The Safety and Quality of Health Care
Copyright © 2008 The McGraw-Hill Companies. All rights reserved.
The Safety and Quality
of Health Care
David W. Bates
The safety and quality of care are two of the central dimensions of
health care. It is increasingly clear that both could be much better, and
in recent years it has become easier to measure both safety and quality.
In addition, the public is—with good justification—demanding mea-
surement and accountability, and increasingly payment for services will
be based on performance in these areas. Thus, physicians must learn
about these two domains, how they can be improved, and the relative
strengths and limitations of our current ability to measure them.
Safety and quality are closely related but do not completely overlap.
The Institute of Medicine has suggested in a seminal series of reports
that safety is the first part of quality, and that health care first must
guarantee that it will deliver safe care, although quality is also pivotal.
In the end, it is likely that more net clinical benefit may be derived
from improving quality than safety, though both are important, and
safety is in many ways more tangible to the public. Accordingly, the
first section of this chapter will address issues relating to the safety of
care, while the second will cover quality of care.
SAFETY IN HEALTH CARE
Safety theory clearly points out that individuals make
errors all the time. Think of driving home from the hospital; you in-
tend to stop and pick up a quart of milk on your way home, but you
find yourself entering your driveway, without realizing how you got
there. We all use low-level, semi-automatic behavior for many of our
activities in daily life; this kind of error is called a “slip.” Slips occur of-
ten during care delivery; e.g., when someone intends to write an order
but forgets because they have to complete another action first. “Mis-
takes,” by contrast, are errors of a higher level; they occur in new or