Setting priorities for patient-safety efforts will mean hard choices

August 25, 2009

Is it more urgent for hospitals, doctors and nurses to focus resources on preventing the thousands of falls that injure hospitalized patients each year, or to home in on preventing rare but dramatic instances of wrong-side surgery? Is it best to concentrate immediately on preventing pediatric medical errors or on preventing drug interactions in the elderly?

With efforts to improve patient safety gathering momentum, two Johns Hopkins experts in patient safety and bioethics urge policy makers to weigh in about which safety interventions deserve the most urgent attention when it's clear that resources are limited.

In a commentary in the August 26 issue of the Journal of the American Medical Association (JAMA), they suggest that health policy makers have yet to come to grips with the complexity of setting such priorities, and that time is of the essence.

"The importance of patient safety to people's lives and the quality of health care is clear, but there aren't enough resources to devote to everything simultaneously," says Ruth R. Faden, M.P.H., Ph.D., executive director of the Johns Hopkins Berman Institute of Bioethics. Faden coauthored the JAMA commentary with award-winning Johns Hopkins patient safety expert Peter J. Pronovost, M.D., M.P.H., a professor in the Departments of Anesthesiology and Critical Care Medicine and Surgery and director of Johns Hopkins Quality and Safety Research Group.

Noting that many patient safety interventions are patterned after safety efforts in commercial aviation, Pronovost—whose "cockpit" style checklists for intensive care unit personnel are one example—points out that deciding patient safety priorities is infinitely more complicated than similar efforts to protect passenger safety.

Aviation safety is almost solely focused on a single goal—preventing death, Pronovost says—while patient safety involves a variety of technologies, treatment risks, judgments and possible outcomes in diverse populations.

"While we're literally all in the same plane with aviation safety, the concerns are very different in healthcare," he says. "You have different kinds of patients in different settings, facing different risks from errors and mistakes," he adds.

Among the social, ethical, scientific and political factors policy makers should consider, the Hopkins pair write, are whether to give priority to medical errors that are rare, devastating and likely to involve individual culpability in a limited setting—like wrong side surgery—or to more frequent, systemic problems—like falls—that are more widespread.

When resources are strained, policy makers need to consider tough choices, such as whether to give more focus to safety issues involving those with a good prognosis rather than to those in which survival from the underlying illness is unlikely.

Fundamentally, they say, informed public policy requires open debate about criteria for setting priorities in the first place. "Choosing patient safety priorities will mean tradeoffs, and policy makers should opt for a transparent, accountable, and ethical framework to set decisions," Faden says.

Source: Johns Hopkins Medical Institutions