2025 – PAGE 451 – PATIENT SAFETY AND QUALITY IMPROVEMENT
NON-PUNITIVE APPROACH
Punishing individuals for mistakes is NOT part of the approach to patient safety and quality improvement. Punishment encourages people to cover up and minimize errors and weaknesses, which is the exact opposite of what we need in order to have a culture of transparency.
LEARNING FROM ERRORS
It’s not enough just to recognize and catalog errors. There must be some way to ensure that they are examined and analyzed. Morbidity and mortality meetings, review boards, or office team meetings are possible settings for such review.
QUALITY IMPROVEMENT
Quality improvement strives to improve patient safety and to look for positive ways to bring the care offered to each patient up to the highest standards. Many of the principles are the same as for patient safety (team approach, recognizing the importance of the whole system, acknowledging errors, etc.). Other important principles include:
- Having a data-driven approach
- Fostering a psychology of change
- Striving for continuous improvement
DATA DRIVEN APPROACH
Ultimately, quality of care is not about having the right standards or procedures, but about getting the right results. We can’t even talk about quality improvement until we have ways of measuring quality, and this means gathering relevant data and using meaningful, accurate methods of interpreting it. So, beware of exam answers that might sound like good ways to start a QI project, but which neglect the data gathering.
The AAP also stresses the recognition of variability in quality data. This simply means that we need to know how to distinguish random variation from true change in quality measures. This will require statistics of some sort.
Example of Control Chart (also called a “run chart”)