Patient Safety and Quality Improvement

Patient Safety And Quality Improvement Act. Public Law 109-41. 109th Congress 2005. 

Department of Health and Human Services. Patient safety and quality improvement final rule. 2008. 

US Congress 2005. Patient Safety and Quality Improvement Act of2005, S. 544, enacted by the 109th Congress. Washington US Government Printing Office. 

Darzi Fellow in Patient Safety and Quality Improvement, Great Ormond Street Hospital, London, England... 

Patient Safety Organizations (PSOs) were created by the Patient Safety and Quality Improvement Act to improve the quality and safety of healthcare by encouraging clinicians and healthcare organizations to voluntarily report patient safety events without fear of legal discovery. PSQs offer a secure environment to identify and reduce the risks associated with patient care. As independent, external experts, PSOs collect, analyze, and aggregate patient safety data locally,... 

US patient safety and quality improvement act, 2005, http //www.ahrq.gov/qual/psoact.htm. 

The Safer Patients Initiative (SPI) is one of the most ambitious programmes of safety and quality improvement yet attempted. It was ambitious partly in scale, in that 24 hospitals were involved in total, but more in the speed of implementation and the bravura of the objeaives. Studies in many countries have shown that about 10% of patients are harmed in hospitals and that there is little sign of any change over time. Yet the SPI programme boldly set out to achieve a 50% reduction in adverse events in two years, as well as a range of other changes. No one knew whether this was achievable or simply naive SPI was, in the best sense, a gigantic experiment. 

This council was established by the Australian govertunent in January 2000 to provide leadership in improving patient safety and quality through advice to all federal, state, and territory health ministers for a five-year term. Its three main specific goals were as follows ... 

Walsh, K., Antony, J., Improving on Patient Safety and Quality What Are the Challenges and Gaps in Introducing an Integrated Electronic Adverse Incident and Record System within Health Care Industry., International Journal of Health Care Quality Assurance, Vol. 20, No. 2,2007, pp. 107-115. 

Simulation-based education (SBE) has been introduced as an efFective method for training healthcare workers [1]. SBE can improve patient safety in healthcare facilities in different ways, particularly if used in individual skills [2]. As a result of the proven efficacy of SBE, there has been an increased number of simulation centers worldwide. These centers have various visions, purposes, and functionahties. Most of them are tailored to deliver education to particular healthcare giver categories or undergraduate trainees, with the end result being better training, reduced medical errors, and thus improved patient safety and quality of care in many medical domains. 

Quality me a.t are merit and improvement requires developing and testing quality measures and investigating the best ways to collect, compare, and communicate these data so they are useful to decision makers. AHRQ s research emphasizes studies of the most effective ways to implement these measures and strategies in order to improve patient safety and healthcare quality. 

To enhance the quality, appropriateness, and effectiveness of health care services, and access to these services the federal government in the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) established the AHCPR. The act, sometimes referred to as the Patient Outcome Research Act, called for the establishment of a broad-based, patient-centered outcomes research program. In addition to the traditional measures of survival, clinical endpoints and disease- and treatment-specific symptoms and problems, the law mandated measures of functional status and well-being and patient satisfaction. In 1999, then President Clinton signed the Healthcare Research and Quality Act, reauthorizing AHCPR as the AHRQ until the end of fiscal year 2005. Presently, its mission is to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors, broaden access to effective services, and improve the quality of health care services. 

Issues of case mix adjustment matter much less however, if a unit or institution simply wishes to track its own progress over time and use the mortality or morbidity data as a stimulus and measure of improvement. If one makes the reasonable assumption that the patient population is relatively stable over time, then an organization can certainly use mortality or morbidity data as an indicator (Bottle and Aylin, 2008). Any change does reflect, albeit imperfectly, a corresponding change in safety and quality, though it may be difficult to identify which improvements were critical to the overall success. 

We are now at a transitional point in the book between the understanding and analysis of incidents and the coining chapters, which discuss methods of prevention and quality improvement. The seven-levels framework has outlined the patient, task and technology, staff, team, working environment, organizational and institutional environmental factors that are revealed in analyses of incidents. These same factors also point to the means of intervention and different levels on which safety and quality must be addressed, which we will explore systematically as the book unfolds. 

One of the challenges of understanding and improving safety and quality is to capture the full range of events that occurs during a patient s journey through healthcare. Clearly a complete description is not feasible, but we would at least like to capture the most important experiences and incidents. Medical records contain some of this information bnt are only a summary of key events and decisions. Interviews with staff can prodnce more detail but, as they have lives to lead and need to sleep periodically, they too have only a partial picture. The hospitalized patient on the other hand is there all the time, with little to do except watch and wait. Potentially therefore, they are an ideal observer. 

Catchpole, K.R., de Leval, M.R., McEwan, A. etai. (2007) Patient handover from surgery to intensive care using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatric Anaesthesia, 17(5), 470-478. 

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