Agency for Healthcare Research and Quality:
Medical Errors and Patient Safety
www.ahcpr.gov/qual/errorsix.htm
The very critical issues of medical errors and
patient safety have received a great deal of attention.
In November 1999, the Institute of Medicine (IOM)
released a report estimating that as many as 98,000
patients die as the result of medical errors in
hospitals each year. A major Federal initiative
has been launched to reduce medical errors and
improve patient safety in Federally funded healthcare
programs and by example and partnership in the
private sector.
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Agency
for Healthcare Research and Quality: Web M&M
www.webmm.ahrq.gov
Agency for Healthcare Research and Quality (AHRQ)
Web M&M is the nation's first Web-based patient
safety resource and journal. An Editorial Board
and Advisory Panel, comprised of experts in the
relevant patient safety and clinical disciplines,
guide the editorial team.
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American Society of Health-System Pharmacists
(ASHP): Patient Safety Resource
Center
www.ashp.org/patient-safety
For nearly half a century, the American Society
of Health-System Pharmacists (ASHP) has played
a leading role in ensuring patient safety as it
relates to the use of medications. From the early
1960s when the society championed the adoption
of the Unit Dose Distribution and Control System
to its contributions to education and research
on patient safety, ASHP has made patient safety
a top priority. The ASHP Leadership Agenda, which
expresses the society's top priorities, includes
fostering fail-safe medication use in health systems.
The development of the ASHP Center on Patient
Safety in 2000 is yet another step in the society's
efforts in this area and builds upon the Institute
of Medicine's recommendation to establish a permanent
focus on safety improvements.
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American Society
for Healthcare Risk Management (ASHRM)
www.ashrm.org
Established in 1980, the American Society for
Healthcare Risk Management (ASHRM) is a personal
membership group of the American Hospital Association
with more than 4,300 members representing health
care, insurance, law, and other related professions.
ASHRM promotes effective and innovative risk management
strategies and professional leadership through
education, recognition, advocacy, publications,
networking, and interactions with leading healthcare
organizations and government agencies. ASHRM initiatives
focus on developing and implementing safe and
effective patient care practices, the preservation
of financial resources, and the maintenance of
safe working environments.
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Anesthesia Patient
Safety Foundation (APSF)
www.apsf.org/
A cardinal goal of the Anesthesia Patient Safety
Foundation (APSF) is to communicate and to disseminate
information about issues of anesthesia safety.
The APSF newsletter, published quarterly, has
a readership of over 60,000. In addition to anesthesiologists
and nurse anesthetists, the distribution includes
the nation's risk managers, the Board of Governors
of the American College of Surgeons, the liability
insurance industry, pharmaceutical companies,
medical device manufacturers, the Joint Commission
on Accreditation of Healthcare Organizations,
the US Food and Drug Administration (FDA), and,
far from least, congressional staffers responsible
for healthcare information.
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Australian Patient
Safety Foundation (APSF)
www.apsf.net.au/
The Australian Patient Safety Foundation (APSF)
is a nonprofit, independent organization dedicated
to the advancement of patient safety. The APSF
has developed an incident monitoring system known
as AIMS (Australian Incident Monitoring System),
which is used in many healthcare systems within
Australia to identify and analyze things that
go wrong in healthcare delivery. The system has
been implemented in a New Zealand site and other
overseas markets are being explored. Introduced
in 1996, AIMS provides a mechanism for any incident
or accident (actual or potential) in health care
to be reported, using a single standard form.
Incidents are then classified on corresponding
software using two unique classification systems
developed by the APSF.
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Centers for Disease
Control and Prevention (CDC): Patient Safety Web
Site
www.cdc.gov/washington/overview/patntsaf.htm
In recent years, patient safety issues have
received considerable media attention, increasing
the public's awareness. Approximately 98,000 patients
die as the result of medical errors in hospitals
each year. Preventable medical errors affect as
many as one of every 25 patients, and they cost
the nation billions of dollars annually.
The public health community works to reduce
medical errors through improving hospital and
other medical facility surveillance systems. For
instance, in the case of hospital-related infections,
surveillance can help identify the site of the
infection and the factors that caused it. Armed
with this information, the infection can be contained
as quickly as possible.
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Institute of Medicine
Patient Safety Reports
Committee on Quality of Health Care in America,
Institute of Medicine. (2000). To err is human:
Building a safer health system. Kohn, L.
T., Corrigan, J. M., & Donaldson, M. S. (Eds).
Washington, D. C.: National Academy Press. www.nap.edu/catalog/9728.html
Committee on Quality of Health Care in America,
Institute of Medicine. (2001). Crossing the
quality chasm: A new health system for the 21st
century. Washington, D. C.: National Academy
Press. www.nap.edu/catalog/10027.html
Hurtado, M. P., Swift, E. K., & Corrigan,
J. M. (Eds). (2001). Envisioning the National
Health Care Quality Report. Washington, D.
C.: National Academy Press. www.nap.edu/catalog/10073.html
Committee on Enhancing Federal Healthcare Quality
Programs, Institute of Medicine. (2001). Leadership
by example: Coordinating government roles in improving
health care quality. Corrigan, J. M., Eden,
J., & Smith, B. M. (Eds). Washington,
D. C.: National Academy Press. www.nap.edu/catalog/10537.html
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Institute for Safe
Medication Practices (ISMP)
www.ismp.org/
The Institute for Safe Medication Practices (ISMP)
is a nonprofit organization that works closely
with healthcare practitioners and institutions,
regulatory agencies, professional organizations,
and the pharmaceutical industry to provide education
about adverse drug events and their prevention.
The institute provides an independent review of
medication errors that have been voluntarily submitted
by practitioners to a national Medication Errors
Reporting Program (MERP) operated by the United
States Pharmacopeia (USP) in the United States.
Information from the reports may be used by USP
to impact on drug standards. All information derived
from the MERP is shared with the U.S. Food and
Drug Administration (FDA) and pharmaceutical companies
whose products are mentioned in reports.
The institute is an FDA MedWatch partner and
regularly communicates with the FDA to help prevent
medication errors. The institute encourages the
appropriate reporting of medication errors to
the MedWatch program. ISMP is dedicated to the
safe use of medications through improvements in
drug distribution, naming, packaging, labeling,
and delivery system design. The organization has
established a national advisory board of practitioners
to assist in problem solving.
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JCAHO National Patient
Safety Goals
www.jointcommission.org/GeneralPublic/NPSG
In July 2002, JCAHO approved its first set of
six National Patient Safety Goals, with 11 related
specific recommendations, for improving the safety
of patient care in healthcare organizations. The
recommendations were developed by the Sentinel
Event Alert Advisory Group through an intensive
review process of all past alert recommendations
published by JCAHO.
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MEDERRORS.com
www.mederrors.com/
MEDERRORS.com is intended as a useful link to
experts in the fields of medication error and
adverse drug event prevention and continuous quality
improvement. With the help of guest editors, MEDERRORS.com
provides a lively forum for the exchange of points
of view among healthcare professionals, experts
on process improvement, and healthcare consumers.
Explore how often errors and adverse drug events
occur, what causes them, and how they can often
be avoided. Use this site to research, debate,
and help solve a problem that is complex, costly,
and often preventable. MEDERRORS.com is sponsored
by Bridge Medical as a service to healthcare professionals
and consumers.
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Medication Error
Reporting and Prevention (MERP)
www.usp.org/patientSafety/reporting/mer.html
This nationwide program makes it possible for
health professionals who encounter actual or potential
medication errors to report confidentially and
anonymously, if preferred, to United States Pharmacopeia
(USP). By sharing these experiences, pharmacists,
nurses, physicians, and other healthcare practitioners
contribute to improved patient safety and to the
development of valuable educational services for
the prevention of future errors. The program encompasses
a wide variety of problems such as misinterpretations,
miscalculations, misadministrations, difficulty
interpreting handwritten orders, or misunderstanding
verbal orders. USP reviews each report for health
hazards and forwards all information to the Food
and Drug Administration (FDA) and the product
manufacturer. USP acts as a liaison with the FDA
and the manufacturer if a record is submitted
anonymously. The MERP is presented in cooperation
with the Institute for Safe Medication Practices
(ISMP).
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Quality Interagency Coordination (QuIC)
Task Force
www.quic.gov/index.htm
The Federal Government plays many important
roles that affect the quality of health care that
Americans receive. In fact, the Federal Government
is the largest purchaser and provider of healthcare
services in the United States. Programs like Medicare
and Medicaid, the Federal Employee's Health Benefits
Plan (FEHBA), and the networks of hospitals and
facilities providing care to people in the armed
forces and veterans serve millions of Americans.
In addition, the Federal Government provides billions
of dollars in support of healthcare research each
year, oversees employer-based healthcare coverage,
and ensures fair competition in the healthcare
market. The QuIC's goal is to ensure that all
Federal agencies involved in purchasing, providing,
studying, or regulating healthcare services are
working in a coordinated way toward the common
goal of improving quality of care.
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SHARPS Injury Control
Program
www.sharpslist.org
The Sharps Injury Control Program (SHARPS) was
established by California Senate Bill 2005 to
study sharps injuries in hospitals, skilled nursing
facilities, and home health agencies in California.
SHARPS is sponsored by the California Department
of Health Services/Occupational Health Branch,
California Department of Industrial Relations/Division
of Occupational Safety and Health, and the University
of California, San Francisco, School of Nursing.
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The
Leapfrog Group
www.leapfroggroup.org
Medical errors are a leading cause of death in
America—there
are more deaths in hospitals each year from preventable
medical mistakes than there are from vehicle accidents,
breast cancer, or AIDS.
While death is the most tragic outcome, preventable
medical mistakes cause other problems as well.
They can lead to permanent disabilities, extended
hospital stays, longer recoveries, and/or even
additional treatments. The real tragedy is that
most of these medical mistakes are preventable.
They are most often caused by systems that break
down and don't support the highly qualified and
dedicated hospital caregivers the way they should.
In response to this serious problem, The Leapfrog
Group—a
coalition of public and private organizations
that provide healthcare benefits—is
taking action. The Leapfrog Group was created
to help save lives and reduce preventable medical
mistakes by mobilizing employer purchasing power
to initiate breakthrough improvements in the safety
of health care and by giving consumers information
to make more informed hospital choices.
It is a voluntary program aimed at mobilizing
large purchasers to alert the healthcare industry
that big leaps in patient safety and customer
value will be recognized and rewarded with preferential
use and other intensified market reinforcements.
The Leapfrog Group was founded by the Business
Roundtable (BRT), a national association of Fortune
500 CEOs.
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U.S.
Food and Drug Administration (FDA): MedWatch
www.fda.gov/medwatch/index.html
FDA has the responsibility for assuring the
safety and efficacy of all regulated marketed
medical products. MedWatch, the FDA Safety Information
and Adverse Event Reporting Program, serves both
healthcare professionals and the medical product-using
public. MedWatch provides important and timely
clinical information about safety issues involving
medical products, including prescription and over-the-counter
drugs, biologics, medical and radiation-emitting
devices, and special nutritional products (e.g.,
medical foods, dietary supplements, and infant
formulas).
Medical product safety alerts, recalls, withdrawals,
and important labeling changes that may affect
the health of all Americans are quickly disseminated
to the medical community and the general public
via this Web site and the MedWatch E-list. Select
"Safety Information" to see reports,
safety notifications, and labeling changes posted
to the Web site since 1996.
MedWatch allows healthcare professionals and
consumers to report serious problems that they
suspect are associated with the drugs and medical
devices they prescribe, dispense, or use. Reporting
can be done online, by phone, or by submitting
the FDA form 3500 by mail or fax.
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United States Pharmacopeia
(USP)
www.usp.org
The United States Pharmacopeia (USP) is a non-government
organization that promotes the public health by
establishing state-of-the-art standards to ensure
the quality of medicines and other healthcare
technologies. These standards are developed by
a unique process of public involvement and are
accepted worldwide. In addition to standards development,
USP's other public health programs focus on promoting
optimal healthcare delivery. USP is a not-for-profit
organization that achieves its goals through the
contributions of volunteers representing pharmacy,
medicine, and other healthcare professions, as
well as science, academia, the U.S. government,
the pharmaceutical industry, and consumer organizations.
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VA National
Center for Patient Safety (NCPS)
www.patientsafety.gov/
The National Center for Patient Safety (NCPS)
embodies the Department of Veterans Affairs' (VA)
uncompromising commitment to reducing and preventing
adverse medical events while enhancing the care
given to all patients. The NCPS represents a unified
and cohesive patient safety program, with active
participation by all of the VA hospitals supported
by dedicated patient safety managers. This program
is unique in health care; the NCPS focuses on
prevention not punishment, applying human factor
analysis and the safety research of high reliability
organizations (aviation and nuclear power) targeted
at identifying and eliminating system vulnerabilities.
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VA Veterans Integrated
Service Network (VISN) 8 Patient Safety Center
of Inquiry
www.visn8.med.va.gov/patientsafetycenter/
The Department of Veteran's Affairs funded the
James A. Haley Veterans Hospital, near Tampa,
Florida, to establish a VISN 8 Patient Safety
Center of Inquiry. The center was originally funded
for 3 years in 1999 but has continued to receive
funding to date. The focus of this center is safe
mobility. Two goals for this center have been:
1) To promote personal freedom and safety for
frail elderly and persons with disabilities across
the continuum of care, and 2) To build a "culture
of safety" to support clinicians in providing
safe patient care and safe working environments.
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