Safe care - what is it?

Safe care - what is it?

There are lots of people talking about safe care, as though there is a sharp dichotomy or that safe care was easy to define. Of course there are all sorts of ways of measuring various outcomes, and comparing the performance of different hospitals on these outcomes, and we can arbitrarily define the lowest performers as providing "unsafe care", but then that tacitly acknowledges that the standards expected change with time - what is an acceptable level of mortality from heart surgery in one era is very high in another. So clearly what is acceptable is relative to the circumstances. 

It is also clear that there will be some natural variation. Some surgeons are more skilled than others for example - but that does not mean that the lesser skilled surgeon is not a good surgeon. The more skilled surgeon who takes on more complex cases may end up with a higher mortality rate than the lesser skilled surgeon. If the patient cannot get his operation because surgeons are worried about their mortality figures, that puts the risk from the hospital to the patient. 

One way of assessing care is the rate of "never events". The concept of never events is related to reimbursement of hospitals in the US Medicare system. The idea was that hospitals shouldn't have a perverse disincentive against preventing certain adverse events that are eminently preventable by getting paid to treat them. A hospital that gets paid for the care of a pressure sore has not lost out due to their negligence, and in fact has gained. The designation of "never event" does not automatically mean that these events should never happen. It is possible to design a system that when implemented properly eliminates the possibility of surgical instrument retention, for example. The system can prevent human error by an individual missing such an error. 

Some of the other "never events" are not in this same category, for example "Intraoperative or immediately post-operative death in an ASA Class I patient". Certainly this should be incredibly rare, but there will be rare circumstances where an unexpected reaction results in death in a fit, healthy individual. Similarly "Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility". Again, this should be very rare, but factors outside the control of the healthcare providers could result in this "never event occurring" (NB: these are US examples). 

Safety of care is a continuum, and there should be constant efforts to improve the safety of healthcare. Complacency is never an option, but constant flagellation doesn't seem too great either.