National Patient Safety Foundation

It s a promising way to automate aspects of medication administration, says Robert Krawisz, former executive director of the National Patient Safety Foundation. The technology s impact at VA hospitals so far has been amazing. The Department of Veterans Affairs (VA) already uses bar codes nationwide in its hospitals, and the result has been a drastic reduction in medication errors. For example, the VA medical center in Topeka, Kan., has reported that bar coding reduced its medication error rate by 86 percent over a nine-year period. 

Gaba DM. Physician work hours the sore thumb of organizational safety in tertiary health care. In Scheffler AL, Zipperer LA, eds. Enhancing Patient Safety and Reducing Errors in Health Care. Chicago National Patient Safety Foundation, 1998 302-305. 

The importance of a comprehensive specimen identification system throughout the clinical laboratory cannot be understated. Both the College of American Pathologists (CAP) (1) and The Joint Commission (JCAHO) (2) have addressed this important subject with directives that address the pre-analytical, analytical and post-analytical phases of specimen processing. These patient safety initiatives date back to the 1990 s and the formation of the National Patient Safety Foundation (3). These mandates have become the backbone of most laboratories Quality and Safety Programs and offer an excellent foundation for procedures that assure the safe and accurate identification of patient specimens throughout the analysis and reporting of critical laboratory tests. 

The National Patient Safety Foundation Website http //www.npsf.org/... 

Collaborative work toward error prevention with the American Hospital Association (AHA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Coordinating council on Medication Error Reporting and Prevention (NCCMERP), the National Patient Safety Foundation (NPSF), the United States Pharmacopeia (USP), and dozens of other consumer and professional organizations. 

The process-improvement approach to system safety evolved from an expert workshop and continuing dialogue on patient safety sponsored by the National Patient Safety Foundation (NPSF). ° This line of thinking says that study of the ultimate (rather than just the proximate) source of errors and ADEs is needed. Reason first developed the idea that harmful patient outcomes are the result of latent, small degradations within a system com-... 

Runkle, D.C. The Scientific Investigation of Avoidable Patient Injury Two Approaches. In Proceedings of Enhancing Patient Safety and Reducing Errors in Health Care Schettler, A.L., Zipperer, L.A., Eds. National Patient Safety Foundation Chicago, 1998 51-52. 

Cook, R.I. Woods, D.D. Miller, C. A Tale of Two Stories Contrasting Views of Patient Safety National Patient Safety Foundation Chicago, 1998. 

NATIONAL PATIENT SAFETY FOUNDATION. REPRINTED WITH PERMISSION OF NPSF. ALL RIGHTS RESERVED)... 

United States National Patient Safety Foundation (2000) Agenda for research and development in patient safety. http /www.npsf.org/pdf/r/researchagenda.pdf. 

Berwick, D. (1999) Taking artion to improve safety. How to improve the chances of success, in Enhancing Patient Safety and Seducing Errors in Healthcare, National Patient Safety Foundation, Chicago IL, pp. 1-11. 

It appears that the modern patient safety movement started in 1991 with the publication of the results of the Harvard Medical Practice Study in the New England Journal of Medicine [2-4], In the study, the medical records of 30,000 patients hospitalized in acute care hospitals in New York State in 1984 were examined. In 1996, the American Medical Association announced the formation of the National Patient Safety Foundation [2], In 1999, the National Academy of Sciences Institute of Medicine released its report entitled "To Err Is Human Building a Safer Health System" [5]. The report stated that medical errors are causing 44,000-98,000 preventable deaths annually in the United States. In 2001, the United States Congress appropriated 50 million per year for patient safety research to the Agency for Healthcare Research and Quality (AHRQ) [2],... 

Proceedings of the Annual National Patient Safety Foundation Congress... 

National Patient Safety Foundation, 132 Mass Moca Way, North Adams, Massachusetts, 01247. 

Research and Quality in the United States, the National Patient Safety Agency in the United Kingdom, and the World Alliance for Patient Safety launched by the World Health Organization (WHO) in October 2004. Similarly, three examples of the independent organizations are the National Patient Safety Foundation in the United States, the Canadian Patient Safety Institute in Canada, and the Australian Patient Safety Foundation in Australia. 

Cook, R. I., Woods, D. D., A Tale of Two Stories Contrasting Views of Patient Safety, Report from a Workshop on Assembling the Scientific Basis for Progress on Patient Safety, National Health Care Safety Council of the National Patient Safety Foundation at the AMA, Chicago, Illinois, 2000. 

The goal is not to eradicate all risk but rather to make it transparent and learn from it, mitigate it, in order to prevent harm in the delivery of care. As National Patient Safety Foundation leaders state, Fimdamental misimderstandings about... 

Understanding the Consumer s View. In 1997, the National Patient Safety Foundation commissioned a survey of how the public perceives risk when interacting with the health care system. Of those who responded, 42 percent reported that either they or someone they knew had experienced an injury when visiting a physician s office (Louis Harris and Associates, 1997). Studies by the Kaiser Family Foundation and the Commonwealth Fund support these results. A 2002 Kaiser Family Foundation survey found that one-third of U.S. physicians reported that they or a family member had been harmed by medical error (Blendon and others, 2002). The Commonwealth Fund found that one in ten consumers reported... 

Louis Harris and Associates (National Patient Safety Foundation, 1997) Telephone survey of 1,513 adults 42 percent of Americans reported they or a family member had experience a medical error of some kind. 

Source K. Luther, Zone Strategy Knowing Your Zone Keeps Patients Safe (Chicago National Patient Safety Foundation, 2001). Used by permission. 

As items for "Children s Safetylist," an e-mail distribution list edited by James Levin that also distributes stories from outside the Children s system as well as alerts and advisories from the Food and Drug Administration, the Centers for Disease Control, the National Patient Safety Foundation, and state public health departments (anyone can subscribe to the e-mail list by visiting www.createsafety.net). 

These sessions are now being replicated in Minnesota, where leaders came together with the support of Harvard University, the National Patient Safety Foundation, and the Minnesota Hospital Association to create a threshold improvement in patient safety. The results of the session are summarized as follows... 

Denham, C. The Economics of Honesty Is There a Business Case for Transparency and Ethics Presentation at the National Patient Safety Foundation Congress, Washington, DC., March 2003. 

Louis Harris and Associates. Public Opinion of Patient Safety Issues Research Findings. Chicago National Patient Safety Foundation, 1997. [http //www.npsf.org/download/... 

National Patient Safety Foundation Statement of Principle... 

The National Patient Safety Foundation urges all health care professionals and institutions to embrace the principle of dealing honesdy with patients. 

Source National Patient Safety Foundation Focus on Patient Safety. 2001 4 l) 3. 

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