Quality management and safety culture in medicine - Do standard quality reports provide insights into the human factor of patient safety?

Abstract

In 1999 the Institute of Medicine (IOM) published the landmark report "To err is human: building a safer healthcare system" highlighting critical deficiencies within the area of patient safety. As a consequence, safety culture evolved as a core component of quality management in medicine. Purpose of the investigation at hand was to find out to what extent this is reflected in standard quality reports issued by German hospitals providing maximum medical care. Reports issued for the year 2006 were analysed with respect to the appearance of indicators for the presence of a safety culture. Results suggest that despite the huge awareness for patient safety caused by the IOM report, the topic of safety culture does not get the anticipated attention within the quality reports. This may indicate that the current requirements for the quality reports do not facilitate transparency when it comes to the human factor of patient safety.

Keywords: error culture; error elasticity; patient safety; quality management; quality report; safety culture.

Figure 1. Sequence of steps performed to assess the quality reports with respect to the appearance of indicators for safety culture

Figure 2. Frequency of occurence for any of the key words within the sample (multiple occurrence per institution possible)

Figure 3. Number of hospitals naming individual indicators for safety culture (total exceeds 96 since risk management tools were documented in hospitals with incident reporting)

Figure 4. Frequency of safety/error culture mentioned in hospitals with incident reporting systems