• Healthcare quality improvement
• Hospital medicine
• Chronic disease management
• Health services research
• Medical error, measurement/epidemiology

To date, most safety and quality improvement efforts to mitigate harm have focused on the single diagnosis for which the patient was admitted to the hospital. Most often, the objective has been to ensure patients receive the appropriate evidence-based therapies for their diagnosis using guidelines, checklists, learning from defect tools1 or other interventions. However, people often have multiple morbidities and the interactions between them may increase their risk of harm when hospitalised.

Approximately half of all Americans have a chronic disease.2 In addition, an estimated 100 million disability-adjusted life years were added between 2000 and 2019 from a global rise in diabetes, ischaemic heart disease and several other non-communicable diseases.3 However, healthcare has paid less attention to mitigating significant risks of harm from the chronic diseases or disabilities patients have when admitted for another health reason. For example, 63% of hospitalised patients with Parkinson’s disease (PD) were discharged to a nursing home or other facilities rather than home because of compromised activities of daily living.4 Additionally, a retrospective study of 790 hospital admissions among 253 patients with severe mental illness (eg, schizophrenia) found a mean of 5.8 patient safety events per hospitalisation and a physical harm rate of 142 per 100 hospital admissions.5 In that study, patients experiencing any event had 3.7 higher odds of death within 30 days of hospitalisation than patients with no event. Patients having surgery often have a chronic disease that elevates their risk of harm, yet patient safety programmes generally assume risk is equal among patients admitted with a specific diagnosis. Healthcare lacks a systematic way to identify and mitigate harm when these types of patients are hospitalised.

In this essay, we describe a framework to systematically identify and mitigate risks in hospitalised patients, offering PD as an example for chronic …