To Err Is Human Building a Safer Health System (2000) / Chapter Skim
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4 Building Leadership and Knowledge for Patient Safety
4 Building Leadership and Knowledge for Patient Safety
Pages 69-85
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From page 69... ...
There must be greater attention placed on evaluating current approaches for reducing errors and building new systems to improve patient safety. RECOMMENDATIONS RECOMMENDATION 4.1 Congress should create a Center for Patient Safety with the Agency for Healthcare Research and Quality.
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From page 70... ...
The goals should also reflect areas that represent opportunities for significant improvement. In carrying out its activities in the areas of research and dissemination, the Center for Patient Safety should collaborate with universities, research centers, and various groups involved in education and dissemination, such as the National Patient Safety Foundation.
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From page 71... ...
The National Patient Safety Foundation conducts educational programs, workshops, and various convening activities but its programs and resources are limited. The Food and Drug Administration (FDA)
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From page 72... ...
The national research agenda is set through several mechanisms. First, a formal process determined how to allocate approximately $60 million committed to the Aviation Safety Program for FY 2000 (Cynthia Null, Ames Research Center, personal communication, May 24, 19991.
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From page 73... ...
For example, both agencies may jointly contribute to a single effort, or they may fund different, but complementary, aspects of an issue. Charles Billings, M.D., designer and founder of the Aviation Safety Reporting System, has stated his belief that aviation would not be as safe as it is today without the FAA.4 By setting standards, maintaining multiple databases to monitor trends, and supporting research to constantly improve systems, the FAA (in collaboration with other agencies such as NASA and NTSB)
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From page 74... ...
Although OSHA provides input into the NIOSH research agenda, it is set mainly through input from other stakeholders, including company requests. Information gathered by NIOSH from these companies for research purposes is not shared with OSHA for regulatory purposes.
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From page 75... ...
OPTIONS FOR ESTABLISHING A CENTER FOR PATIENT SAFETY Ob jectives The objectives of a Center for Patient Safety are to provide leadership for safety improvements throughout the industry, to establish goals and track progress in achieving results, and to expand the knowledge base for improving safety in health care. A central objective of the Center for Patient Safety is to provide visibility to safety concerns.
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From page 76... ...
Collaboration with the National Patient Safety Foundation might be desirable in carrying out vari ous agenda-setting and education activities. The committee discussed three alternative organizational arrangements for a Center for Patient Safety.
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From page 77... ...
Technologies tested in AHRQ-sponsored research that would improve patient safety include computerized monitoring of adverse drug events, computer-generated reminders for follow-up testing, standardized protocols, and computer-assisted de .
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From page 78... ...
FUNCTIONS OF THE CENTER FOR PATIENT SAFETY Creating an information infrastructure and building a better evidence base for patient safety are critical to taking a more strategic approach to reducing medical errors and improving patient safety. The goal is to improve decision making by policy makers, regulators, health care organizations, and others, so that decisions are based on evidence rather than anecdote.
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From page 79... ...
Issue an annual report on progress made to improve patient safety, and recommend changes for continuously improving patient safety to appropriate parties, such as FDA, states, accrediting agencies, professional associations, group purchasers, and health care organizations. In setting the research agenda, the Center for Patient Safety should establish a formal process to gather input on priorities, methodologies and approaches for research.
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From page 80... ...
, which has pursued a similar strategy on a much smaller scale. As part of its comprehensive program in improving patient safety throughout their delivery system, the Veterans Health Administration has committed $6 million to establish four Patient Safety Centers of Inquiry, focused on researching new knowledge in patient safety, with special emphasis on transferring safety technologies from other high-risk industries to health care, and on disseminating existing knowledge.1l It is also imperative that the Center for Patient Safety focus adequate attention on the communication of information on and knowledge of patient safety.
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From page 81... ...
NPSF's core strategies include activities to raise awareness ancl foster communication ancl dialogue to enhance patient safety ancl to develop information, collaborative relationships, ancl educational approaches that advance patient safety.13 It supports an annual grant program for innovative research to prevent patient injuries; has conducted a benchmark survey to capture consumer attitucles, experience ancl expectations about health care safety; conducts regional forums to bring together community ancl health leaders in local communities ancl convenes national conferences that brings together leaders in patient safety from around the worlcl.14 APSE has also begun developing a clearinghouse function to collect patient safety information that can be accessed by both health professionals ancl consumers. The National Patient Safety Partnership is a voluntary public-private partnership, comprised of the American Hospital Association, American
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From page 82... ...
issues and adverse drug events.15 The deliverables previously identified for the Center for Patient Safety include the development of tools and methods for educating consumers about patient safety. Although consumers are an important audience, there are many other constituencies that must be reached, including health professionals and managers, health care organizations, state and national policy makers, regulators, pharmaceutical companies and medical device manufacturers, professional groups and associations, medical and health care training centers, and various forms of media.
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From page 83... ...
The Aviation Safety Program at NASA Ames Research Center allocated approximately $60 million for FY 2000. Another funding comparison is the resources devoted by AHRQ to different programs.
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From page 84... ...
6, March 22, 1999, The National Patient Safety Foundation at the AMA. http://www.ama-assn.org/med-sci/npsf/news/03_22_99.htm.
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From page 85... ...
vdget EstimatesforAppropriations Committees, Fiscal Year 2000. Agency for Healthcare Research and Quality, Rockville, MD.
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