Measurement of quality and assurance of safety in the critically ill.

Peter Pronovost; Bryan Sexton; Julius Cuong Pham; Christine A. Goeschel; Bradford D. Winters; Marlene R. Miller

Commentary

Measurement of quality and assurance of safety in the critically ill.

April 8, 2009

Pronovost P, Sexton B, Pham JC, et al. Clin Chest Med. 2009;30(1):169-79, x.

View more articles from the same authors.

This commentary discusses how challenges in measuring patient safety may stall improvement efforts. The authors describe a framework for evaluating safety measures and offer recommendations for future research.

PubMed citation

Available at

Related Resources From the Same Author(s)

Rapid response teams—walk, don't run.

October 11, 2006

Framework for patient safety research and improvement.

February 4, 2009

Why don't we know whether care is safe?

April 10, 2013

Reducing health care hazards: lessons from the Commercial Aviation Safety Team.

April 15, 2009

ReCASTing the RCA: an improved model for performing root cause analyses.

May 26, 2010

Rapid response systems as a patient safety strategy: a systematic review.

March 20, 2013

What to do with healthcare incident reporting systems.

January 29, 2014

Eradicating central line–associated bloodstream infections statewide: the Hawaii experience.

November 16, 2011

Maintaining and sustaining the On the CUSP: Stop BSI model in Hawaii.

January 30, 2013

The harm susceptibility model: a method to prioritise risks identified in patient safety reporting systems.

June 9, 2010

Clinical review: Checklists—translating evidence into practice.

January 27, 2010

Rapid response systems: should we still question their implementation?

May 8, 2013

On the CUSP: Stop BSI: evaluating the relationship between central line–associated bloodstream infection rate and patient safety climate profile.

November 12, 2014

Cardiac surgery errors: results from the UK National Reporting and Learning System.

February 16, 2011

Are temporary staff associated with more severe emergency department medication errors?

September 7, 2011

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

Viewing health care delivery as science: challenges, benefits, and policy implications.

October 13, 2010

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

March 9, 2011

Measuring patient safety in the emergency department.

June 19, 2013

Reducing medical errors and adverse events.

February 8, 2012

Using the opportunity estimator tool to improve engagement in a quality and safety intervention.

January 18, 2012

Tracking progress in patient safety: an elusive target.

August 16, 2006

Hospital board checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital.

June 12, 2013

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

June 29, 2011

Toward improving patient safety through voluntary peer-to-peer assessment.

January 25, 2012

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

July 21, 2010

The wisdom and justice of not paying for "preventable complications."

May 14, 2008

Assessing and improving safety climate in a large cohort of intensive care units.

February 23, 2011

The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs.

September 7, 2011

A morning briefing: setting the stage for a clinically and operationally good day.

August 10, 2005

Using a logic model to design and evaluate quality and patient safety improvement programs.

July 25, 2012

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

Effective approaches to control non-actionable alarms and alarm fatigue.

September 12, 2018

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

December 22, 2010

Simulation of in-hospital pediatric medical emergencies and cardiopulmonary arrests: highlighting the importance of the first 5 minutes.

January 16, 2008

A tool for the concise analysis of patient safety incidents.

January 13, 2016

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

January 15, 2014

Creating high reliability in health care organizations.

December 20, 2006

Patient safety in surgery.

May 10, 2006

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

June 7, 2006

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

January 16, 2013

Integrating CUSP and TRIP to improve patient safety.

November 24, 2010

Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.

May 17, 2006

Developing process-support tools for patient safety: finding the balance between validity and feasibility.

October 8, 2008

Establishing a global learning community for incident-reporting systems.

November 10, 2010

Infection preventionist checklist to improve culture and reduce central line–associated bloodstream infections.

December 8, 2010

A multicenter, phased, cluster-randomized controlled trial to reduce central line–associated bloodstream infections in intensive care units.

August 29, 2012

Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes.

February 22, 2012

Reality check for checklists.

August 19, 2009

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

A check-up for safety culture in "my patient care area."

November 14, 2007

Statewide collaborative to reduce surgical site infections: results of the Hawaii Surgical Unit-Based Safety Program.

June 20, 2018

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

April 18, 2007

Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.

January 16, 2008

Board quality scorecards: measuring improvement.

August 10, 2011

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

March 15, 2006

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

March 4, 2015

The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.

October 8, 2008

Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis.

July 13, 2016

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Needlestick injuries among surgeons in training.

July 4, 2007

Comparison of intensive care unit medication errors reported to the United States' MedMarx and the United Kingdom's National Reporting and Learning System: a cross-sectional study.

May 29, 2013

Explaining Michigan: developing an ex post theory of a quality improvement program.

August 3, 2011

An intervention to decrease catheter-related bloodstream infections in the ICU.

January 3, 2007

Paying the piper: investing in infrastructure for patient safety.

June 4, 2008

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

November 2, 2005

Safety culture as a patient safety practice for alarm fatigue.

October 13, 2021

Improving patient safety in intensive care units in Michigan.

June 25, 2008

Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.

May 18, 2016

Monitoring and reducing central line-associated bloodstream infections: a national survey of state hospital associations.

June 30, 2010

Operating room briefings.

July 5, 2006

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.

March 6, 2005

February 17, 2016

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

March 10, 2010

Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting database.

July 29, 2009

Impact of preoperative briefings on operating room delays.

November 26, 2008

Triangulating case-finding tools for patient safety surveillance: a cross-sectional case study of puncture/laceration.

February 29, 2012

Toward learning from patient safety reporting systems.

January 10, 2007

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

August 8, 2012

Sustaining reliability on accountability measures at the Johns Hopkins Hospital.

January 27, 2016

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital.

December 4, 2013

Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.

May 6, 2009

Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

February 16, 2011

Implementing standardized operating room briefings and debriefings at a large regional medical center.

August 5, 2009

A novel approach to implementation of quality and safety programmes in anaesthesiology.

December 7, 2011

Organising a manuscript reporting quality improvement or patient safety research.

August 21, 2013

Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.

April 23, 2014

Operating room briefings and wrong-site surgery.

February 7, 2007

Characteristics of pediatric chemotherapy medication errors in a national error reporting database.

June 13, 2007

Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit.

June 2, 2010

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

Implementing a team-based daily goals sheet in a non-ICU setting.

July 1, 2009

Do nurse and patient injuries share common antecedents? An analysis of associations with safety climate and working conditions.

February 8, 2012

View the world through a different lens: shadowing another provider.

October 8, 2008

Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience.

September 18, 2013

Pediatric antidepressant medication errors in a national error reporting database.

February 17, 2010

Perceptions of safety culture vary across the intensive care units of a single institution.

December 6, 2006

Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.

December 18, 2013

Decreasing errors in pediatric continuous intravenous infusions.

May 24, 2006

Related Resources

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Primers

Patient Safety Indicators.

April 26, 2023

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Rapid response teams as a patient safety practice for failure to rescue.

July 7, 2021

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Acting between guidelines and reality- an interview study exploring the strategies of first line managers in patient safety work.

February 3, 2021

The effect of blue-enriched lighting on medical error rate in a university hospital ICU.

January 27, 2021

Potential harm caused by physicians' a-priori beliefs in the clinical effectiveness of hydroxychloroquine and its impact on clinical and economic outcome--a simulation approach.

January 20, 2021

Adverse events present on arrival to the emergency department: the ED as a dual safety net.

March 11, 2020

Preventing central line–associated bloodstream infections in the intensive care unit: application of high-reliability principles.

December 19, 2018

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit.

August 8, 2018

Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge.

March 18, 2015

Lost in translation? Addressing barriers in the application of industrial process improvement methodologies to health care.

October 29, 2014

Reducing medication errors in critical care: a multimodal approach.

October 1, 2014

Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM.

September 17, 2014

Patient safety: this is public health.

August 20, 2014

Patient safety: let's measure what matters.

May 21, 2014

Implementing the Safety Thermometer tool in one NHS trust.

April 16, 2014

Researchers' roles in patient safety improvement.

April 9, 2014

The sterile cockpit: an effective approach to reducing medication errors?

April 2, 2014

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

January 15, 2014

The Orthopaedic Error Index: development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach.

December 18, 2013

The effect of collaboration on obstetric patient safety in three academic facilities.

December 4, 2013

Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? A randomized controlled trial.

September 4, 2013

Explaining Matching Michigan: an ethnographic study of a patient safety program.

August 21, 2013

Measuring patient safety in the emergency department.

June 19, 2013

Examining markers of safety in homecare using the international classification for patient safety.

June 12, 2013

A clinical case of electronic health record drug alert fatigue: consequences for patient outcome.

June 12, 2013

Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections.

June 5, 2013

Targeted versus universal decolonization to prevent ICU infection.

May 1, 2013

See More About The Topic

Intensive Care Units

Quality and Safety Professionals

Safety Scientists

Critical Care

Quality Improvement Strategies

Measurement of quality and assurance of safety in the critically ill.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Patient Safety Indicators.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Measurement of quality and assurance of safety in the critically ill.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Patient Safety Indicators.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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