Patient safety organization
Encyclopedia
A patient safety organization (PSO) is a group, institution or association that improves medical care by reducing medical errors. In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable adverse health care events. In the United States, the Institute of Medicine
report (1999) called for a broad national effort to include the establishment of patient safety centers, expanded reporting of adverse events and development of safety programs in health care organizations. The organizations that developed ranged from governmental to private, and some founded by industry, professional or consumer groups. Common functions of patient safety
organizations are data collection and analysis, reporting, education, funding and advocacy.
organizations may use several approaches to reducing adverse events
:
(WHO) launched the World Alliance for Patient Safety in October 2004. The goal was to develop standards for patient safety and assist UN member states to improve the safety of health care. The Alliance raises awareness and political commitment to improve the safety of care and facilitates the development of patient safety policy and practice in all WHO Member States. Each year, the Alliance delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world.
At the Fifty-Ninth World Health Assembly in May 2006, the Secretariat reported that the Alliance held patient safety meetings in five of the six WHO regions and 40 technical workshops in 18 countries. Since the launch of the Alliance in October 2004, significant progress was achieved in six areas:
to the Adverse Drug Reactions Advisory Committee
(ADRAC) of the TGA; reporting by medical professionals and consumers is voluntary. ADRAC notifies medical professionals and the public by recalls and alerts on its website and publications.
In December 2003, the Australian and New Zealand Governments signed an agreement to establish a joint regulatory organization for therapeutic products. The Australia New Zealand Therapeutic Products Authority (ANZTPA) will replace the Australian Therapeutic Goods Administration (TGA) and the New Zealand Medicines and Medical Devices Safety Authority (Medsafe), and be accountable to the Australian and New Zealand Governments. Implementing legislation is scheduled for introduction into both countries' parliaments in July 2006.
On 16 July 2007, the New Zealand State Services Minister Annette King announced that "The Government is not proceeding at this stage with legislation that would have enabled the establishment of a joint agency with Australia to regulate therapeutic products." She further advised that "The [New Zealand] Government does not have the numbers in Parliament to put in place a sensible, acceptable compromise that would satisfy all parties at this time. The Australian Government has been informed of the situation and agrees that suspending negotiations on the joint authority is a sensible course of action."
The Commission engages in collaborative work in patient safety and healthcare quality that benefits from national coordination. This includes the development of the Australian Charter of Healthcare Rights and the National Safety and Quality Health Service Standards, improving areas such as patient identification, medication safety, clinical handover and open disclosure, and reducing healthcare associated infection. The Commission has also developed the National Safety and Quality Framework to improve the safety and quality of the Australian health system.
Other key areas of work for the Commission include National Health Service accreditation, recognising and responding to clinical deterioration, patient centred care, safety and quality in mental health and primary care and the development of national safety and quality indicators as part of the information strategies activity.
In its role primarily as a coordination and facilitation body, the Commission utilises evidence and data and the experience, enthusiasm and commitment of consumers, clinicians, managers and other stakeholders to influence the system to make changes for the safety and quality of health care in Australia.
The Commission aims to reduce avoidable deaths and harm, reduce wastage, and make the best use of the health dollar. It works towards the New Zealand Triple Aim for quality improvement:
Commission programmes include medication safety, infection prevention and control, reportable events, consumer engagement and participation, and mortality review committees. More information can be found at www.hqsc.govt.nz
(NPSA) is an NHS special health authority
created in July 2001 to improve patient safety within the National Health Service
(NHS) by encouraging voluntary reporting of medical errors, conducting analysis and initiating preventative measures. Since 2005, the NPSA has also been responsible for: safety aspects of hospital design, cleanliness and food; safe research practices through the National Research Ethics Service (NRES); and performance of individual doctors and dentists, through the National Clinical Assessment Service (NCAS). The NPSA identifies patient safety deficiencies with the input of clinical experts and patients, develops solutions and monitors results of corrections within the NHS. Initiatives and alerts include hand hygiene, information for doctors and patients on steps to reduce risk of error, vaccine safety and disclosure of error to injured patients. In addition, the National Reporting and Learning System (NRLS) allows NHS employees to provide the NPSA with reports anonymously.
is an independent organisation that produces guidance on public health, health technologies and clinical practice in England and Wales. NICE has three centres of excellence. The Centre for Public Health Excellence develops public health guidance, with information for patients on diagnosis and treatment of specific illnesses and conditions. The Centre for Health Technology Evaluation recommends medicines and evaluates the safety and efficacy of procedures within the National Health Service
. The Centre for Clinical Practice develops evidence-based clinical guidelines
for clinicians on the appropriate treatment of people with specific diseases. NICE and the National Patient Safety Agency (NPSA) cooperate in risk assessment of new technology, monitoring safety incidents associated with procedures, and providing solutions if adverse outcomes are reported. In addition, NICE and NPSA share reporting in areas known as "Confidential Enquiries": maternal or infant deaths, childhood deaths to age 16, deaths in persons with mental illness, and perioperative and unexpected medical deaths.
(AHRQ), the lead federal agency for health care safety. The AHRQ organizes patient safety activities, provides grants to other organizations, serves as a clearinghouse for safety information, and publishes guidelines
for evidence-based
or "best practices". By 2006, the National Guideline Clearinghouse (NGC) contained more than 1,700 disease-specific diagnosis, management and treatment recommendations, developed from current medical literature. The goal of the NGC is to provide health professionals and institutions, health plans and health care purchasers an accessible mechanism for obtaining objective clinical practice guidelines. Adoption of guidelines has been slowed by physician and hospital concern that practice guidelines threaten physician autonomy and authority, fuel malpractice
liability, and allow managed care
insurers to curtail patient care expenditures.
Under the Secretary of Health and Human Services, the Agency for Healthcare Research and Quality coordinates the Patient Safety Task Force composed of three other agencies with regulatory and data collection responsibilities: the Centers for Disease Control and Prevention
(CDC) and its National Electronic Disease Surveillance System, the Centers for Medicare and Medicaid Services
(CMS) and state Quality improvement organizations
, and the Food and Drug Administration
(FDA).
The AHRQ, in partnership with data organizations in 37 states, sponsors the Nationwide Inpatient Sample (NIS), a database of the Healthcare Cost and Utilization Project (HCUP). The HCUP is a Federal-State-Industry partnership providing all discharge data from 994 hospitals—approximately 8 million hospital stays each year. The Nationwide Inpatient Sample is the largest all-payer inpatient care database in the United States from which national estimates of inpatient care can be derived. Using safety data from the NIS, the AHRQ has been able to provide complication rates and risk data, even for rare surgical procedures, such as bariatric surgery
.
In 2005, AHRQ provided links to a compendium of 140 research articles, implementation programs and tools and products used to improve patient safety, sponsored jointly with the Department of Defense
(DoD)-Health Affairs.
is an agency of the United States government that regulates food, drugs, medical devices and biological products for human use. The FDA receives medication error reports on marketed human drugs from direct contacts and manufacturer's reports, and in 1992, began monitoring medication error reports that are forwarded from the United States Pharmacopeia (USP) and the Institute of Safe Medication Practices (ISMP).
The effectiveness of the FDA's drug safety monitoring procedures was called into question after several approved drugs were shown to have serious side-effects. In September 2006, an Institute of Medicine
report commissioned by the FDA found that its drug safety system is limited by inadequate funding, insufficient regulatory authority, and a lack of oversight by experts free of pharmaceutical industry ties.
The FDA launched a new program in 2005 to provide drug risk information directly to the public through internet-accessible drug sheets and bulletins. The enactment of the Food and Drug Administration Amendments Act of 2007 (FDAAA), expanded the authority of the FDA over drug safety monitoring after approval and introduction for use by the public. In 2008, the FDA established a single website for both the public and the healthcare profession with access to drug safety information, including warnings, recalls, and reporting of adverse reactions, using MedWatch
.
. An independent non-profit corporation, the CPSI promotes solutions and collaboration among governments and stakeholders to improve patient safety, and has a five year mandate. Areas of improvement are education, system innovation, communication, regulatory affairs and research. Together with the Institute For Safe Medication Practices Canada and Saskatchewan Health, a Canadian Root Cause Analysis
Framework is offered to healthcare organizations to analyze the contributing factors that led to a critical incident or close call.
In April 2005, CPSI launched the Safer Healthcare Now! campaign, aimed at reducing error-related injuries by focusing on six evidence-based measures and through over 200 local organizations, based on the 100,000 lives campaign.
is a not-profit organisation, which co-ordinates healthcare quality programmes.. In the field of patient safety
AQUMED was one of the first German organisations calling for effective patient safety programs. The agency was co-founder of the German Coalition for Patient Safety
. AQUMED established a national network of Critical Incident Reporting Systems
. The institution is partner of the international High 5 Project.
(APS), established in 2005 and located in Bonn
is a German non-profit asssociation of organisations and individuals interested and involved in promotion of patient safety. APS' multidisciplinary working groups develop recommendations for patient safety activities in in- and outpatient healthcare institutions. The recommendations are available as open-access documents and distributed in healthcare institutions for free. APS acting together with the German Agency for Quality in Medicine
is a Lead Technical Agency of the High 5 Project.
, a practical manifesto aimed at improving the safety of anaesthesia care throughout Europe. He is now part of a joint European Society of Anaesthesiology/European Board of Anaesthesiology Task Force overseeing the implementation of the Declaration.
In 2002, the National Quality Forum defined 27 events that should never occur within a health care facility.
In 2003, the National Quality Forum (NQF) endorsed a set of 30 safe practices that should be universally utilized in applicable clinical care settings to reduce the risk of harm to patients.
There are six types of "never events" (officially called Serious Reportable Events): surgical events (e.g., surgery being performed on the wrong patient), product or device events (e.g., using contaminated drugs), patient protection events (e.g., an infant discharged to the wrong person), care management events (e.g., a medication error), environmental events (e.g., electric shock or burn), and criminal events (e.g., sexual assault of a patient). The NQF’s report recommends a national state-based event reporting system to improve the quality of patient care. , a little more than half of U.S. states have some version of a reporting system for Serious Reportable Events.
NQF has now formally launched the Consensus Standards Maintenance Committee on Serious Reportable Events to review the list and recommend additions or changes for Members to consider so that the set remains current and appropriate.
The organization has many ongoing projects including National Voluntary Consensus Standards for the Reporting of Healthcare-Associated Infections(HAIs) and developing a national consensus on symptom management and end-of-life care in cancer patients.
and Leapfrog members.
(JCAHO) is an independent, not-for-profit organization that evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An organization must undergo an on-site survey by a Joint Commission survey team at least every three years. The scope of reviews by JCAHO is broad, including hospitals, home care agencies, medical equipment providers, nursing homes, rehabilitation facilities, surgical centers and medical laboratories. Passing a survey is crucial for most organizations, since accreditation by JCAHO is required for participation in Medicare
and some state and private health care programs. Since the accreditation rate is over 90%, there have been questions raised regarding the effectiveness of these surveys.
In 1997, JCAHO began including outcomes and other performance data into the accreditation process (the "ORYX initiative"). Information gained allowed the Joint Commission to develop National Patient Safety Goals to promote specific improvements in patient safety. The Goals highlight problem areas in health care and describe evidence-based solutions. Examples include prevention of falls, patient identification, reducing hospital infections and pressure ulcers, and improving hospital staff communication. In addition, the Joint Commission created a "do not use" list of abbreviations in 2004 to avoid acronyms and symbols that lead to misinterpretation.
Identifying sentinel event
s and analyzing the root causes has been a focus of JCAHO since 1996; the first eight alerts were published in 1998. The Commission defines a sentinel event as "any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." The heath care facility experiencing the sentinel event is expected to complete a thorough root cause analysis
, make improvements to the underlying processes, and monitor the effectiveness of the changes. Although the cause of most sentinel events is human error, changes in organizational systems will reduce the likelihood of human error in the future and protect patients from harm when human error does occur. Specific causes of sentinel events and the solutions that hospitals then used successfully to reduce risks are publicized by JCAHO annually. Alerts have included issues as varied as wrong site surgery, restraint deaths, transfusion
and medication errors and patient abductions.
In 2005, JCAHO established an International Center for Patient Safety to collaborate with international patient safety organizations to identify, develop and share safety solutions, conduct joint research, and advocate public policy changes. Educational materials to help patients prevent medical errors, sentinel event alerts and other resources are provide on the internet.
PRHI was the first regional consortium of medical, business and civic leaders to address healthcare safety and quality improvement as a social and business imperative. Turning its own community into a demonstration lab, PRHI strives to accelerate improvement and set the pace for the nation. Its experiment reflects three principles:
PRHI offers clinicians and other healthcare professionals necessary tools, expertise, education, models and networks to perfect patient care and safety in their organizations. Using the Toyota Production System and Alcoa Business System as models, PRHI developed a quality improvement method for clinical settings known as Perfecting Patient Care. PRHI teaches this method through a five-day curriculum called Perfecting Patient Care University, as well as in advanced and individualized courses and on-site coaching.
PRHI reports that thousands across the nation have already learned how to use Perfecting Patient Care principles and are demonstrating the value of quality engineering in any healthcare setting—from neighborhood clinics, to hospitals and nursing homes.
PRHI, cofounded by Paul O’Neill and Karen Wolk Feinstein, is a nonprofit operating arm of the Jewish Healthcare Foundation. It is funded by local corporations, foundations, health plans and government contracts and grants.
Employing a staff of approximately 100 people and maintaining partnerships with hundreds of faculty members, IHI offers comprehensive programs that aim to improve the lives of patients, the health of communities, and the joy of the health care workforce.
is a not-for-profit organization founded in 1996 by the American Medical Association
, CNA HealthPro, and 3M
, with significant support from the Schering-Plough Corporation. Based on the model of the Anesthesia Patient Safety Foundation, the NPSF provides leadership training, research support, and education. Since 1998, an Annual Patient Safety Congress has been held to promote patient safety and medical error research in the United States. The Foundation publishes the Journal of Patient Safety, containing original papers and reviews, and provides a searchable database on its website of active research projects.
(USP) sets official standards for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States, but USP standards are also recognized and used in more than 130 other countries. USP operates two programs to promote patient safety. The Medication Errors Reporting Program enables healthcare professionals to report medication errors directly to USP. MEDMARX, an internet-based error and drug reaction reporting program, is designed for use in hospitals. The USP analyzes the data it receives through its reporting programs, develops professional education programs and disseminates alerts related to medication errors. The MEDMARX report released in 2007 analyzed 11,000 medication errors during surgery in 500 hospitals between 1998 and 2005. The analysis showed that medication errors that happen in the operating room or recovery areas are three times more likely to harm a patient than errors occurring in other types of hospital care. , this was the largest known analysis of medical errors related to surgery.
is a not-for-profit corporation created to help eradicate hospital acquired infections. Its goal is to instigate a national change in ideology and practices within the health care environment in regard to hand hygiene, by emphasizing well-established methods proven to result in safer patient care. The organization compiles, develops, distributes and promotes educational resource material as well as creates targeted media campaigns aimed at safe care so that patients may become better informed, proactive, true partners in their own medical treatment and recovery.
The Safe Care Campaign was formed by Victoria and Armando Nahum after three members of their family acquired nosocomial infections in hospitals in three different states in the timespan of a year. The campaign seeks to partner with like-minded organizations and individuals including hospitals, corporations, advocacies, insurance companies and caregivers dedicated to bringing safer procedures to the US health care system.
laboratory in the world. TMIT focuses on accelerating adoption of measures that directly affect patient care, as measured by the Institute of Medicine
(IOM) quality aims of patient safety
, clinical effectiveness, efficiency, timeliness, patient-centeredness, and equity. This enables providers to succeed in national and local pay for performance programs. It co-funded and co-led the development of the National Quality Forum 2009 Safe Practices for Better Healthcare, which consist of 34 best practices applicable to all U.S. hospitals and most ambulatory care settings. The National Quality Forum (NQF) established a public/private partnership charged by the U.S. Congress to establish standards and guidelines under the auspices of the Innovation Transfer Act of 1995. In collaboration with The Leapfrog Group, TMIT has supported development of a survey and program that ranks U.S. hospitals annually. TMIT has funded and leads this multi-year program with yearly updates to a survey, scoring method, and national ranking system. TMIT has had formal collaborative initiatives with numerous federal agencies and associated organizations, including NASA, the Institute of Medicine
(IOM), Health Resources and Services Administration
(HRSA), and the Agency for Healthcare Research and Quality
(AHRQ). TMIT operates an individual TMIT task force with each of the Joint Commission, Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality
(AHRQ), the Institute for Healthcare Improvement (IHI), and The Leapfrog Group to provide a harmonized set of targets that the payers can build into their P4P rewards. Dr. Charles Denham
is the founder of TMIT and chairs its NQF Safe Practice Advisory Board, whose members are Dr. Lucian Leape
, Dr. Don Berwick, Prof. James T. Reason, Dr. David W. Bates, Dr. David Classen, Dr. Carol Haraden, Dr. Gregg Meyer, Dr. James P. Bagian
, and Dr. Roger Resar.
Achievements: ISOBS is a first of its kind organization that addresses specific patient safety concerns related to office based sugery, and has been a leader in many patient safety initiatives such as online information site for patient education, national advocacy efforts, and credentialing services. It has been featured in local and national news.
Leadership: The Institute leadership includes prominent members of medical community as well as the members of the public. It is represented by many different medical specialties.
Clarity PSO is a certified Patient Safety Organization federally listed with the Agency for Healthcare Research and Quality. Clarity PSO offers extensive experience in analytical benchmarking and risk-quality-safety resource and systems development. Clarity PSO works with all facets and sizes of healthcare providers from acute care to home care, from physician groups to long term care, and in each case Clarity PSO focuses on the specific needs of the organization and constituents being served.
http://blog.udn.com/ptsafetyrm/2095256
Institute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
report (1999) called for a broad national effort to include the establishment of patient safety centers, expanded reporting of adverse events and development of safety programs in health care organizations. The organizations that developed ranged from governmental to private, and some founded by industry, professional or consumer groups. Common functions of patient safety
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
organizations are data collection and analysis, reporting, education, funding and advocacy.
Functions
Patient safetyPatient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
organizations may use several approaches to reducing adverse events
Adverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
:
- Collect data on the prevalence and individual details of errors.
- Analyze sources of error by root cause analysisRoot cause analysisRoot cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
. - Propose and disseminate methods for error prevention.
- Design and conduct pilot projects to study safety initiatives, including monitoring of results.
- Raise awareness and inform the public, health professionals, providers, purchasers and employers.
- Conduct fundraising and provide funding for research and safety projects
- Advocate for regulatory and legislative changes.
World Alliance for Patient Safety
In response to a 2002 World Health Assembly Resolution, the World Health OrganizationWorld Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(WHO) launched the World Alliance for Patient Safety in October 2004. The goal was to develop standards for patient safety and assist UN member states to improve the safety of health care. The Alliance raises awareness and political commitment to improve the safety of care and facilitates the development of patient safety policy and practice in all WHO Member States. Each year, the Alliance delivers a number of programmes covering systemic and technical aspects to improve patient safety around the world.
At the Fifty-Ninth World Health Assembly in May 2006, the Secretariat reported that the Alliance held patient safety meetings in five of the six WHO regions and 40 technical workshops in 18 countries. Since the launch of the Alliance in October 2004, significant progress was achieved in six areas:
- The First Global Patient Safety Challenge, which for 2005-2006 (addressing health care-associated infection) developed the WHO Guidelines on Hand Hygiene in Health Care.
- A patient involvement group, Patients for Patient Safety, built networks of patients’ organizations from around the world, through regional workshops.
- A patient safety taxonomyTaxonomyTaxonomy is the science of identifying and naming species, and arranging them into a classification. The field of taxonomy, sometimes referred to as "biological taxonomy", revolves around the description and use of taxonomic units, known as taxa...
was developed to classify data on patient safety problems. - Prevalence studies conducted on patient harm in ten developing countries.
- A WHO Collaborating Centre was established to develop and disseminate safety solutions.
- The WHO Draft Guidelines on Adverse Event Reporting and Learning Systems.
Patients for Patient Safety (PfPS)
Patients for Patient Safety is part of the World Alliance for Patient Safety lunched in 2004 by the WHO. The project emphasizes the central role patients and consumers can play in efforts to improve the quality and safety of healthcare around the world. PFPS works with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programmes, both within countries and in the global programmes of the World Alliance for Patient Safety.Therapeutic Goods Administration and Adverse Drug Reactions Advisory Committee
The Therapeutic Goods Administration (TGA) is a unit of the Australian Government Department of Health and Ageing. The TGA approves and monitors prescription and non-prescription drugs (including herbal products), medical supplies and devices, and blood and biological products. Risks to users are assessed prior to product introduction, and manufacturers are regularly audited for efficacy, quality and safety. Manufacturers are required to report adverse drug effectsAdverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
to the Adverse Drug Reactions Advisory Committee
Adverse Drug Reactions Advisory Committee
The Adverse Drug Reactions Advisory Committee or ADRAC is a subcommittee of the Australian Drug Evaluation Committee which monitors the safety of medicines in Australia...
(ADRAC) of the TGA; reporting by medical professionals and consumers is voluntary. ADRAC notifies medical professionals and the public by recalls and alerts on its website and publications.
In December 2003, the Australian and New Zealand Governments signed an agreement to establish a joint regulatory organization for therapeutic products. The Australia New Zealand Therapeutic Products Authority (ANZTPA) will replace the Australian Therapeutic Goods Administration (TGA) and the New Zealand Medicines and Medical Devices Safety Authority (Medsafe), and be accountable to the Australian and New Zealand Governments. Implementing legislation is scheduled for introduction into both countries' parliaments in July 2006.
On 16 July 2007, the New Zealand State Services Minister Annette King announced that "The Government is not proceeding at this stage with legislation that would have enabled the establishment of a joint agency with Australia to regulate therapeutic products." She further advised that "The [New Zealand] Government does not have the numbers in Parliament to put in place a sensible, acceptable compromise that would satisfy all parties at this time. The Australian Government has been informed of the situation and agrees that suspending negotiations on the joint authority is a sensible course of action."
Australian Commission on Safety and Quality in Health Care
The Australian Commission on Safety and Quality in Health Care (the Commission) was established by the Australian, State and Territory Governments to lead and coordinate national improvements in safety and quality. The Commission replaced the Australian Council for Safety and Quality in Health Care in 2006.The Commission engages in collaborative work in patient safety and healthcare quality that benefits from national coordination. This includes the development of the Australian Charter of Healthcare Rights and the National Safety and Quality Health Service Standards, improving areas such as patient identification, medication safety, clinical handover and open disclosure, and reducing healthcare associated infection. The Commission has also developed the National Safety and Quality Framework to improve the safety and quality of the Australian health system.
Other key areas of work for the Commission include National Health Service accreditation, recognising and responding to clinical deterioration, patient centred care, safety and quality in mental health and primary care and the development of national safety and quality indicators as part of the information strategies activity.
In its role primarily as a coordination and facilitation body, the Commission utilises evidence and data and the experience, enthusiasm and commitment of consumers, clinicians, managers and other stakeholders to influence the system to make changes for the safety and quality of health care in Australia.
New Zealand Health Quality & Safety Commission
The New Zealand Health Quality & Safety Commission was established in November 2010 as a Crown Entity under the New Zealand Public Health and Disability Act 2000 to lead and co-ordinate work across the health and disability sector for the purposes of:- monitoring and improving the quality and safety of health and disability support services
- helping providers across the whole sector to improve the quality and safety of services.
The Commission aims to reduce avoidable deaths and harm, reduce wastage, and make the best use of the health dollar. It works towards the New Zealand Triple Aim for quality improvement:
- improved quality, safety and experience of care
- improved health and equity for all populations
- best value for public health system resources.
Commission programmes include medication safety, infection prevention and control, reportable events, consumer engagement and participation, and mortality review committees. More information can be found at www.hqsc.govt.nz
National Patient Safety Agency
The National Patient Safety AgencyNational Patient Safety Agency
The National Patient Safety Agency is a special health authority of the National Health Service in England. It was created to monitor patient safety incidents, including medication and prescribing error reporting, in the NHS....
(NPSA) is an NHS special health authority
NHS Special Health Authority
A special health authority is a type of NHS trust which provide services on behalf of the National Health Service in England. Unlike other types of Trust, they operate nationally rather than serve a specific geographical area....
created in July 2001 to improve patient safety within the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
(NHS) by encouraging voluntary reporting of medical errors, conducting analysis and initiating preventative measures. Since 2005, the NPSA has also been responsible for: safety aspects of hospital design, cleanliness and food; safe research practices through the National Research Ethics Service (NRES); and performance of individual doctors and dentists, through the National Clinical Assessment Service (NCAS). The NPSA identifies patient safety deficiencies with the input of clinical experts and patients, develops solutions and monitors results of corrections within the NHS. Initiatives and alerts include hand hygiene, information for doctors and patients on steps to reduce risk of error, vaccine safety and disclosure of error to injured patients. In addition, the National Reporting and Learning System (NRLS) allows NHS employees to provide the NPSA with reports anonymously.
National Institute for Health and Clinical Excellence
The National Institute for Health and Clinical ExcellenceNational Institute for Health and Clinical Excellence
The National Institute for Health and Clinical Excellence is a special health authority of the English National Health Service , serving both English NHS and the Welsh NHS...
is an independent organisation that produces guidance on public health, health technologies and clinical practice in England and Wales. NICE has three centres of excellence. The Centre for Public Health Excellence develops public health guidance, with information for patients on diagnosis and treatment of specific illnesses and conditions. The Centre for Health Technology Evaluation recommends medicines and evaluates the safety and efficacy of procedures within the National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
. The Centre for Clinical Practice develops evidence-based clinical guidelines
Guideline (medical)
A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
for clinicians on the appropriate treatment of people with specific diseases. NICE and the National Patient Safety Agency (NPSA) cooperate in risk assessment of new technology, monitoring safety incidents associated with procedures, and providing solutions if adverse outcomes are reported. In addition, NICE and NPSA share reporting in areas known as "Confidential Enquiries": maternal or infant deaths, childhood deaths to age 16, deaths in persons with mental illness, and perioperative and unexpected medical deaths.
United States
On July 29, 2005, the United States Congress established guidelines for Patient Safety Organizations under the Patient Safety Quality Act of 2005. The focus of the legislation is to provide incentives for clinicians to participate in voluntary initiatives to improve the outcomes of patient care, provide information about the underlying causes of errors in the delivery of health care, and to disseminate this information in order to speed the pace of improvement.Composition
President Clinton's Advisory Commission on Consumer Protection and Quality in the Health Care Industry completed its work on March 12, 1998. Its final report. entitled "Quality First: Better Health Care for All Americans," recommends the following characteristics of a patient safety organization:- Be located in an entity that is credible and respected.
- Be located in an entity that does not have public or private regulatory responsibilities (i.e., it should not be a licensing, accrediting, or compliance entity).
- Have the ability to collect and analyze data.
- Have mechanisms for communicating with a variety of health care entities, facilities, providers, and plans.
- Be linked with initiatives for conducting interdisciplinary research and demonstrations addressing health care quality improvement.
Agency for Healthcare Research and Quality
In 2001, the US Congress responded to the IOM recommendation to create a National Center for Patient Safety by allocating $50 million annually for patient safety research to the Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...
(AHRQ), the lead federal agency for health care safety. The AHRQ organizes patient safety activities, provides grants to other organizations, serves as a clearinghouse for safety information, and publishes guidelines
Guideline (medical)
A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
for evidence-based
Evidence-based medicine
Evidence-based medicine or evidence-based practice aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments and diagnostic tests...
or "best practices". By 2006, the National Guideline Clearinghouse (NGC) contained more than 1,700 disease-specific diagnosis, management and treatment recommendations, developed from current medical literature. The goal of the NGC is to provide health professionals and institutions, health plans and health care purchasers an accessible mechanism for obtaining objective clinical practice guidelines. Adoption of guidelines has been slowed by physician and hospital concern that practice guidelines threaten physician autonomy and authority, fuel malpractice
Malpractice
In law, malpractice is a type of negligence in, which the professional under a duty to act, fails to follow generally accepted professional standards, and that breach of duty is the proximate cause of injury to a plaintiff who suffers harm...
liability, and allow managed care
Managed care
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on...
insurers to curtail patient care expenditures.
Under the Secretary of Health and Human Services, the Agency for Healthcare Research and Quality coordinates the Patient Safety Task Force composed of three other agencies with regulatory and data collection responsibilities: the Centers for Disease Control and Prevention
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention are a United States federal agency under the Department of Health and Human Services headquartered in Druid Hills, unincorporated DeKalb County, Georgia, in Greater Atlanta...
(CDC) and its National Electronic Disease Surveillance System, the Centers for Medicare and Medicaid Services
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services , previously known as the Health Care Financing Administration , is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state governments to administer...
(CMS) and state Quality improvement organizations
Quality improvement organizations
Quality Improvement Organizations monitor the appropriateness, effectiveness, and quality of care provided to Medicare beneficiaries. They are private contractor extensions of the federal government that work under the auspices of the U.S...
, and the Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
(FDA).
The AHRQ, in partnership with data organizations in 37 states, sponsors the Nationwide Inpatient Sample (NIS), a database of the Healthcare Cost and Utilization Project (HCUP). The HCUP is a Federal-State-Industry partnership providing all discharge data from 994 hospitals—approximately 8 million hospital stays each year. The Nationwide Inpatient Sample is the largest all-payer inpatient care database in the United States from which national estimates of inpatient care can be derived. Using safety data from the NIS, the AHRQ has been able to provide complication rates and risk data, even for rare surgical procedures, such as bariatric surgery
Bariatric surgery
Bariatric surgery includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device or through removal of a portion of the stomach or by resecting and re-routing the small intestines...
.
In 2005, AHRQ provided links to a compendium of 140 research articles, implementation programs and tools and products used to improve patient safety, sponsored jointly with the Department of Defense
United States Department of Defense
The United States Department of Defense is the U.S...
(DoD)-Health Affairs.
Food and Drug Administration
The Food and Drug AdministrationFood and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
is an agency of the United States government that regulates food, drugs, medical devices and biological products for human use. The FDA receives medication error reports on marketed human drugs from direct contacts and manufacturer's reports, and in 1992, began monitoring medication error reports that are forwarded from the United States Pharmacopeia (USP) and the Institute of Safe Medication Practices (ISMP).
The effectiveness of the FDA's drug safety monitoring procedures was called into question after several approved drugs were shown to have serious side-effects. In September 2006, an Institute of Medicine
Institute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
report commissioned by the FDA found that its drug safety system is limited by inadequate funding, insufficient regulatory authority, and a lack of oversight by experts free of pharmaceutical industry ties.
The FDA launched a new program in 2005 to provide drug risk information directly to the public through internet-accessible drug sheets and bulletins. The enactment of the Food and Drug Administration Amendments Act of 2007 (FDAAA), expanded the authority of the FDA over drug safety monitoring after approval and introduction for use by the public. In 2008, the FDA established a single website for both the public and the healthcare profession with access to drug safety information, including warnings, recalls, and reporting of adverse reactions, using MedWatch
MedWatch
MedWatch is the Food and Drug Administration’s reporting system for an adverse event or sentinel event, founded in 1993. An adverse event is any undesirable experience associated with the use of a medical product...
.
Australian Patient Safety Foundation
The APSF is a non-profit independent organisation founded in 1989 for anaesthesia error monitoring, and expanded to patient incident reporting and monitoring after results from the Quality in Australian Health Care Study (QAHCS) in 1995 prompted reaction from the public. Adverse medical events, both sentinel events (patient death and injury) and near misses (medical errors with potential harm), are reported and analyzed through its subsidiary, Patient Safety International (PSI), using a software tool, the Advanced Incident Management System (AIMS). AIMS is used in over half of Australia's hospitals, and was adopted in 2005 by the New Zealand Accident Compensation Corporation and the University of Miami Medical Group in Florida. Data remains confidential is protected from legal discovery under Australian Commonwealth Quality Assurance legislation. Patient safety information is provided by electronic newsletters.Canadian Patient Safety Institute
The Canadian Patient Safety Institute (CPSI) was developed in 2003 after consultations among Canadian healthcare professional organizations, provincial and territorial ministries of health and Health CanadaHealth Canada
Health Canada is the department of the government of Canada with responsibility for national public health.The current Minister of Health is Leona Aglukkaq, a Conservative Member of Parliament appointed to the position by Prime Minister Stephen Harper.-Branches, regions and agencies:Health Canada...
. An independent non-profit corporation, the CPSI promotes solutions and collaboration among governments and stakeholders to improve patient safety, and has a five year mandate. Areas of improvement are education, system innovation, communication, regulatory affairs and research. Together with the Institute For Safe Medication Practices Canada and Saskatchewan Health, a Canadian Root Cause Analysis
Root cause analysis
Root cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
Framework is offered to healthcare organizations to analyze the contributing factors that led to a critical incident or close call.
In April 2005, CPSI launched the Safer Healthcare Now! campaign, aimed at reducing error-related injuries by focusing on six evidence-based measures and through over 200 local organizations, based on the 100,000 lives campaign.
Institute for Safe Medication Practices Canada
The Institute for Safe Medication Practices Canada (ISMP) is an independent national non-profit agency that reviews and analyzes medication incident and near-miss reports. In collaboration with the Canadian Institute for Health Information (CIHI), and Health Canada, ISMP established the Canadian Medication Incident Prevention and Reporting System (CMIRPS) in 2003. ISMP takes the lead role of collecting reports from heath practitioners, analysing incidents, and disseminating preventative methods.German Agency for Quality in Medicine
Based in Berlin, the German Agency for Quality in MedicineGerman Agency for Quality in Medicine
The German Agency for Quality in Medicine - in German "Ärztliches Zentrum für Qualität in der Medizin ", established in 1995 and located in Berlin co-ordinates healthcare quality programmes with special focus on evidence-based medicine, medical guidelines, patient empowerment, patient safety...
is a not-profit organisation, which co-ordinates healthcare quality programmes.. In the field of patient safety
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
AQUMED was one of the first German organisations calling for effective patient safety programs. The agency was co-founder of the German Coalition for Patient Safety
German Coalition for Patient Safety
The German Coalition for Patient Safety - in German "Aktionsbündnis Patientensicherheit ", established in 2005 and located in Bonn is a German non-profit asssociation of organisations and individuals interested and involved in promotion of patient safety.-Activities:APS' multidisciplinary working...
. AQUMED established a national network of Critical Incident Reporting Systems
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
. The institution is partner of the international High 5 Project.
German Coalition for Patient Safety
The German Coalition for Patient SafetyGerman Coalition for Patient Safety
The German Coalition for Patient Safety - in German "Aktionsbündnis Patientensicherheit ", established in 2005 and located in Bonn is a German non-profit asssociation of organisations and individuals interested and involved in promotion of patient safety.-Activities:APS' multidisciplinary working...
(APS), established in 2005 and located in Bonn
Bonn
Bonn is the 19th largest city in Germany. Located in the Cologne/Bonn Region, about 25 kilometres south of Cologne on the river Rhine in the State of North Rhine-Westphalia, it was the capital of West Germany from 1949 to 1990 and the official seat of government of united Germany from 1990 to 1999....
is a German non-profit asssociation of organisations and individuals interested and involved in promotion of patient safety. APS' multidisciplinary working groups develop recommendations for patient safety activities in in- and outpatient healthcare institutions. The recommendations are available as open-access documents and distributed in healthcare institutions for free. APS acting together with the German Agency for Quality in Medicine
German Agency for Quality in Medicine
The German Agency for Quality in Medicine - in German "Ärztliches Zentrum für Qualität in der Medizin ", established in 1995 and located in Berlin co-ordinates healthcare quality programmes with special focus on evidence-based medicine, medical guidelines, patient empowerment, patient safety...
is a Lead Technical Agency of the High 5 Project.
The Health Foundation
Based in London, England, the Health Foundation is an independent charity that aims to improve the quality of health care for the people of the United Kingdom. The Safer Patients Initiative, one of the Foundation’s quality and performance improvement programmes, targets reducing medication-related adverse events and errors, reducing infections associated with intensive care units or surgery and improving organisational culture, leadership and expertise in measuring improvement. The goal of the initiative is a 50 percent reduction in adverse events per 1,000 patient days for each site. In 2004, The Health Foundation selected four hospitals from across the UK to work on a £4.3 million patient safety improvement programme. These four hospitals continue to show measurable improvements in their patient safety performance, and 16 more hospitals are being selected in 2006 to join the second phase.Lancaster Patient Safety Research Unit
The Unit was founded in January 2008 and is a collaborative venture between the University Hospitals of Morecambe Bay NHS Trust and Lancaster University. It is funded by the UK National Health Service through the National Institute for Health Research. The unit has two aims. The first is to conduct world-class, high-quality research in patient safety. The second is to make sure that the unit's findings are used in practice, to improve the welfare of people in North Lancashire and South Cumbria and throughout the National Health Service. In June 2010 the Unit's director, Professor Andrew Smith, helped launch The Helsinki Declaration for Patient Safety in AnaesthesiologyThe Helsinki Declaration for Patient Safety in Anaesthesiology
The Helsinki Declaration for Patient Safety in Anaesthesiology is a document prepared jointly by the two principal anaesthesiology organizations in Europe, The European Board of Anaesthesiology and the European Society of Anaesthesiology . It was launched in June 2010 at the Euroanaesthesia...
, a practical manifesto aimed at improving the safety of anaesthesia care throughout Europe. He is now part of a joint European Society of Anaesthesiology/European Board of Anaesthesiology Task Force overseeing the implementation of the Declaration.
American Society of Medication Safety Officers
The American Society of Medication Safety Officers (ASMSO) is a not-for-profit association established in 2006 with a mission to advance and encourage excellence in the profession of pharmacy by providing leadership, direction, education and communication among its members, to represent pharmacy in organized healthcare settings and promote the advancement of safe medication use.National Quality Forum
The National Quality Forum(NQF) is a not-for-profit membership organization created in 1999 to develop and implement a national strategy for health care quality measurement and reporting. Membership is open to national, state, regional, and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement. The NQF has focused on several areas: error rates, unnecessary procedures and undertreatment, especially preventive care. Policies are formed through one of four Member Councils: the Consumer Council, Purchaser Council, Provider and Health Plan Council, and Research and Quality Improvement Council.In 2002, the National Quality Forum defined 27 events that should never occur within a health care facility.
In 2003, the National Quality Forum (NQF) endorsed a set of 30 safe practices that should be universally utilized in applicable clinical care settings to reduce the risk of harm to patients.
There are six types of "never events" (officially called Serious Reportable Events): surgical events (e.g., surgery being performed on the wrong patient), product or device events (e.g., using contaminated drugs), patient protection events (e.g., an infant discharged to the wrong person), care management events (e.g., a medication error), environmental events (e.g., electric shock or burn), and criminal events (e.g., sexual assault of a patient). The NQF’s report recommends a national state-based event reporting system to improve the quality of patient care. , a little more than half of U.S. states have some version of a reporting system for Serious Reportable Events.
NQF has now formally launched the Consensus Standards Maintenance Committee on Serious Reportable Events to review the list and recommend additions or changes for Members to consider so that the set remains current and appropriate.
The organization has many ongoing projects including National Voluntary Consensus Standards for the Reporting of Healthcare-Associated Infections(HAIs) and developing a national consensus on symptom management and end-of-life care in cancer patients.
Leapfrog
Staggered by increasing health insurance costs, several large US companies met in 1998 to influence quality and affordability. The resulting Leapfrog Group agreed to base their purchase of health care on principles that "encourage provider quality improvement and consumer involvement". The group was officially launched in November 2000 with the initial focus provided by the 1999 Institute of Medicine report – reducing preventable medical mistakes (the report recommended that large employers leverage their purchasing power for the quality and safety of health care). The "leapfrog" concept involved large advances stimulated by rewarding hospitals that implement significant improvements (the Leapfrog Hospital Rewards Program). The quality practices mandated are computer physician order entry CPOE, evidence-based hospital referral, intensive care unit (ICU) staffing by physicians experienced in critical care medicine, and a "Leapfrog Safe Practices Score", based on the National Quality Forum endorsed Safe Practices. Additional initiatives now include public reporting of health care quality and outcomes (hospital quality ratings) to influence consumers' choices. Leapfrog now includes more than 170 large private and public healthcare purchasers providing health benefits to more than 37 million employees and retirees, funded by the Business Roundtable, the Robert Wood Johnson FoundationRobert Wood Johnson Foundation
The Robert Wood Johnson Foundation is the United States' largest philanthropy devoted exclusively to health and health care; it is based in Princeton, New Jersey. The foundation's mission is to improve the health and health care of all Americans...
and Leapfrog members.
Joint Commission on Accreditation of Healthcare Organizations
Founded in 1951, the Joint Commission on Accreditation of Healthcare OrganizationsJoint Commission on Accreditation of Healthcare Organizations
The Joint Commission , formerly the Joint Commission on Accreditation of Healthcare Organizations , is a United States-based not-for-profit organization that accredits over 19,000 health care organizations and programs in the United States...
(JCAHO) is an independent, not-for-profit organization that evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An organization must undergo an on-site survey by a Joint Commission survey team at least every three years. The scope of reviews by JCAHO is broad, including hospitals, home care agencies, medical equipment providers, nursing homes, rehabilitation facilities, surgical centers and medical laboratories. Passing a survey is crucial for most organizations, since accreditation by JCAHO is required for participation in Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
and some state and private health care programs. Since the accreditation rate is over 90%, there have been questions raised regarding the effectiveness of these surveys.
In 1997, JCAHO began including outcomes and other performance data into the accreditation process (the "ORYX initiative"). Information gained allowed the Joint Commission to develop National Patient Safety Goals to promote specific improvements in patient safety. The Goals highlight problem areas in health care and describe evidence-based solutions. Examples include prevention of falls, patient identification, reducing hospital infections and pressure ulcers, and improving hospital staff communication. In addition, the Joint Commission created a "do not use" list of abbreviations in 2004 to avoid acronyms and symbols that lead to misinterpretation.
Identifying sentinel event
Sentinel event
A Sentinel Event is defined by The Joint Commission as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness...
s and analyzing the root causes has been a focus of JCAHO since 1996; the first eight alerts were published in 1998. The Commission defines a sentinel event as "any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." The heath care facility experiencing the sentinel event is expected to complete a thorough root cause analysis
Root cause analysis
Root cause analysis is a class of problem solving methods aimed at identifying the root causes of problems or events.Root Cause Analysis is any structured approach to identifying the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one...
, make improvements to the underlying processes, and monitor the effectiveness of the changes. Although the cause of most sentinel events is human error, changes in organizational systems will reduce the likelihood of human error in the future and protect patients from harm when human error does occur. Specific causes of sentinel events and the solutions that hospitals then used successfully to reduce risks are publicized by JCAHO annually. Alerts have included issues as varied as wrong site surgery, restraint deaths, transfusion
Blood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
and medication errors and patient abductions.
In 2005, JCAHO established an International Center for Patient Safety to collaborate with international patient safety organizations to identify, develop and share safety solutions, conduct joint research, and advocate public policy changes. Educational materials to help patients prevent medical errors, sentinel event alerts and other resources are provide on the internet.
Pittsburgh Regional Health Initiative
The Pittsburgh Regional Health Initiative, or PRHI, is an independent catalyst for improving healthcare safety and quality in Southwestern Pennsylvania. It operates on the premise that dramatic quality improvement is the best cost-containment strategy for health care.PRHI was the first regional consortium of medical, business and civic leaders to address healthcare safety and quality improvement as a social and business imperative. Turning its own community into a demonstration lab, PRHI strives to accelerate improvement and set the pace for the nation. Its experiment reflects three principles:
- Health care is local. Federal policy changes alone cannot achieve needed reform.
- Those who work at the point of care develop quality and safety improvements that work and last.
- Continuous improvement in quality and safety requires the highest possible standard, namely perfection. To settle for less limits achievement.
PRHI offers clinicians and other healthcare professionals necessary tools, expertise, education, models and networks to perfect patient care and safety in their organizations. Using the Toyota Production System and Alcoa Business System as models, PRHI developed a quality improvement method for clinical settings known as Perfecting Patient Care. PRHI teaches this method through a five-day curriculum called Perfecting Patient Care University, as well as in advanced and individualized courses and on-site coaching.
PRHI reports that thousands across the nation have already learned how to use Perfecting Patient Care principles and are demonstrating the value of quality engineering in any healthcare setting—from neighborhood clinics, to hospitals and nursing homes.
PRHI, cofounded by Paul O’Neill and Karen Wolk Feinstein, is a nonprofit operating arm of the Jewish Healthcare Foundation. It is funded by local corporations, foundations, health plans and government contracts and grants.
Institute for Healthcare Improvement
The Institute for Healthcare Improvement (IHI) is an independent not-for-profit organization helping to lead the improvement of health care throughout the world. Founded in 1991 and based in Cambridge, Massachusetts, IHI works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping health care systems put those ideas into action.Employing a staff of approximately 100 people and maintaining partnerships with hundreds of faculty members, IHI offers comprehensive programs that aim to improve the lives of patients, the health of communities, and the joy of the health care workforce.
National Patient Safety Foundation
The National Patient Safety FoundationNational Patient Safety Foundation
The National Patient Safety Foundation is an independent not-for-profit 501 organization.-Programs:Stand Up For Patient SafetyThis program provides a way for organizations to participate in the patient safety movement both within their environment and across their communities...
is a not-for-profit organization founded in 1996 by the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...
, CNA HealthPro, and 3M
3M
3M Company , formerly known as the Minnesota Mining and Manufacturing Company, is an American multinational conglomerate corporation based in Maplewood, Minnesota, United States....
, with significant support from the Schering-Plough Corporation. Based on the model of the Anesthesia Patient Safety Foundation, the NPSF provides leadership training, research support, and education. Since 1998, an Annual Patient Safety Congress has been held to promote patient safety and medical error research in the United States. The Foundation publishes the Journal of Patient Safety, containing original papers and reviews, and provides a searchable database on its website of active research projects.
United States Pharmacopeia
The United States PharmacopeiaUnited States Pharmacopeia
The United States Pharmacopeia is the official pharmacopeia of the United States, published dually with the National Formulary as the USP-NF. The United States Pharmacopeial Convention is the nonprofit organization that owns the trademark and copyright to the USP-NF and publishes it every year...
(USP) sets official standards for all prescription and over-the-counter medicines, dietary supplements, and other healthcare products manufactured and sold in the United States, but USP standards are also recognized and used in more than 130 other countries. USP operates two programs to promote patient safety. The Medication Errors Reporting Program enables healthcare professionals to report medication errors directly to USP. MEDMARX, an internet-based error and drug reaction reporting program, is designed for use in hospitals. The USP analyzes the data it receives through its reporting programs, develops professional education programs and disseminates alerts related to medication errors. The MEDMARX report released in 2007 analyzed 11,000 medication errors during surgery in 500 hospitals between 1998 and 2005. The analysis showed that medication errors that happen in the operating room or recovery areas are three times more likely to harm a patient than errors occurring in other types of hospital care. , this was the largest known analysis of medical errors related to surgery.
Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP), based in suburban Philadelphia, is the only nonprofit organization in the US devoted entirely to medication error prevention and safe medication use. Its medication error prevention efforts began in 1975 with a column in Hospital Pharmacy to inform healthcare professionals and others about medication error prevention. ISMP operates a voluntary practitioner error-reporting program to tabulate errors nationally, understand their causes, and share “lessons learned” with the healthcare community, known as the Medication Errors Reporting Program (MERP), operated by the United States Pharmacopeia (USP) in cooperation with ISMP. In addition, ISMP’s corporate subsidiary, Med-E.R.R.S. (Medical Error Recognition and Revision Strategies), works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design. The ISMP list of error-prone abbreviations is distributed nationally.Safe Care Campaign
The Safe Care CampaignSafe Care Campaign
The Safe Care Campaign is an Atlanta, Georgia based corporation seeking to help eradicate hospital acquired infections. Its goal is to instigate a national change in ideology and practices within the health care environment in regard to hand hygiene...
is a not-for-profit corporation created to help eradicate hospital acquired infections. Its goal is to instigate a national change in ideology and practices within the health care environment in regard to hand hygiene, by emphasizing well-established methods proven to result in safer patient care. The organization compiles, develops, distributes and promotes educational resource material as well as creates targeted media campaigns aimed at safe care so that patients may become better informed, proactive, true partners in their own medical treatment and recovery.
The Safe Care Campaign was formed by Victoria and Armando Nahum after three members of their family acquired nosocomial infections in hospitals in three different states in the timespan of a year. The campaign seeks to partner with like-minded organizations and individuals including hospitals, corporations, advocacies, insurance companies and caregivers dedicated to bringing safer procedures to the US health care system.
TMIT
TMIT (Texas Medical Institute of Technology) is a medical research organization founded in 1984. As of 2009, more than 3,100 U.S. hospitals, delivering more than 70% of U.S. acute care, comprise its National Research Test Bed, making it the largest virtual patient safetyPatient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
laboratory in the world. TMIT focuses on accelerating adoption of measures that directly affect patient care, as measured by the Institute of Medicine
Institute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
(IOM) quality aims of patient safety
Patient safety
Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
, clinical effectiveness, efficiency, timeliness, patient-centeredness, and equity. This enables providers to succeed in national and local pay for performance programs. It co-funded and co-led the development of the National Quality Forum 2009 Safe Practices for Better Healthcare, which consist of 34 best practices applicable to all U.S. hospitals and most ambulatory care settings. The National Quality Forum (NQF) established a public/private partnership charged by the U.S. Congress to establish standards and guidelines under the auspices of the Innovation Transfer Act of 1995. In collaboration with The Leapfrog Group, TMIT has supported development of a survey and program that ranks U.S. hospitals annually. TMIT has funded and leads this multi-year program with yearly updates to a survey, scoring method, and national ranking system. TMIT has had formal collaborative initiatives with numerous federal agencies and associated organizations, including NASA, the Institute of Medicine
Institute of Medicine
The Institute of Medicine is a not-for-profit, non-governmental American organization founded in 1970, under the congressional charter of the National Academy of Sciences...
(IOM), Health Resources and Services Administration
Health Resources and Services Administration
The Health Resources and Services Administration , is an agency of the U.S. Department of Health and Human Services located in Rockville, Maryland...
(HRSA), and the Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...
(AHRQ). TMIT operates an individual TMIT task force with each of the Joint Commission, Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality
The Agency for Healthcare Research and Quality is a part of the United States Department of Health and Human Services, which supports research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, and broaden access to effective...
(AHRQ), the Institute for Healthcare Improvement (IHI), and The Leapfrog Group to provide a harmonized set of targets that the payers can build into their P4P rewards. Dr. Charles Denham
Charles Denham
Charles Denham is the Chairman of Texas Medical Institute of Technology , an independent medical nonprofit organization dedicated to saving lives, saving money, and building value in the 3,100 hospital research test bed it serves. He is CEO of Health Care Concepts Corporation .Dr...
is the founder of TMIT and chairs its NQF Safe Practice Advisory Board, whose members are Dr. Lucian Leape
Lucian Leape
Dr. Lucian Leape MD is a physician and professor at Harvard School of Public Health, who has been very active in trying to improve the medical system to reduce medical error. In 1994 he had an article, "Error in Medicine," published in JAMA...
, Dr. Don Berwick, Prof. James T. Reason, Dr. David W. Bates, Dr. David Classen, Dr. Carol Haraden, Dr. Gregg Meyer, Dr. James P. Bagian
James P. Bagian
James Philip Bagian, MD, PE , born 22 February 1952 in Philadelphia, is an engineer and former NASA scientific astronaut. He is of Armenian descent.- Education :...
, and Dr. Roger Resar.
ECRI Institute
The ECRI Institute has been officially listed effective 11/5/08 by the U.S. Department of Health and Human Services as a federal Patient Safety Organization under the Patient Safety and Quality Improvement Act of 2005. ECRI Institute Patient Safety Organization will serve as a PSO directly for providers as well as provide “back office” support services to other PSOs. ECRI Institute PSO services are based on applied research, interactive tools, a learning network, and a reporting platform powered by RL Solutions. To enable healthcare providers to learn from near misses and adverse events, and to improve patient care, the PSO provides incident report collection and analysis; culture of safety recommendations; best practices library, advisories and publications; continuing medical education; and ready-to-use toolkits. ECRI Institute has 40 years of experience operating healthcare problem reporting systems and safety initiatives, and is designated as an Evidence-based Practice Center by the U. S. Agency for Healthcare Research and Quality, and is designated a Collaborating Center for Patient Safety, Risk Management, and Healthcare Technology by the World Health Organization. ECRI Institute has developed and implements the Pennsylvania Patient Safety Reporting System, a mandatory error and near-miss reporting program for Pennsylvania hospitals and other healthcare facilities, under contract to the Pennsylvania Patient Safety Authority.Institute for Safety in Office-Based Surgery
The Institute for Safety in Office-Based Surgery, Inc. (ISOBS) http://www.isobs.org is an national nonprofit organization founded in 2009 in Boston, Massachusetts. The organization was founded in 2009 by physicians to improve the safety of office-based surgery through physician education, research, and patient advocacy. The Institute sponsors educational activities for healthcare providers, offers a Certificate of Quality to safety office practices, and confers annual awards to individuals who have advanced the field of office surgery safety.Achievements: ISOBS is a first of its kind organization that addresses specific patient safety concerns related to office based sugery, and has been a leader in many patient safety initiatives such as online information site for patient education, national advocacy efforts, and credentialing services. It has been featured in local and national news.
Leadership: The Institute leadership includes prominent members of medical community as well as the members of the public. It is represented by many different medical specialties.
Clarity Group, Inc.
Clarity PSO, A Division of Clarity Group, Inc., offers healthcare providers the opportunity to participate in patient safety and quality improvement efforts without the risk of losing the protection of data confidentiality or fearing discovery in the case of potential litigation. Hospitals, long term care, home care, medical groups and others can gain this protection by following certain conditions set forth in the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act).Clarity PSO is a certified Patient Safety Organization federally listed with the Agency for Healthcare Research and Quality. Clarity PSO offers extensive experience in analytical benchmarking and risk-quality-safety resource and systems development. Clarity PSO works with all facets and sizes of healthcare providers from acute care to home care, from physician groups to long term care, and in each case Clarity PSO focuses on the specific needs of the organization and constituents being served.
See also
- Adverse effect (medicine)Adverse effect (medicine)In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
- Adverse eventAdverse eventAn adverse event is any adverse change in health or side effect that occurs in a person who participates in a clinical trial while the patient is receiving the treatment or within a previously specified period of time after the treatment has been completed.AEs in patients participating in...
- Serious adverse eventSerious adverse eventA serious adverse event in human drug trials are defined as any untowardmedical occurrence that at any dose#results in death,#is life-threatening#requires inpatient hospitalization or prolongation of existing hospitalization...
- Health informaticsHealth informatics.Health informatics is a discipline at the intersection of information science, computer science, and health care...
- High 5s ProjectHigh 5s ProjectThe High 5s Project is an international patient safety collaborationlaunched by the World Health Organization in 2006.The project addresses concerns about patient safety around the world....
- IatrogenesisIatrogenesisIatrogenesis, or an iatrogenic artifact is an inadvertent adverse effect or complication resulting from medical treatment or advice, including that of psychologists, therapists, pharmacists, nurses, physicians and dentists...
- Iatrogenic disorder
- Medical errorMedical errorA medical error may be defined as a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.-Definitions:As a general...
- Patient safetyPatient safetyPatient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events. The frequency and magnitude of avoidable adverse patient events was not well known until the 1990s, when multiple countries reported...
- Patient Safety and Quality Improvement ActPatient Safety and Quality Improvement ActThe Patient Safety and Quality Improvement Act of 2005 : , 42 U.S.C. , established a system of patient safety organizations and a national patient safety database...
of 2005 - Pharmacy informatics
- Public healthPublic healthPublic health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...
- Improvement Science Research NetworkImprovement Science Research NetworkThe ' is a large-scale practice based research network and coordinating center that was created to accelerate inter-professional improvement science in a systems context across multiple hospital sites...
External links
http://blog.udn.com/ptsafetyrm/2095256