#PSW2015 - Patient Safety Week, Enthusiasm, and New Projects

It's Patient Safety Week and it's great to see the passion, enthusiasm and sharing this week. Are you and your organization eager to try out some new projects you learned during the latest conferences and webinars? Wonderful but....WAIT!

What do I mean wait? Why shouldn't you rush to introduce these new interventions while the excitement and enthusiasm is high? This may surprise you, but on the basis of chance alone, there is more potential for change to introduce harm than good. HOW?

You have the opportunity to increase benefit, decrease benefit, or get no change in benefit to patients or staff from implementing an intervention. Also remember, an intervention may increase harm, decrease harm, or have no effect on the amount of harm to patients or staff. By chance alone, any new intervention could create the following options:

Effect on Harm          Effect on Benefit                 Overall Result

Decrease Harm           Increase Benefit                   WIN/WIN

No change in Harm    Increase Benefit                   WIN

Increase Harm            Increase Benefit                   Can you manage the harm?

Decrease Harm           No change in Benefit           Value dependent

No change in Harm    No change in Benefit           LOSS - What a waste

Increase Harm            No change in Benefit           LOSS

Decrease Harm           Decrease Benefit                  Value dependent

No change in Harm    Decrease Benefit                  LOSS

Increase Harm            Decrease Benefit                  MAJOR LOSS

You have a 1 in 9 chance of increasing benefit and decreasing harm, your preferred outcome. You have the exact same chance, 1 in 9 of getting a major loss by increasing harm and reducing benefit. But you also have a 4 in 9 overall chance of outcomes you do not want, and 3 in 9 of outcomes that may or may not be a net improvement for your organization. By chance alone, only 2 out of 9 are definite improvements.

How can you improve your odds? To get the odds in your favor, you need evidence. You can use evidence-based methods to choose practices likely to have better chance of success in your organization. See TheEvidenceDoc checklist for more detail. Things to consider are to evaluate whether or not the innovation actually worked where it was tested - Were the outcomes measured in the same way before and after implementation, for example? If it makes a clinically important (not just statistically significant difference), could it work for you? The project leaders need to provide enough detail about the setting, the patient population, the intervention and the outcomes for you to evaluate how well the innovation might translate to other organizations. And what are the harms? Could you make it safe to try the project in your organization?

Learn to use evidence to increase your chances for a success!