Editorial

Using Evidence to Improve Patient Safety andthe Quality of Health Care

Hospitals today treat increasingly complex patients suf-fering from multiple health care problems. Despite

the best efforts of hospital staff, many patients admittedto hospital suffer a serious adverse event (SAE) that is notattributable to their underlying medical condition. Thesefindings are not unique to one country. Patient safety isan international concern that affects both developed anddeveloping countries. Studies in Australia (Wilson et al.1995), New Zealand (Davis et al. 2002, 2003), England(Vincent et al. 2001), Canada (Baker et al. 2004), and theUnited States (Schimmel 1964; Brennan et al. 1991; Leapeet al. 1991; Andrews et al. 1997; Thomas et al. 2000) esti-mate the incidence of adverse events to be between 3.7%(Brennan et al. 1991) and 17.7% (Andrews et al. 1997).This leaves us in no doubt that there are ethical, humani-tarian, and financial imperatives to expose the extent andetiology of adverse events, analyze the data, and gener-ate new strategies to improve detection, management, andprevention (Runciman et al. 2001).

Prior to 1990, there was little knowledge or evidence onthe performance of health care organizations in maintain-ing patient safety. Significantly, in one of the first studies toundertake a review of medical histories for adverse events,the Harvard Medical Practice Study found approximately70% of adverse events were preventable (Brennan et al.1991). Similarly, an Australian study found that there wasa 40-fold greater risk of dying during hospital care than be-ing in traffic (Runciman et al. 2001). A few years later, theseminal report by the Institute of Medicine (IOM) To Err isHuman highlighted the millions of U.S. patients who wereseriously harmed during hospitalization and an estimated98,000 who died as a result of medical errors (Kohn et al.2000). Not surprisingly, preventable adverse events havea significant direct medical cost, as well as a human costfor those who are harmed, their families and friends, andthose who care for them (Runciman et al. 2001). Whileprogress has been made since the IOM publication, lead-ers in the field have strongly argued that progress has beenfrustratingly slow, culminating in defective practice beingrewarded for the additional services that are needed afterharm has resulted (Leape et al. 2005).

Copyright ©2011 Sigma Theta Tau Internationaldoi: 10.1111/j.1741-6787.2010.00213.x

Major initiatives internationally, such as hand hygieneand surgical checklists (Leape et al. 2005), have shownsome success. However, barriers to greater improvementarguably relate to the complexity of, and culture withinthe health care system. Issues such as professional frag-mentation, individualism, hierarchical authority, blurredaccountability, and lack of leadership generate barriers toteamwork and individual responsibility; overcoming theseissues are prerequisites for generating a culture of safety inhealth care (Leape et al. 2009).

Many reports evaluating health care performance advo-cate the critical importance of information in being ableto identify and establish the scope of the problem, im-plement corrective actions, and continuously track out-comes (McGlynn 2003). Yet Gawande (2010) claims thatthe sheer volume of information and the environmen-tal complexity encumbers the system; thus outweighinga clinician’s or an organization’s ability to deliver care con-sistently, correctly, and safely. Increasing awareness of pa-tient safety concerns has promulgated recommendationsand examples of patient safety practices. Many of thesepractices intuitively sound like good ideas and are oftenrapidly disseminated and implemented by well-intentionedhealth care leaders. One international example was high-lighted by Shojania and colleagues (2002) in addressingfatigue among health professionals. The belief being thatan overtired or exhausted health professional was morelikely to make cognitive errors in practice. Yet the evi-dence showed no reduction in the hospital mortality, anincrease in complications, and delayed test ordering af-ter restrictions of resident work hours (Laine et al. 1993).Furthermore, a recent article reiterates that patient safetyis not improved by reducing resident hours to 80 hours perweek (Nasca et al. 2010). This reveals that while practicesmay be deemed safer, they may not necessarily be evidencebased. It also reinforces that changes in one aspect of thehealth system may lead to unexpected repercussions fol-lowing the change.

Similar to evidence-based practice (EBP), the main aimin patient safety is to eliminate unproven practices by im-plementing evidence of proven benefit for patients. Theproblem for the patient safety movement has been one ofimmaturity. Most of the momentum has occurred since theIOM report in 2001, which recommended the identifica-tion and dissemination to all clinicians of a list of safety

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Editorial

practices that were effective. Shortly afterwards, Shojaniaand colleagues (2002) were commissioned to evaluate theevidence supporting a list of proposed safety practices. Acompendium of practices was compiled following system-atic review and analysis of the literature with emphasison evidence from randomized controlled trials. Not sur-prisingly there was minimal evidence available, and fewpractices were shown to be highly recommended becausethey failed to meet the criteria for the highest level of ev-idence (Leape et al. 2002). Arguably, the lack of progressin developing an evidential base is a consequence of alack of prioritizing patient safety by the health leaders andfunders.

Fortunately, in the last decade we have seen an increasein research and funding toward patient safety initiatives.Yet Leape and colleagues (2002) disapprove of the researchfocus on individual practices, arguing it fails to recognizethe importance of the system-level interventions neces-sary to advance the patient safety agenda. They arguedthat a classic medical model may be suitable for clini-cal medicine, but is less likely to be useful for improv-ing patient safety. This criticism is also one frequentlyput forward in EBP. Human factors or safety theory aretwo examples used by other industries that might offer amore suitable approach for reducing adverse events andredesigning health care (Leape et al. 2002). Implementa-tion of evidence into practice is complex and multifaceted,requiring significant skills and systematic change concern-ing individuals, teams, and organizations if the process islikely to be successful and sustainable. As such, theoriesand models from outside health care may be more relevantand offer researchers and clinicians a valuable guidance instructuring their research (Rycroft-Malone et al. 2010) andpatient safety practices.

The clinical challenges proposed by Shojania and col-leagues (2002) remain relevant today. In a complex and dy-namic health system, scientific and technological advancesone day may lead to incidents and adverse events the next.The clinicians and administrators need to be aware thatimplementation of non evidence-based practices may notonly cause harm to patients, but they may also lead to lostopportunities in improving the system. However, practi-cal, low-risk but understudied interventions that seem towork should not be discounted. Rather, health care leadersneed to prioritize the evaluation of patient safety practices,and feedback the information to the clinicians in order tofurther refine practices. This special edition of Worldviewson Evidence-Based Nursing provides a variety of researchexamples that address earlier criticisms of patient safetyresearch by recognizing the social and environmental in-

fluences characterizing health care today and tackling theimplementation of evidence in clinical practice.

Tracey Bucknall, RN, PhD, BN, ICU Certificate, Grad DipAdv Nurs

Associate Editortracey.bucknall@deakin.edu.au

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