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August 26, 2019

When New Standards to Improve Safety Do Not Actually Improve Safety

Author Affiliations
  • 1Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor
JAMA Pediatr. 2019;173(10):921-922. doi:10.1001/jamapediatrics.2019.2726

Efforts to improve patient safety encompass a wide variety of strategies, with many using a change in policy to either standardize care or correct an identified process that may cause harm. Ideally, changes in policy are guided by evidence. However, sometimes changes may seem so obvious to either regulatory bodies or a health system leadership team that actual data are not used to validate or justify the modification. Further, especially if seemingly self-evident, changes in policies may not always be evaluated to determine their true effectiveness in accomplishing their stated safety goals. In an intriguing article in this issue of JAMA Pediatrics, Adelman et al1 evaluated the outcomes at 2 hospitals of one such recent change in policy, intended to prevent wrong-patient orders among single-birth vs multiple-birth infants in the neonatal intensive care unit. The policy change was implemented as a result of a new requirement from the Joint Commission.