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Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Commentary
Roberts KH, Madsen P, Desai V, Van Stralen D. Qual Saf Health Care. 2005;14:216-220.
This commentary reviews the characteristics of a high-reliability organization (HRO). The authors present the story of a pediatric intensive care unit at a tertiary children's hospital to illustrate how HRO processes were adopted. They discuss how the unit evolved into a functioning and safe HRO and how staff reverted to a standard medical model when advocates of the HRO model left the organization. The authors emphasize the importance of constant attention to factors that support an HRO.
Journal Article > Study
Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.
Wachter RM, Flanders SA, Fee C, Pronovost PJ. Ann Intern Med. 2008;149:29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Bethesda, MD: Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. May 21, 2018. PA-18-790; PA-18-791.