Safety at what cost?

Improving patient safety is a complicated business. Sometimes we don't know exactly what to do. Other times we must balance increased safety with decreased patient autonomy or slowed availability of possibly life-saving medications. We have examples of all of these in this week's BMJ.

In response to patient safety concerns many hospitals have set up routine incident reporting systems. Ali Sari and colleagues reviewed the results of such a system in a large hospital and compared them to a structured review of case notes for the same 1000 admissions. Their study (doi: 10.1136/bmj.39031.507153.AE) found that the incident reporting system missed almost half of the important patients safety incidents—those that actually resulted in patients being harmed. In an accompanying editorial (doi: 10.1136/bmj.39071.441609.80), Charles Vincent agrees that reporting systems are not an effective way to improve patient safety. He argues that only active measurement and improvement programs focused on known high-risk activities will meaningfully decrease the risks of adverse events.

Falls are the most common adverse event in hospitals and nursing homes and often lead to injury and subsequent functional impairment. David Oliver et al performed a systematic review (doi: 10.1136/bmj.39049.706493.55) of strategies to decrease falls in these settings. They found evidence that comprehensive hospital fall prevention programs lead to a modest reduction in hip fracture rates and that hip protectors help prevent hip fractures in nursing homes. Ian Cameron and Susan Kurrle comment (doi: 10.1136/bmj.39084.388553.80) that most research on fall prevention has been done in the community and less is known about institutional settings. Hospital and nursing home patients are generally frailer and have a higher prevalence of dementia, both risk factors for falls. How to best prevent falls in institutional settings is still largely an unanswered question.

Finally, Linda Horton comments (doi: 10.1136/bmj.39049.545880.BE) on an Institute of Medicine report on the US Food and Drug Administration. She advocates increased FDA funding, enlarged focus on postmarketing safety studies, and increased international collaboration to improve the drug approval process. But no drugs are completely without risk. Faster, earlier drug approvals will undoubtedly lead to the discovery of some of those risks after drugs have been approved and marketed.