Skip to main content
Quality & Safety in Health Care logoLink to Quality & Safety in Health Care
. 2003 Dec;12(Suppl 2):ii2–ii7. doi: 10.1136/qhc.12.suppl_2.ii2

Organizing patient safety research to identify risks and hazards

J Battles, R Lilford
PMCID: PMC1765780  PMID: 14645888

Abstract

Patient safety has become an international priority with major research programmes being carried out in the USA, UK, and elsewhere. The challenge is how to organize research efforts that will produce the greatest yield in making health care safer for patients. Patient safety research initiatives can be considered in three different stages: (1) identification of the risks and hazards; (2) design, implementation, and evaluation of patient safety practices; and (3) maintaining vigilance to ensure that a safe environment continues and patient safety cultures remain in place. Clearly, different research methods and approaches are needed at each of the different stages of the continuum. A number of research approaches can be used at stage 1 to identify risks and hazards including the use of medical records and administrative record review, event reporting, direct observation, process mapping, focus groups, probabilistic risk assessment, and safety culture assessment. No single method can be universally applied to identify risks and hazards in patient safety. Rather, multiple approaches using combinations of these methods should be used to increase identification of risks and hazards of health care associated injury or harm to patients.

Full Text

The Full Text of this article is available as a PDF (159.6 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Brennan T. A., Leape L. L., Laird N. M., Hebert L., Localio A. R., Lawthers A. G., Newhouse J. P., Weiler P. C., Hiatt H. H. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991 Feb 7;324(6):370–376. doi: 10.1056/NEJM199102073240604. [DOI] [PubMed] [Google Scholar]
  2. Coyle Y. M., Battles J. B. Using antecedents of medical care to develop valid quality of care measures. Int J Qual Health Care. 1999 Feb;11(1):5–12. doi: 10.1093/intqhc/11.1.5. [DOI] [PubMed] [Google Scholar]
  3. Cullen D. J., Bates D. W., Small S. D., Cooper J. B., Nemeskal A. R., Leape L. L. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995 Oct;21(10):541–548. doi: 10.1016/s1070-3241(16)30180-8. [DOI] [PubMed] [Google Scholar]
  4. Helmreich R. L. On error management: lessons from aviation. BMJ. 2000 Mar 18;320(7237):781–785. doi: 10.1136/bmj.320.7237.781. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Kaplan H. S., Battles J. B., Van der Schaaf T. W., Shea C. E., Mercer S. Q. Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998 Nov-Dec;38(11-12):1071–1081. doi: 10.1046/j.1537-2995.1998.38111299056319.x. [DOI] [PubMed] [Google Scholar]
  6. Thomas E. J., Studdert D. M., Burstin H. R., Orav E. J., Zeena T., Williams E. J., Howard K. M., Weiler P. C., Brennan T. A. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000 Mar;38(3):261–271. doi: 10.1097/00005650-200003000-00003. [DOI] [PubMed] [Google Scholar]
  7. Thomas Eric J., Petersen Laura A. Measuring errors and adverse events in health care. J Gen Intern Med. 2003 Jan;18(1):61–67. doi: 10.1046/j.1525-1497.2003.20147.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Vincent C., Neale G., Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ. 2001 Mar 3;322(7285):517–519. doi: 10.1136/bmj.322.7285.517. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Quality & safety in health care are provided here courtesy of BMJ Publishing Group

RESOURCES