Homework

Patient Safety: The Past

Decade

Chapter 6

Institute of Medicine:

Four Tier Approach

1) Leadership and Knowledge

2) Identifying and Learning from Errors

3) Setting performance standards and

expectations for safety

4) Implementing safety systems in health care

organizations

Leadership & Knowledge – Tier 2

Patient Safety and Quality

Improvement Act of 2005 (PSQIA) Duties:

• Provide for the certification and recertification of Patient Safety Organizations

• Collect and disseminate information related to patient safety

• Establish a patient safety database

• Facilitate development of consensus among health care providers, patients, & interested parties concerning patient safety and recommendations to improve patient safety

• Provide technical assistance to states that have medical -error reporting systems, assist states in developing standardized methods for data collection, and collect data from state reporting systems for inclusion in the patient safety database

Leadership & Knowledge- Tier 2

National Quality Forum

• Established in 1999

• Goal: improve the quality of American health

care by setting national standards

• Members include hospitals, physicians,

businesses and policymakers & national, health,

government, and consumer organizations

committed to specific, measurable actions and

goals for performance measurement and public

reporting regarding patient safety

Setting Performance Standards and

Expectations for Patient Safety- Tier 3

• Professional groups already working to improve patient safety:

– American Medical Association (AMA)

– National Patient Safety Foundation (NPSF)

– American Nurses Association (ANA)

• IOM Recommendations:

– Professional societies that make a clear commitment to improving patient safety.

– Food and Drug Administration (FDA) increase attention to the safe use of drugs and devices

Creating Safety Systems Inside Health

Care Organizations- Tier 4

• The Joint Commission- established the

National Patient Safety Goal program in 2002

with the first set of goals taking effect in

January 2003

• Developed the national patient safety goals

(NPSGs)

– 13 goals with multiple elements of performance

AHRQ

• Developed a tool to assist hospitals in evaluating how well they establish a culture of patient safety within their institution

– Hospital staff provides opinions about patient safety, medical-error and adverse-event reporting

– Purpose:

• (1) allow hospitals to compare themselves with each other

• (2) facilitate internal learning in patient safety improvements

• (3) assist hospitals in identifying strengths and areas for improvement

• (4) show trends in patient safety over time