care is delivered outside hospitals and nursing homes by clinicians in small practice settings who lack any strong tie to an organization.

Reaction 3: Micromanage

Most health care delivery consists of complex processes and systems involving many interacting factors that are usually summed by performance metrics. As a result, such summary measures will exhibit a component of apparently random variation (Berwick, 1991). The use of data for accountability can lead health professionals to attempt to focus on tracking and responding to minute, random fluctuations in their process data, whereas careful analysis and redesign of work processes are needed to improve performance. Indeed, micromanagement can lead to worse outcomes, causing overseers to demand more rigorous inspection and oversight, which will likely lead to another iteration of the cycle of fear.

The Concept of Preventability

The most effective patient safety strategies rest upon a broad definition of preventable adverse events. As defined in this report, an adverse event is any unintended harm to a patient caused by medical management rather than by the underlying disease or condition of the patient. Some adverse events are unavoidable. Patients and their caregivers are sometimes forced to knowingly accept adverse secondary consequences to achieve a more important primary treatment goal. The concept of preventability separates care delivery errors from such recognized but unavoidable treatment consequences.

Providers seeking to improve safety generally focus on preventable adverse events. Members of the health care professions, who often associate the term “error” with professional neglect or incompetence or fear that others will do so, may seek to define preventability very narrowly, greatly limiting the scope and impact of patient safety improvement.

For example, a hospital team developed a data-based clinical trigger tool to identify adverse drug events (ADEs), increasing the ADE detection rate by almost two orders of magnitude. The team then analyzed and prioritized causes for the ADEs detected. The single largest category, accounting for 28 percent of events, was allergic and idiosyncratic drug reactions among patients with no previous history of reaction. Thinking at the level of individual health professionals, all members of the team initially agreed that such injuries were outside clinicians’ control and accountability and that the



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