Refocusing on Patient Safety.

Abstract

Patient safety provides an important foundation for high-quality care. Research in Canada and elsewhere has identified substantial levels of harm in hospitals and other settings; these results spurred the development and spread of safety practices, along with strategies to strengthen organizational training, incident reporting and analysis and a host of resources intended to reduce the burden of harm. Yet, despite these efforts, 20 years after the publication of the Canadian Adverse Event study (Baker et al. 2004) and other studies, many leaders believe progress in patient safety has stalled (NEJM Catalyst 2023). Indeed, some recent studies indicate that the levels of harm have increased. One notable study by David Bates and colleagues (2023), building on approaches used in earlier studies, identified at least one adverse event in 23.6% of a random sample of patients in Massachusetts hospitals in 2018. Among 978 events, 22.7% were judged preventable and one-third required at least substantial intervention or prolonged recovery.