Improving safety for patients and staff requires that leaders apply the latest science. A key part of that is knowing how to track event rates, and an institution's progress in their improvement. Since the Institute of Medicine released “To Err Is Human in 1999,” estimating care-associated event rates has remained controversial. This session will review the current "state of the art" for measuring clinical harm associated with patient care events. It will extend event measurement into implementation costs, potential cost savings as injury rates drop, and methods for harvesting savings back to the bottom line. Finally, it will link internal patient safety measurement and management strategies to emerging demands for external accountability.

After this presentation you will be able to:

• Describe the origins of the original IOM “To Err Is Human” preventable mortality estimates, and summarize major studies that extend those initial results.
• Compare the contributions of prospective clinical review (concurrent clinical triggers), retrospective chart review (retrospective triggers), and voluntary reporting (sentinel event reporting) to a comprehensive event tracking system.
• Outline methods to estimate the marginal costs associated with managing care-associated patient injuries, and provide general (but reliable) estimates of per-event costs.
• Link a hospital's internal injury tracking systems to the IHI 5 Million Lives Campaign, and to otheremerging national standards.