outcomes and costs in the ED.

August 27, 2014

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

September 28, 2011

Related Resources

Patient Safety Authority Annual Reports.

May 1, 2023

Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.

September 21, 2022

Hospital Compare.

May 13, 2021

An organization-specific and modifiable inpatient safety composite measure.

May 8, 2019

Patient safety climate strength: a concept that requires more attention.

August 31, 2016

A reduced duty hours model for senior internal medicine residents: a qualitative analysis of residents' experiences and perceptions.

August 24, 2016

Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto.

March 12, 2014

Twelve tips on engaging learners in checking health care decisions.

December 11, 2013

'Not another safety culture survey': using the Canadian patient safety climate survey (Can-PSCS) to measure provider perceptions of PSC across health settings.

November 13, 2013

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study).

November 6, 2013

Beyond crisis resource management: new frontiers in human factors training for acute care medicine.

October 30, 2013

The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study.

October 2, 2013

Health economic evaluation of an infection prevention and control program: are quality and patient safety programs worth the investment?

September 25, 2013

Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records.

September 11, 2013

Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members.

September 4, 2013

Associations of patient safety outcomes with models of nursing care organization at unit level in hospitals.

June 26, 2013

Has improved hand hygiene compliance reduced the risk of hospital-acquired infections among hospitalized patients in Ontario? Analysis of publicly reported patient safety data from 2008 to 2011.

June 5, 2013

Leadership and patient safety: a review of the literature.

May 29, 2013

Development of a checklist of safe discharge practices for hospital patients.

April 24, 2013

Improving patient safety through the systematic evaluation of patient outcomes.

February 13, 2013

The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals.

February 13, 2013

Review of computerized physician handoff tools for improving the quality of patient care.

December 12, 2012

Perspective: a business school view of medical interprofessional rounds: transforming rounding groups into rounding teams.

November 14, 2012

The economic burden of patient safety targets in acute care: a systematic review.

November 7, 2012

Taking a detour: positive and negative effects of supervisors' interruptions during admission case review discussions.

October 3, 2012

Achieving the 'perfect handoff' in patient transfers: building teamwork and trust.

August 8, 2012

Computerised provider order entry and residency education in an academic medical centre.

August 1, 2012

Harm to Healing - Partnering with Patients Who Have Been Harmed.

August 1, 2012

Comparative economic analyses of patient safety improvement strategies in acute care: a systematic review.

May 9, 2012

Medication reconciliation in the hospital: what, why, where, when, who and how?

May 2, 2012

See More About The Topic

Hospitals

General Internal Medicine

Hospital Medicine

Benchmarking

Hospital mortality: when failure is not a good measure of success.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Hospital mortality: when failure is not a good measure of success.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site