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of Action Items
Focus and Leadership
- AHRQ will
take immediate action to establish the Center for Quality Improvement
and Patient Safety (CQuIPS), which will replace and broaden the
mission of AHRQ’s Center for Quality Measurement and Improvement.
- CQuIPS will
coordinate with and complement other public- and private-sector
initiatives to improve patient safety.
- QuIC will
coordinate Federal activities on patient safety, as it does on
the broader quality agenda. This will include both regular meetings
of the QuIC and use of its current structure to redirect QuIC
working group efforts towards enhancing patient safety.
- AHRQ will
sponsor a program to educate personnel of QuIC member agencies
about patient safety, bringing them together with leading researchers
on human factors analysis, systems design, error reporting, and
quality improvement. This curriculum will serve as a model and
be expanded for future educational activities with private-sector
- QuIC agencies
such as OPM, HCFA, DoD, and VA will demonstrate their national
leadership as purchasers and providers of care, developing model
programs that use information on errors to improve patient safety.
- Federal agencies
and other bodies, including AHRQ, FDA, CDC, and HCFA, will collaborate
to provide national leadership in developing and testing systems
of mandatory reporting for public accountability.
- Hold national
summits on medical error and patient safety research: AHRQ will
lead the convening of conferences and expert meetings to review
the information needs of those who wish to improve safety, assess
the current state of patient safety research, set coordinated
research agendas, and develop adequate reporting mechanisms. VA
will lead a summit on lessons learned from its experiences in
improving patient safety, and the FDA will lead a summit on drug
errors. These summits will take place within 1 year.
joint research solicitations (including partnerships between AHRQ,
CDC, FDA, and VA) for:
Fundamental Research on Errors: Investigate root causes
analysis, informatics, the role(s) of human factors, and legal/judicial
Research on Reporting Systems: Identify critical components
of successful reporting systems used for learning, examine options
for voluntary and mandatory reporting systems, implement and evaluate
demonstration programs for reporting, evaluate existing State mandatory
reporting systems, and investigate techniques and methods for analyzing
and disseminating patient safety data (including integration into
a National Quality Report being prepared by DHHS under the leadership
of AHRQ and CDC).
Applied Research on Patient Safety: Test the application
of human factors knowledge to the design of health care products,
processes, and systems; identify best practices in reducing errors;
fund patient safety "Centers of Research Excellence";
and support research and demonstrations on-site, as well as level-of-care
and cross-cutting research, such as in diagnostic accuracy, informatics
applications, and systems re-engineering.
- Develop tools
for the public and private sector to support efforts to enhance
patient safety, including:
Identify tools and approaches from other industries that could be
applied to the health care sector and develop community-based settings
that can serve as laboratories for error reduction through medical
specialty societies, primary care networks, and integrated service
Measures: Develop and evaluate data specifications
for reporting on patient safety and work with the Quality Forum
and other private- and public-sector efforts on developing consensus
around a core set of measures for patient safety.
a QuIC Research Agenda on Working Conditions and Patient Safety.
The QuIC will finalize a research agenda to explore the relationship
between health care workers’ working conditions and the quality
of patient care, including patient safety. CDC and AHRQ will coordinate
this activity with VA and other agencies.
and Learning From Errors
- The QuIC
will ask the Quality Forum to define unambiguously, within 12
months, a set of egregious errors that are preventable and should
never occur. These measures will serve as criteria for a HCFA-sponsored
mandatory reporting demonstration project with a State that already
has an existing mandatory reporting requirement. HCFA will publish
the hospital rates for these events without patient identifiers.
- HCFA and
its QuIC partners will evaluate whether consumers found this information
valuable and what they understood about it. Based on these results,
HCFA will move towards a national mandatory reporting system,
with publication of findings, for all hospitals participating
- Federal agencies,
in partnership with other organizations, will develop options
for mandatory reporting systems that provide the public and purchasers
with publicly available information about programs and procedures
in place to reduce errors. This work will require the development
of evidence-based, systems-level measures in collaboration with
the Quality Forum.
- OPM will
require that health plans have error reduction plans and will
report on its web site whether the health plans have reliable
patient safety initiatives in place.
- QuIC will
ask the Quality Forum to identify, within 12 months, patient safety
practices that institutions should undertake and urges that information
about whether the measures are in place be made available to the
- FDA will
report to the public on the safety of drugs, devices, and biologic
- QuIC proposes
that State and Federal mandatory reporting systems, as well as
those of private accrediting and other oversight groups, be evaluated
to determine the ways in which they are helpful in assuring public
accountability for patient safety, and that these results be used
to develop future reporting systems.
- AHRQ will
include information on patient safety in the National Quality
Report it is developing in collaboration with other agencies,
in particular, the National Center for Health Statistics.
- OPM will
require that health plans describe their patient safety initiatives,
will make patient safety information available in both print and
electronic formats for the open enrollment period in Fall, 2000,
and will expand its Web site to include information about programs
designed to reduce errors and enhance patient safety.
- OPM will
encourage health plans to annotate Preferred Provider Organization
(PPO) directories to indicate which hospitals and physicians’
offices use automated information systems.
- FDA will
improve the safety of transfusions by expanding mandatory reporting
requirements for blood bank errors and accidents, so that they
apply to all registered blood establishments.
- The new Center
for Quality Improvement and Patient Safety (CQuIPS) at AHRQ will
identify existing State and Federal reporting systems (both mandatory
and voluntary), evaluate their suitability in helping to build
a national system of errors reporting, and evaluate how their
data collection or enforcement efforts can be enhanced to improve
the value of those systems.
- QuIC will
work with the Quality Forum to develop reporting criteria that
assure that information can be pooled and shared as needed across
- CQuIPS, working
with the QuIC, will describe and disseminate information on characteristics
of existing voluntary reporting programs associated with successful
error reduction and patient safety improvement efforts. FDA, CDC,
and NASA will provide expertise in the development of these nonpunitive
- Within six
months, HCFA, working with a Peer Review Organization (PRO) program,
will develop a pilot of a confidential, penalty-free learning
system with several hospitals on a voluntary basis.
- Federal agencies,
including the FDA, VA, DoD, CDC, HCFA, and AHRQ, will integrate
data from different sources and conduct and support analysis to
identify error prone procedures, products, and systems.
- By August
2000, the DoD will complete development of a patient safety improvement
program based on a reporting system modeled on that of the VA.
- VA will establish
a voluntary reporting system to supplement its existing mandatory
- AHRQ, in
collaboration with other Federal agencies, will investigate, develop
and test strategies to provide effective feedback to clinicians
and institutions on methods for improving patient safety.
- Federal agencies
will assist health care providers to develop the skills necessary
for analyzing adverse events and near misses (e.g., root cause
analysis, trending, search tools). Federal agencies providing
health care will develop internal systems to 1) identify and report
errors to clinicians and other decision makers, and 2) learn from
those errors and near misses to prevent future events.
to Stakeholders: QuIC will develop programs to foster the dissemination
of research findings to end users through activities such as AHRQ’s
User Liaison Program; provide support to the Quality Forum to
increase the national discussion on errors, their reduction, and
standardized measures of errors; and fund collaborative agreements
with health care professional organizations that foster education,
track patient safety initiatives, provide input to the new patient
safety research centers, and translate, disseminate, and promote
adoption of research findings.
- Patient Safety
Clearinghouse: AHRQ will develop a clearinghouse in partnership
with other Federal agencies and private-sector organizations to
provide an objective source of state-of-the art information on
- AHRQ will
initiate a "National Morbidity & Mortality Conference"
posting selected cases (stripped of identifying information) in
a public forum via Internet technology, and establish a Web site
where patients can report incidents that will be analyzed to identify
- The QuIC
supports the extension of peer review protections to facilitate
reporting of errors in a blame-free environment, and will propose
considerations of confidentiality that will not undermine current
mechanisms to address criminal activity or negligence.
- As part the
development of the national reporting system, appropriate electronic
protections (i.e., firewalls and encryption) will be constructed
to ensure that the confidentiality of the patients involved and
the clinician or institution providing the information is maintained,
and that the information gathered will not be used for punitive
purposes. Experience with reporting systems in other industries
demonstrates that this approach encourages reporting of errors.
Performance Standards and Expectations for Safety
Standards for Health Care Organizations
- HCFA will
use its power as a purchaser and regulator to promote the use
of effective error-reduction initiatives in the health care institutions
with which it deals.
- HCFA will
publish regulations this year requiring hospitals participating
in the Medicare Program to ongoing medical error reduction programs.
- OPM will
follow the lead of selected private purchasers to raise the standard
for participation by requiring that all health plans with which
it contracts seek accreditation from an independent, national
accrediting organization that includes evaluation of patient safety
and programs to reduce errors in health care.
- In its call
letter for the 2001 contract year, OPM will ask health plans to
encourage their preferred hospitals to use automated prescription
systems and other integrated data systems. OPM will encourage
health plans to annotate PPO directories to indicate which hospitals
and physicians’ offices use such automated programs.
Standards for Health Care Professionals
The QuIC will:
- Develop and
evaluate programs introducing health professionals to errors analysis
and the challenges of practicing in a technically complex environment,
explore the use and testing of simulators and automation as education
tools, support training in errors research and evaluation, and
develop patient safety expertise at the State level using the
CDC’s Epidemic Intelligence Service as a model.
- Convene a
meeting of the accrediting, licensing, and certifying bodies of
the health professions to review information on medical errors
in the context of current practice requirements and propose methods
of strengthening health professions’ education in the areas of
medical error prevention and medical error evaluation as a means
of improving patient safety.
with the Federation of State Medical Boards and other entities
to encourage that error reduction and prevention education be
a provision for relicensing of health professionals.
in the planning, implementation, and evaluation of a national
summit addressing patient safety and medical error reduction programs,
and in producing directives for the future.
- Provide training
within the QuIC agencies that provide care to encourage use of
patient safety information and encourage enhanced reporting in
partnership with private-sector accreditors, purchasers, and providers.
- Provide technical
assistance to State or professional agencies seeking to ensure
a basic level of knowledge for health care providers on patient
of Drugs and Devices
Within 1 year,
the FDA will initiate programs to:
- Develop additional
standards for proprietary drug names to avoid name confusion.
- Develop standards
for packaging to prevent dosing and drug mix-ups.
- Develop new
label standards for drugs, highlight drug–drug interactions, potential
dosing errors, and address other common errors related to medications.
the Phase II pilot study of the Congressionally mandated Medical
Product Surveillance Network (MedSUN).
efforts to ensure manufacturers’ compliance with FDA programs,
specifically naming, labeling, and packaging.
- Provide access
to databases linked to health care systems and other sources of
adverse-event and marketing data, and link these to existing registries
of product users.
the on-line Adverse Event Reporting Systems (AERS) for drugs and
FDA's analytical and investigative capacities.
FDA outreach activities and collaboration with other Government
agencies and stakeholders.
Safety Systems in Health Care Organizations
- Under the
leadership of the CQuIPS, the QuIC will promote, at the executive
level, the development and dissemination of evidence-based, best
patient-safety practices to provider organizations.
- QuIC participants,
including HCFA, VA, DoD, AHRQ, CDC, and FDA, will explore opportunities
with private-sector accreditation, purchaser, and provider organizations
to develop organization-based, patient-safety models that could
be evaluated, and if found effective, disseminated widely. In
addition, these stakeholders will be engaged in a regular dialogue
with QuIC participants to ensure that the stakeholders’organizational
needs are being met through Federal research and reporting initiatives.
- Through its
exemplary patient safety program, VA will continue to scrutinize
its care provision for opportunities to improve safety, and develop
and expand its reporting system.
- VA will invest
$47.6 million this year to increase patient safety training for
staff (select for details in Chapter
- DoD will
invest $64 million in FY 2001 to begin implementation of a new
computerized medical record system, including an automated order
entry system for pharmaceuticals (details in Chapter
- Other QuIC
direct-care providers will initiate patient safety programs (e.g.,
HRSA’s community health care centers are investigating the most
effective programs that can be implemented in their health care
- QuIC member
agencies will begin a collaborative project this summer with the
Institute for Healthcare Improvement to reduce errors in high-hazard
health care delivery settings.
Public Awareness of Medical Errors
- Through the
QuIC’s Enhancing Patient and Consumer Information Working Group,
led by OPM and HCFA, Federal agencies will develop and coordinate
an information campaign for their constituencies and beneficiaries
to increase their awareness of the problem of medical errors and
- AHRQ will
develop generic material for the public on preventing medical
errors that Federal agencies can disseminate, reprint, or adapt.
This material will enable patients to become more involved in
their care and to be more active participants in the decisionmaking
surrounding their care.
- The CQuIPS
will develop and test patient safety questions for inclusion in
the patient survey now being developed for provider-level assessment
of health care.
- HCFA will
conduct research aimed at shaping programs to educate beneficiaries
about medical errors.
- Within 1
year, FDA will increase collaborative programs with patient and
consumer groups regarding patient safety.
- FDA will
enhance its interactions with the public through meetings with
consumer and patient organizations, and through grass-roots informational
meetings. The meetings will focus on patient needs and the safe
use of medical products, particularly for home use. The meetings
will also discuss how to reach patients with important information
on safe use of medical productsincluding through the use
of local networks, the Internet, and electronic and print media.
This will occur within 1 year.
- Patient safety
and reducing medical errors will be a featured topic at OPM’s
Fall 2000 annual health plan conference.
Purchasers’ Awareness of the Problem
on existing relationships with purchasers and business coalitions,
such as the National Business Coalition on Health, and the Washington
(DC) and Midwest Business Coalitions on Health, DOL, HCFA, OPM,
and AHRQ will spearhead the QuIC’s efforts to promote collaborative
programs with other public- and private-sector partners to increase
purchasers’ and providers’ awareness of medical errors as a health
care problem and of steps that each can take to address this problem,
such as addressing patients’ health literacy skills.
- At the Federal
Benefits Conference (June 2000), OPM will share information about
patient safety with representatives from Federal agencies throughout
Providers to Improve Patient Safety
- Through the
QuIC, Federal agencies will take advantage of existing resources
to promote collaborative patient safety programs involving agency
constituents, the health professions community, the public, academia,
and other stakeholders, such as the American Medical Association,
the American Nurses Association, NPSF, NPSP, and the Quality Forum.
- VA will develop
and run pilot patient safety education programs for medical residents
Systems and Information Technologies
- AHRQ and
CDC will expand research efforts in the area of informatics to
include initiatives aimed at developing and evaluating electronic
systems to identify, track, and address patient safety concerns.
- CQuIPS at
AHRQ, along with VA, DoD, FDA and other QuIC member agencies,
will evaluate the effectiveness of automated physician order entry
systems in hospitals.
- DoD, VA,
and IHS will introduce electronic patient records to offer structured
documentation and a common clinical lexicon for practitioners
working throughout those systems. The QuIC will encourage other
potential Federal participants to do likewise.
Procedures, Checklists, and the Results of Human Factors Research
- CDC and FDA
will work with the DHHS Advisory Committee on Blood Safety and
Availability to help ensure that the highest quality standards
are met in blood collection and transfusion.
- Within 1
year, FDA will begin working with manufacturers of medical products
to explore incorporating standards, including human factors standards,
into guidance to ensure that medical products are designed to
minimize the chance of errors.
- NASA will
be invited to become a participant in QuIC activities and bring
its understanding and experience in redesigning processes and
procedures to enhance safety. Linkages between NASA and the CQuIPS
will be established through the NASA Medical Policy Board.
- The QuIC
will sponsor an educational program, noted in the section on research
above, to increase the awareness of Federal regulators and policymakers
regarding patient safety, human factors, and systems-based improvement.
- VA will continue
to work with private-sector organizations (e. g., the American
Hospital Association and JCAHO) to explore the utility of its
comprehensive error analysis and corrective action system.
- The QuIC
and its member agencies will ask independent accrediting organizations
to demonstrate how they are coordinating and strengthening their
patient safety standards.
- AHRQ’s CQuIPS,
through the research agenda articulated above, will develop evidence-based
measures that integrate human factors and lessons from other industries.
- As with the
DQIP measurement set, the QuIC will solicit formal adoption and
use by member agencies of common, validated, and standardized
performance measures in the area of error reduction. The QuIC
will work with certifying boards for healthcare professionals
to incorporate these measures into certification and recertification
programs where appropriate.
- QuIC agencies
will encourage their private-sector partner organizations to support
the implementation of more rigorous safety standards and will
act to facilitate the ability of private-sector partners to do
- The QuIC
will work through the Quality Forum, the NPSF, and the NPSP to
collaborate with private-sector organizations, industry representatives,
academic institutions, and scientific and health care professionals
to examine issues related to standards, to test standards of performance
measurement, and to establish a set of core standards.
- DOL will
build on an existing collaboration with the National Association
of Insurance Commissioners (NAIC) to exchange information between
DOL, the States, employers, plans, and individual patients on
medical errors and safe, high-quality health care.
- OPM will
participate with private-sector organizations in the development
of standards and measures, will share QuIC-adopted standards and
measures with its health plans, and advocate the use of such standards
and measures throughout plan networks.
- OPM will
also begin collecting performance measurement data from its participating
plans, and will make performance information available to beneficiaries
of the Federal Employees Health Benefits Program.
safety and reducing medical errors will be a featured topic at
OPM’s Fall 2000 annual health plan conference.
- The QuIC
members will work with and support the Quality Forum in its identification
of a core set of errors reporting data.
- AHRQ, working
with its QuIC partners, will identify existing data sets (such
as the State mandatory errors reporting data) that can be brought
together to enhance the Nation’s knowledge and understanding of
errors. Based upon experience with the HCUP and the CDC’s data
integration efforts, AHRQ will work with those entities that have
the data, to determine the feasibility of pooling the data and
using this resource to learn about opportunities to reduce errors
and enhance patient safety.
- OPM will
discuss with health plans and preferred provider organizations
the development of strategies for focusing disease management
programs and integrated data systems on the goal of avoiding medical
errors and improving patient outcomes.
- HCFA, in
collaboration with FDA and AHRQ, will develop a strategy for incorporating
initiatives to increase patient safety into the pharmacy benefit
managers program under an expanded Medicare drug benefit.
Errors: Part of a Broader Quality Agenda
are a fact of life. It's the response to the error that counts."
Giovanni (American poet, 1943- )
experts have recognized that medical errors exist and compromise
health care quality, but the response to the November 30,
1999, release of the Institute of Medicine’s (IOM) report,
To Err is Human: Building a Safer Health System, brought
medical errors to the forefront of public attention. The report’s
estimate that 44,000 to 98,000 Americans die each year as
a result of adverse events has captured the public’s concern
and resulted in a sense of urgency about increased attention
to safety in the health care system. On December 7, 1999,
one week after the IOM report’s release, the President directed
the Quality Interagency Coordination Task Force (QuIC) to
evaluate the recommendations in To Err is Human and
report to him through the Vice President within 60 days "with
recommendations to improve health care through the prevention
of medical errors and enhancements of patient safety."
was established by the President in the spring of 1998. Its
goals are to ensure that all Federal agencies involved in
purchasing, providing, studying, or regulating health care
services are working in a coordinated way toward the common
goal of improving the quality of care; to provide beneficiaries
with information to assist them in making choices about their
care; and to develop the infrastructure needed to improve
the health care system, including knowledgeable and empowered
workers, well-designed systems of care, and useful information
Federal agencies include the Departments of Health and Human
Services, Labor, Defense, Veterans Affairs, and Commerce;
the Office of Personnel Management, the Office of Management
and Budget, the U.S. Coast Guard, the Federal Bureau of Prisons,
the National Highway Transportation and Safety Administration,
and the Federal Trade Commission. The QuIC is co-chaired by
Secretary of Health and Human Services Donna Shalala and Secretary
of Labor Alexis Herman. John Eisenberg, Director of the Agency
for Healthcare Research and Quality, serves as Operating Chair
of the QuIC.
believes that the IOM report has performed an important service
in drawing national attention to the problems of patient safety,
showing how preventable errors cause an immense burden for
patients and the Nation’s health care system. The Federal
agencies that are members of the QuIC are working actively
to reduce this burden through their roles as purchasers (i.e.,
buyers of health care services through private insurers or
health maintenance organizations), program funders, research
agencies, regulators, patient advocates, and providers of
care. Some of the QuIC participants are already recognized
as leaders in error recognition and prevention, and all are
committed to improving the health care that Americans receive.
agencies are aware of several challenges, many of which were
dealt with in the IOM report, that must be addressed if there
is to be a substantial increase in patient safety. This report
addresses those issues, recognizing that the improvement of
patient safety will require coordinated actions from a wide
array of individuals and organizations involved in health
care, including public and private-sector purchasers, providers,
and oversight bodies, as well as patients. This report discusses
ways the Federal Government, in collaboration with its partners
in the private sector and in State and local government, can
uncover the root causes of errors, identify best practices
to avoid them, accelerate the widespread adoption of these
best practices, and ensure that the public can be assured
that the health care delivery systems on which their lives
depend are operating safely.
emphasized that errors should not be studied in isolation
from other health care issues. Rather, the IOM report To
Err is Human is part of a larger project on quality in
health care that is investigating ways to redesign the delivery
system, realign financial incentives to reward high quality
care, and use information technology as a tool for measuring
and understanding quality. Because the QuIC also has a broad
quality mandate, member agencies are already working in these
areas and believe that progress in the broad domain of health
care quality is essential to the more specific but compelling
need to reduce errors.
to documenting the need for attention to the issue of patient
safety, the IOM report makes specific recommendations for
actions to galvanize the health care industry into action
to improve safety. In brief, the key recommendations of the
IOM report include:
a Center for Patient Safety at the Agency for Healthcare
Research and Quality (AHRQ). The IOM recommends that a center
be established within AHRQ with responsibility for promoting
the development of knowledge about errors and to encourage
the sharing of strategies for reducing errors. The IOM committee
recommends substantial budget increases over the next several
voluntary and mandatory reporting of errors. First, the
IOM recommends that voluntary reporting systems should
focus on errors that result in little or no harm to patients,
and should be encouraged by AHRQ. Second, a mandatory
reporting system should be established to allow State governments
to collect standardized information on adverse events resulting
in death or serious harm.
reporting systems from being used in litigation. The IOM
urges Congress to pass legislation extending peer review
protections to data related to patient safety and quality
improvement that are collected and analyzed by health care
organizations for purposes of improving safety and quality.
patient safety the focus of performance standards for health
care organizations and professionals. Regulators and accreditors
should require health care organizations to have meaningful
patient safety programs. Purchasers are also encouraged
to provide incentives for patient safety programs. The IOM
suggests that professional licensing organizations periodically
reexamine and relicense professionals based, in part, on
their knowledge of patient safety. Licensing organizations
also need to develop more effective means of identifying
unsafe practitioners and taking actions against them. It
also suggests that professional societies should promote
patient safety education.
FDA attention to safety in pre- and postmarket reviews of
drugs. The IOM specifically suggests developing standards
for safe packaging and labeling; testing of drug names to
prevent sound-alike and look-alike errors; and working with
doctors, pharmacists, and patients to identify and rectify
problems in the post-marketing phase.
health care organizations to make a commitment to improving
patient safety and to implement safe medication practices.
Health care organizations should develop a culture of safety
and implement nonpunitive systems for reporting and analyzing
errors. These organizations should also follow recommendations
for safe medication practices as published by professional
and collaborative organizations interested in patient safety.
to the IOM report, the President directed the QuIC to prepare
a set of recommendations for specific actions to improve health
care outcomes and prevent medical errors. These recommendations
were to include specific actions in both the public and private
sectors, and be consistent with the strong privacy protections
proposed by the Administration. Specifically, the President
requested that the QuIC report:
prevalent threats to patient safety and medical errors that
can be prevented through the use of decision-support systems,
such as patient monitoring and reminder systems.
the feasibility and advisability of the recommendations
provided by the Institute of Medicine's Quality of Health
Care in America Committee on Patient Safety.
additional strategies to reduce medical errors and ensure
patient safety in Federal health care programs.
the extent to which medical errors are caused by misuse
of medications and medical devices, and consider steps to
strengthen the Food and Drug Administration's surveillance
and response system to reduce their incidence.
opportunities for the Federal Government to take specific
action to improve patient safety and health care quality
nationwide through collaboration with the private sector,
including through the National Forum for Health Care Quality
Measurement and Reporting (the Quality Forum).
requested that the recommended actions serve as a foundation
for a national system that prevents adverse medical events.
has prepared this response to the President’s directive with
several principles in mind. First, it agrees with the IOM
and with private-sector experts that medical errors are generally
due to systemic flaws in health care rather than individual
incompetence or neglect. Bad care givers are sometimes a problem,
but most errors are the result of weaknesses in the organization
of the health care system and its component services. Thus,
the QuIC agrees with the IOM emphasis on systemic solutions
and avoidance of the assignment of blame.
the QuIC agrees with the IOM and other experts that errors
are one of a number of problems in the health care system
that compromise patient safety and quality and endanger large
numbers of patients in ways that can be avoided. These include
under-treatment, excessive treatment, and widespread deviations
in practice that cannot be explained scientifically.
the QuIC shares the belief of many experts that errors can
be reduced and safety enhanced in health care by applying
lessons from successful efforts in other American industries
to improve quality. Now is the time to use these lessons in
the QuIC recognizes that errors occur in all sectors of health
care, not just hospitals, and in all types of care, including
prevention, diagnosis, drug therapy, anesthesia, surgery,
the Nation’s response to errors should emphasize opportunities
to learn from errors in order to avoid future errors. The
QuIC believes that Government can assist health care institutions
to develop appropriate systems for capturing such knowledge,
which will require some degree of confidentiality to operate
Federal and State governments have the responsibility to ensure,
through mandatory public reporting, that the Nation can determine
whether health care institutions have met an adequate standard
of patient safety. Public reporting of both certain types
of errors and the use of proven error-reduction techniques
would provide the Nation with information that is needed to
make choices about where to seek health care.
the QuIC agrees with the IOM on the importance of launching
patient safety initiatives within the context of the roles
of the Federal Government in health care quality, as purchasers,
program funders, research agencies, regulators, patient advocates,
and providers of care.
to the President focuses on the roles that the Federal Government
can and should play in the development and implementation
of systemic solutions for avoiding medical errors. The Federal
Government, in partnership with State and local governments
and the private sector, can lead the way toward reaching this
chapters describe the steps that QuIC’s member agencies are
taking to assure patient safety. These steps can serve as
a framework for developing a national strategy to reduce errors
and variations in health care practices so that Americans
not only get the best health care in the world, but the best
health care possible.
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