Need to Improve Measurement

The patient safety movement is bogged down. The reason is that it cannot measure its central concept – safety – and measurement is a necessary (albeit not sufficient) condition for a subject to advance. Jha and Pronovost [1] make the excellent point that billing systems (read routine data in an NHS context) are not up to the job as they are subject to surveillance bias (better institutions report more incidents), and are heavily gamed. Signal-to-noise ratios are often poor.[2] They correctly point out that clinical data are needed, and these are now becoming available on both sides of the Atlantic as hospitals implement electronic clinical records. The authors give nice examples of adverse events that are contingent on the clinical situation and that can be harvested from notes. But they do not emphasise process measures that provide one of the richest source of data for quality enhancement.[3-5]

— Richard Lilford, CLAHRC WM Director


  1. Jha A, & Pronovost P. Toward a Safer Health Care System. The Critical Need to Improve Measurement. JAMA. 2016; 315(17):1831-2.
  2. Girling AJ, Hofer TP, Wu J, et al. Case-mix adjusted hospital mortality is a poor proxy for preventable mortality: a modelling study. BMJ Qual Saf. 2012; 21(12): 1052-6.
  3. Coleman JJ, Hodson J, Brooks HL, Rosser D. Missed medication doses in hospitalised patients: a descriptive account of quality improvement measures and time series analysis. Int J Qual Health Care. 2013; 25(5): 564-72.
  4. Coleman JJ, Hemming K, Nightingale PG, et al. Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error? J R Soc Med. 2011; 104(5): 208-18.
  5. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010; 341: c4413.

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