How reliable is your hospital? A qualitative framework for analysing reliability levels.

David E Ikkersheim; Marc Berg

Commentary

How reliable is your hospital? A qualitative framework for analysing reliability levels.

September 7, 2011

Ikkersheim DE, Berg M. BMJ Qual Saf. 2011;20(9):785-790.

View more articles from the same authors.

This commentary discusses reliability theory in patient safety and describes an assessment framework to help measure the reliability of processes and practices in hospitals.

PubMed citation

Available at

Related Resources From the Same Author(s)

Computer technology and clinical work: still waiting for Godot.

April 3, 2005

OZIS and the politics of safety: using ICT to create a regionally accessible patient medication record.

July 26, 2006

Some unintended consequences of information technology in health care: the nature of patient care information system-related errors.

March 6, 2005

The impact of computerized provider order entry systems on inpatient clinical workflow: a literature review.

July 22, 2009

Overriding of drug safety alerts in computerized physician order entry.

January 11, 2006

Impact of a computerized physician order entry system on nurse-physician collaboration in the medication process.

February 4, 2009

Understanding handling of drug safety alerts: a simulation study.

May 5, 2010

Turning off frequently overridden drug alerts: limited opportunities for doing it safely.

May 21, 2008

Feasibility first: developing public performance indicators on patient safety and clinical effectiveness for Dutch hospitals.

December 7, 2005

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

December 2, 2009

Feasibility of patient-reported diagnostic errors following emergency department discharge: a pilot study.

October 28, 2020

Diagnostic errors--The next frontier for patient safety.

March 18, 2009

Diagnosis is a team sport—partnering with allied health professionals to reduce diagnostic errors: a case study on the role of a vestibular therapist in diagnosing dizziness.

July 27, 2016

Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.

February 21, 2018

How much diagnostic safety can we afford, and how should we decide? A health economics perspective.

October 2, 2013

Are teaching hospitals treated fairly in the Hospital-Acquired Condition Reduction Program?

December 12, 2018

A systematic review of teamwork training interventions in medical student and resident education.

June 4, 2008

Association between the Centers for Medicare and Medicaid Services hospital star rating and patient outcomes.

May 4, 2016

Identifying and analyzing diagnostic paths: a new approach for studying diagnostic practices.

June 21, 2017

Crossing academic boundaries for diagnostic safety: 10 complex challenges and potential solutions from clinical perspectives and high-reliability organizing principles.

March 24, 2021

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database.

October 23, 2019

Cognitive and system factors contributing to diagnostic errors in radiology.

October 9, 2013

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.

March 18, 2015

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.

April 23, 2014

Oncology nurses' perceptions about involving patients in the prevention of chemotherapy administration errors.

April 14, 2010

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

July 19, 2006

An official Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action.

July 27, 2016

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis.

May 3, 2017

Detection, classification, and correction of defective chemotherapy orders through nursing and pharmacy oversight.

September 17, 2008

Acceptance of recommendations by inpatient pharmacy case managers: unintended consequences of hospitalist and specialist care.

March 27, 2013

Label design affects medication safety in an operating room crisis: a controlled simulation study.

April 1, 2015

Diagnostic errors in the pediatric and neonatal ICU: a systematic review.

March 4, 2015

Incoming interns recognize inadequate physical examination as a cause of patient harm.

July 15, 2020

Consensus bundle on prevention of surgical site infections after major gynecologic surgery.

December 21, 2016

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods.

July 21, 2021

25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank.

May 1, 2013

Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity.

May 3, 2023

In pursuit of quality and safety: an 8-year study of clinical peer review best practices in US hospitals.

November 28, 2018

An assessment of the impact of just culture on quality and safety in US hospitals.

May 9, 2018

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.

November 27, 2013

An organizational learning framework for patient safety.

April 13, 2016

The objective impact of clinical peer review on hospital quality and safety.

February 16, 2011

Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences.

December 23, 2020

Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis.

August 17, 2022

Physician prescribing of opioids to patients at increased risk of overdose from benzodiazepine use in the United States.

May 16, 2018

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

November 15, 2017

Using simulation to improve patient safety: dawn of a new era.

March 18, 2015

Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.

January 25, 2006

Outpatient adverse drug events identified by screening electronic health records.

June 9, 2010

Use of simulation to measure the effects of just-in-time information to prevent nursing medication errors: a randomized controlled study.

January 27, 2021

Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method.

August 19, 2020

Diagnostic performance dashboards: tracking diagnostic errors using big data.

April 4, 2018

Diagnostic errors in the intensive care unit: a systematic review of autopsy studies.

August 8, 2012

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.

December 15, 2021

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

January 17, 2007

Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the “Big Three”.

June 3, 2020

Serious misdiagnosis-related harms in malpractice claims: the "Big Three": vascular events, infections, and cancers.

July 17, 2019

Learning from tragedy: the Julia Berg story.

December 12, 2018

Rapid response teams: a systematic review and meta-analysis.

January 20, 2010

Impact of diagnosis-timing indicators on measures of safety, comorbidity, and case mix groupings from administrative data sources.

August 15, 2007

Patient safety: moving the bar in prison health care standards.

October 13, 2010

Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems.

March 8, 2006

COVID-19: the dark side and the sunny side for patient safety.

October 14, 2020

Supporting the emotional well-being of health care workers during the COVID-19 pandemic.

August 5, 2020

Defining the critical role of nurses in diagnostic error prevention: a conceptual framework and a call to action.

December 6, 2017

Burden of serious harms from diagnostic error in the USA.

July 28, 2023

Interruptions in emergency department work: an observational and interview study.

May 15, 2013

An ethical framework for allocating scarce life-saving chemotherapy and supportive care drugs for childhood cancer.

February 17, 2016

Unannounced versus announced hospital surveys: a nationwide cluster-randomized controlled trial.

May 3, 2017

Improving medical residents’ self-assessment of their diagnostic accuracy: does feedback help?

February 2, 2022

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.

May 12, 2021

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.

December 8, 2021

Knowledge, attitudes, and expectations of medical staff toward medical error management policies in humanitarian medicine: a qualitative study.

February 10, 2021

A call for the application of patient safety culture in medical humanitarian action: a literature review.

May 6, 2020

Access to prescription opioids—Primum Non Nocere: a teachable moment.

July 27, 2016

Hospital-wide code rates and mortality before and after implementation of a rapid response team.

December 10, 2008

STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration.

October 14, 2016

Failure events in transition of care for surgical patients.

March 5, 2014

Toward a definition of teamwork in emergency medicine.

October 22, 2008

Development and expression of a high-reliability organization.

December 1, 2021

Effect of illness severity and comorbidity on patient safety and adverse events.

November 9, 2011

Safety culture in the operating room: variability among perioperative healthcare workers.

September 13, 2017

Opioid prescribing after nonfatal overdose and association with repeated overdose: a cohort study.

January 20, 2016

Effect of computerisation on the quality and safety of chemotherapy prescription.

January 3, 2007

A comparison of hospital adverse events identified by three widely used detection methods.

August 5, 2009

Better nurse staffing is associated with survival for Black patients and diminishes racial disparities in survival after in-hospital cardiac arrests.

December 9, 2020

A contemporary analysis of closed claims related to wrong site surgery.

March 29, 2023

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

November 17, 2021

Physicians, information technology, and health care systems: a journey, not a destination.

March 6, 2005

Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application.

September 7, 2005

Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room.

November 23, 2016

Observational study of drug formulation manipulation in pediatric versus adult inpatients.

January 13, 2021

New persistent opioid use after postoperative intensive care in US veterans.

June 19, 2019

Missing diagnoses during the COVID-19 pandemic: a year in review.

June 23, 2021

Profiles in patient safety: medication errors in the emergency department.

March 6, 2005

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

January 25, 2023

Four states with robust prescription drug monitoring programs reduced opioid dosages.

June 27, 2018

Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.

July 29, 2009

Improving patient safety by identifying latent failures in successful operations.

August 1, 2007

Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory.

May 18, 2022

Related Resources

Safer Hospital Care: Strategies for Continuous Innovation, Second Edition.

May 16, 2019

High Reliability in Health Care.

June 8, 2016

Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.

May 18, 2016

A collaborative learning network approach to improvement: the CUSP learning network.

April 8, 2015

Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.

March 11, 2015

Patient safety culture transformation in a children's hospital: an interprofessional approach.

April 30, 2014

Healthcare-associated infections: a national patient safety problem and the coordinated response.

February 19, 2014

Patient Safety Collaboration.

November 27, 2013

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.

November 27, 2013

Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety.

November 20, 2013

Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2013.

November 13, 2013

Solving the puzzle: improving safety outcomes.

October 23, 2013

Positive deviance: a new tool for infection prevention and patient safety.

October 16, 2013

High-reliability health care: getting there from here.

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

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

September 4, 2013

Patient safety: threats and solutions.

August 28, 2013

Setting quality and safety priorities in a target-rich environment: an academic medical center's challenge.

August 28, 2013

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

August 21, 2013

A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.

August 21, 2013

A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality.

August 21, 2013

A perinatal care quality and safety initiative: are there financial rewards for improved quality?

July 31, 2013

Does health care role and experience influence perception of safety culture related to preventing infections?

July 17, 2013

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce.

July 17, 2013

National Healthcare Safety Network.

July 10, 2013

Resident Projects for Improvement.

June 19, 2013

Advancing Successful Care Transitions to Improve Outcomes.

June 12, 2013

The leader's role in medical device safety.

May 29, 2013

Physicians with multiple patient complaints: ending our silence.

May 8, 2013

A framework for patient safety: a defense nuclear industry-based high-reliability model.

May 1, 2013

See More About The Topic

Hospitals

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Quality Improvement Strategies

How reliable is your hospital? A qualitative framework for analysing reliability levels.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

How reliable is your hospital? A qualitative framework for analysing reliability levels.

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