Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The paradox of hospital safety data
- Anthony P Morton (30 November 2008)
|
|
|||
|
Anthony P Morton, Medical Statistician Princess Alexandra Hospital Woolloongabba 4102 Australia
Send response to journal:
|
The paper by Vincent and colleagues echoes a familiar cry for better data about hospital safety1 that continues to go largely unanswered. Perhaps our approach is back-to-front. We owe a great debt to Professor Vincent and his colleagues for emphasizing a key concept: work is done in systems. Achieving safety is a system and good data are part of it, but the data represent the “cart” and not the “horse”. Safe work is done when competent people supplied with adequate resources implement systems based on evidence. Competence implies knowledge, judgment and technical skill. After good training programs (also a system) it is probable that the development and use of simulators has a great deal to offer in enhancing competence and in testing for its maintenance.2 Regular mandatory mortality and morbidity meetings3,4 complemented if necessary by independent audit5 seem to be powerful ways of enhancing safe practice. Surely governments can mandate and practitioners can formalize these activities and their reporting so that both safety and data improve. There is a growing body of evidence concerning safe practices, now commonly provided as bundles, and the UK NHS has made an impressive start.6 But it needs to be improved progressively. For example, we do not know enough about the transmission of a number of organisms causing hospital-acquired infections. Also, there are gaping holes in some existing bundles. As a recent Letter has indirectly pointed out,7 it is not a Hawthorne effect as is often reported that improves surgical site infection rates when there is feedback, it is that surgeons start to take more care with wound closure. Wound closure is something that is lacking in current bundles. Of course we need better evidence and health departments could structure their data collection with this objective in mind rather than inflicting more and more key performance indicators (KPIs) on harassed staff. And we need to institute methods of sequential learning such as Bayesian Networks for the analysis of these data. Crucially, resources must be considered. In Australia we know that one of the greatest single impediments to hospital safety is overcrowding.8 Clinicians have little or no control over this. It does not matter how much KPI data we collect, our hospitals have very limited capacity to become safer until a solution is found to this very difficult system problem that currently we seem to have no idea how to deal with. Our quest should be for safer systems based on better evidence and if we go about this properly we should succeed in having safer hospitals and, as an added bonus, better data. References 1. Vincent C, Aylin P et al “Is health care getting safer?” BMJ 2008;337:1205-7. 2. Foote C “Simulation for Team Crisis Management Training in Critical Care - Where Have We Been, Where Are We Now and Where Are We Going?” in Australian Anaesthesia Ed Riley R 2007 Melbourne Australian and New Zealand College of Anaesthetists pages 87-94. 3. Singer A “Mandatory regular meetings of hospital staff would complement medical audit and revalidation” BMJ 2000;320:1072. 4. Singer A “The Bristol Affair – a view from New York” Annals of the Royal College of Surgeons of England (Supplement) 2001;83:306-307. 5. Thompson A and Stonebridge L “Building a Framework for Trust: Critical Event Analysis for Deaths in Surgical Care” BMJ 2005;330:1139- 1142. 6. www.clean-safe-care.nhs.uk. 7. Mahaffey P Letter Surgical Site Infection “Guidelines or misguidance?” BMJ 2008;337:a2578. 8. Bland B “Underfunding of Australian health system leads to 1500 unnecessary deaths a year, doctors say” News BMJ 2008;337:1193. Anthony Morton MSc(Appl),MS,MD. amor5444@bigpond.net.au Competing interests: None declared |
|||