CDM Seminar Series 2003-04


How safe is that hospital?
Qualitative and quantitative models of medical error

Meghan Dierks, MD
Harvard Risk Management Foundation

Wednesday, May 12
2nd floor lounge 32-250

Concerns about patient safety are nowhere more acute than now. The safety crisis is highlighted by medical malpractice judgments that have reached historic proportions. What accounts for the significant but unexpected variations in medical care? What initiates the sequence of faults that leads to an adverse event? Once a sequence is initiated, what accounts for propagation in some cases and recovery in others? Why has it been so difficult to anticipate and manage anything other than patient-specific risk?

In order for us to answer these questions, we need to look beyond the patient and the individual provider, at the system in which the care is delivered. The clinical environment is an extraordinarily complex system of care. Being able to model important interactions and interdependencies between different system components (staff, instrumentation, protocols, procedures, information, communication, and scheduling cycles) and the sequence of events that lead to a particular adverse event is a first step in making the clinical environment safer.

In this presentation, Dr. Dierks will initially present some modeling techniques that have proved very useful for understanding how events and system properties can propagate leading to severe patient injury. She will then discuss whether risk can be quantitatively estimated by applying probabilistic techniques to the qualitative models. Probabilistic risk analysis has been widely applied to other high-risk sectors including transportation, energy and chemical processing, aerospace and the military. However, it has some limitations when applied to the medical world. The extent to which it can be used to reliably quantify risk and inform policy and regulatory decisions in the area of medical safety will be explored.


CDM Seminar Series