EFFORTS TO IMPROVE SAFETY FROM EVALUATION OF INDIVIDUAL PATIENTS

The review of incidents or defects in the care of individual patients is common in health care. Examples include peer review, morbidity and mortality conferences, liability claims, and incident reports. Many of the improvements in anesthesia safety derived from review of closed liability claims. In all of these, the caregivers typically evaluate single events that are not linked to denominators, thereby limiting the ability to estimate rates. Many of the improvements in anesthesia safety resulted from review of closed claims. Many caregivers lack a systematic approach to investigating adverse events, focusing on individual providers rather than the systems in which they deliver care. Nevertheless, such methods, when appropriately applied,^[31] help to identify what is broken. One of these methods, health care incident reporting, is growing rapidly.^[32] Unlike other methods that evaluate harmed patients, incident reporting holds the potential to learn what is broken from near misses, incidents that did not lead to harm but could have.