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Improved Patient Safety

Sharing Issues, Successes, and Challenges Across States

A Workshop for State Patient Safety Teams

The 1999 release of the Institute of Medicine's (IOM) report To Err is Human focused public attention on the important issue of patient safety within our health care system. It cited medical errors as the fourth leading cause of death, accounting for up to 98,000 hospital deaths in hospitals alone at a cost of more than $29 million each year. To address this problem, the report urged that action be taken at the Federal, State, and community level by both the public and private sector. It called for the careful alignment of regulatory, economic, professional, and other incentives; the expansion of the current knowledge base; and the development of appropriate tools and strategies to identify and eliminate the causes of medical errors.

This workshop was designed for teams of senior health policy leaders from State-based patient safety organizations, State governments, hospitals with patient safety programs, and other private and/or public patient safety organizations interested in improving patient safety in their States and jurisdictions. The overall goal of the workshop was to share new knowledge, tools, and strategies that States could use to develop and implement effective programs and policies to improve patient safety in their health care system.

The following is a summary of the workshop, which was held in Seattle, Washington, on June 2-4, 2003.

About the Workshop Sponsor.


Summary of Key Workshop Themes

AHRQ Update

AHRQ supports a wide variety of research, tool development, information dissemination, and support activities to reduce medical error and improve patient safety in the United States. Some of the activities/initiatives highlighted include patient safety indicators, the use of information technology to improve patient safety, WebM&M, Patient Safety Improvement Corps, and Safe Practices Implementation Challenge Grants.

Highlights of Other Initiatives

In addition to AHRQ's efforts in the area of patient safety, a number of other important patient safety-related activities are being pursued by Federal government agencies, such as the U.S. Food and Drug Administration, and national organizations (i.e., the Institute of Medicine and the National Quality Forum). Two pieces of legislation addressing patient safety issues are also under consideration by the U.S. Congress.

A Framework for Addressing Medical Errors

The "Just Culture" offers a framework for designing a disciplinary system where health care providers and others are willing to come forward with information related to medical errors in a way that allows them to learn from their mistakes, while at the same time recognizing the need for accountability.

State Reporting: Issues and Activities

State-based systems for reporting medical errors provide a valuable tool for improving patient safety at the State and facility levels. Over 20 States have established some type of error reporting system. An important objective of many of these systems is to generate and share information that can be used for quality improvement purposes. New York and Utah offer two unique examples of State-based medical error reporting systems.

Other Promising Practices

In addition to establishing reporting systems, States have pursued a variety of approaches to improve patient safety, including educational efforts directed at providers, policymakers, and patients and their families, and efforts to promote and share information on best practices that reduce the risk of errors.

Developing a Patient-Safety Culture

States and health care organizations can use two surveys to measure and assess the attitudes and experiences on key patient safety issues in their facilities. Another resource, "Nothing About Me Without Me," offers a roadmap for developing a patient-centered culture of safety.

Patient Safety: An Innovative Approach

One hospital's experience in designing and building a new facility using patient safety as a blueprint offers insights and lessons for designing a safe facility, reconfiguring work processes and systems, incorporating state-of-the-art technology and equipment, and making changes to the physical environment.

Finding Support and Resources

Other high priority Federal initiatives in areas such as bioterrorism and quality improvement represent useful vehicles and potential funding streams through which patient safety can be addressed.

State Action Steps

State teams discussed steps they could take to build on the momentum generated at the workshop, reduce medical errors, and improve patient safety are discussed.

AHRQ's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.

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