Patient Safety: Grantmakers Join The Effort To Reduce Medical Errors

4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections: A challenge for change

Millennial Health Care: Change You Can Believe in

In the late summer of 2004, the Veterans Health Administration (VHA) convened an invitational symposium, one in a series of state-of-the-art (SOTA) conferences. VHA's SOTAs are high-level “think tank” sessions with a defined agenda focusing on a specific health care topic. The theme of this SOTA conference was “Implementing the Evidence: Transforming Practices, Systems, and Organizations.” About 100 individuals from across North America, not just from within VHA, gathered for 2 days in the Nation's capital. These were the perceived thought leaders in the implementation sciences, enriched by a few influential “movers” within the largest single health care system in the United States (the VHA). To maximize the yield of the 2 days of SOTA conference brainstorming, VHA commissioned papers to be circulated in draft form before the SOTA, with the intent of priming the pump for discussions organized into specific work groups. This issue of the Journal presents these commissioned papers, revised after the conference, selected and refined through peer review, and augmented by additional manuscripts from SOTA participants and their collaborators who responded to a thematic solicitation.

Aligning Healthcare Safety and Quality Competencies: Quality and Safety Education for Nurses (QSEN), The Joint Commission, and American Nurses Credentialing Center (ANCC) Magnet® Standards Crosswalk

From good to better: Toward a patient safety initiative in dentistry

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

Back to table of contents Previous article Next article Government NewsFull AccessCongress Considers Strategy To Reduce Medical ErrorsChristine LehmannChristine LehmannSearch for more papers by this authorPublished Online:1 Nov 2002https://doi.org/10.1176/pn.37.21.0009Before adjourning for its winter recess last month, Congress acted on legislation that would improve patient safety and explain the privacy impact of federal rules.To encourage physicians and health care professionals to report medical mistakes, the legislation would ensure confidentiality for anyone who reports that information.The Ways and Means and Energy and Commerce committees of the House of Representatives approved similar patient safety bills in September, though the bills had yet to be reconciled at press time. A key difference is that the Ways and Means bill would be included in the Medicare statute, while the Energy and Commerce version would be included in the Public Health Service Act, according to an article in the October 4 iHealth Beat.The Ways and Means bill, the Patient Safety Improvement Act (HR 4889), was introduced in June by Rep. Nancy Johnson (R-Conn.) and has the support of the Bush administration.Reports of medical mistakes by health care professionals, organizations, and facilities would be considered privileged information and shielded from the discovery process in lawsuits, according to Johnson’s bill.Johnson chairs the Ways and Means Subcommittee on Health, which held a hearing on medical error legislation in September. “The fear of legal liability has had a chilling effect on the development of the reporting and analysis of errors. These data can save lives and create a health care delivery system capable of continuous quality improvement,” said Johnson in a press statement.A Senate companion bill (S 2590) was introduced in June by Sens. James Jeffords (I-Vt.) and Bill Frist (R-Tenn.). However, some Democrats and consumer advocates oppose the legal shield for patient safety data during the discovery process, fearing that attorneys would not be able to gain access to any patient information such as medical diagnosis and treatment, according to the September 25 iHealth Beat.To remedy that, Sen. Edward Kennedy (D-Mass.) introduced the Patient Safety Improvement and Medical Injury Reduction Act (S 3029) last month. This bill would allow patient and hospital records to be used in federal or state civil or administrative proceedings under certain conditions and when permitted by federal or state law.The bill was referred to the Health, Education, Labor, and Pensions Committee, where it is awaiting action. Kenned is chair of this committee.The bills would establish local independent Patient Safety Organizations (PSOs) to collect and analyze medical error data and report back to health care professionals to prevent future mistakes, according to the legislation.The PSOs would forward the confidential health information to the Center for Quality Improvement and Patient Safety, housed in the federal Agency for Healthcare Research and Quality (AHRQ).The center would collect the information in a national medical-errors database that researchers could use to identify national trends and recommend best practices to the health care industry, according to Johnson’s statement.The legislation would also provide federal grants to encourage local health care organizations to increase their use of information technology and develop physician electronic prescribing systems to reduce medical errors.The use of advanced prescribing software and computerized physician order systems was one of the recommendations made in the landmark 1999 Institute of Medicine report titled “To Err Is Human: Building a Safer Health System.”The report estimated that between 44,000 and 98,000 Americans die annually due to medical errors, making them the eighth-leading cause of death in the United States.In other congressional news, the House of Representatives passed a bill last month (HR 4561) written by Rep. Bob Barr (R-Ga.) requiring federal agencies that issue proposed regulations for public comment to include an analysis of how privacy would be affected.The bill would also allow individuals to file lawsuits against agencies whose reviews are inadequate. A companion bill (S 2492) was awaiting action in the Senate last month.Details and summaries of the legislation can be accessed on the Web at www.thomas.loc.gov by searching on the appropriate bill number. ▪ ISSUES NewArchived

A Role for Government: An Observation on Federal Healthcare Efforts in Prevention

Introduction to Special Issue: At the Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and Medication Safety : At the Precipice of Quality Health Care: The Role of the Toxicologist in Enhancing Patient and Medication Safety. Venue: 2014 North American Congress of Clinical Toxicology. ACMT Pre-Meeting Symposium, New Orleans, LA.

Enlisting Patients to Reduce Medical Errors

Safety in health care today: more than just freedom from errors and accidents?

Implementing Team-Based Care: It's Our Duty

The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety.

The health research and policy communities have made significant progress in recent years in improving the data and analysis needed by federal, state, and local officials to guide policymaking on the uninsured.If the United States provided universal coverage to all Americans and had implemented a uniform electronic medical record, we might not have to depend on survey data as much as we currently do to assess the extent and consequence of being uninsured.Health surveys can provide critical information on insurance coverage and access to care at the national, state, and community levels that policy makers need to monitor the performance of the health care system and to develop programs to respond to shortcomings like excessive cost growth, uneven quality, and inequitable access to coverage and care.The principal federal agencies that produce these data are the United States Department of Commerce's Census Bureau, the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS), and the Agency for Healthcare Research and Quality (AHRQ).Recognizing the need to augment the availability of reliable and timely state and community health data produced by the federal agencies, national foundations over the last several decades have sought to fill identified gaps--both in the questions asked and the ability of these surveys to produce estimates at the state and substate level.These data help national policy makers understand the variations across our nation and help state and community leaders develop programs to meet the needs of their citizens.For example, in 1993-1994, the Robert Wood Johnson

Emergency Nurses Association Position Statement: Medication Management and Reconciliation in the Emergency Setting