The overall findings were not pretty. The six hospitals included, but not named, in the study ultimately didn't have a full understanding of where the problems were coming from, how to fix them, or how to get hospital staff to take the matter seriously. Specifically, the GAO said they all faced the following "challenges in implementing patient safety practices:"

Obtaining data to identify adverse events in their own hospitals: According to hospital officials, obtaining useful information on adverse events can be challenging because, substantial time and resources are required to gather the necessary data, among other things.
Determining which patient safety practices should be implemented: Officials noted that they face challenges identifying which evidence-based patient safety practices should be implemented in their own hospitals, such as when only limited evidence exists on which practices are effective. One hospital told GAO that the hospital tried several different practices in an effort to reduce patient falls without knowing which, if any, would prove effective.
Ensuring that staff consistently implement the practices over time: Officials from the selected hospitals told GAO that the hospitals face challenges ensuring that hospital staff consistently implement the hospitals' patient safety practices.

Given these enormous gaps in hospitals' patient safety programs, one might lose hope of ever emerging from a hospital in better shape than when one entered.

Instant Insights /

HHS patient safety initiative offers ray of hope

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