Patient Safety Board

Hansen LB, Fernald D, Akaya-Guerra R, et al. 2006. Pharmacy clarification of prescriptions ordered in primary care A report from the Applied Strategies for Improving Patient Safety (ASIPS) collaborative. J Am Board Fam Med 19 24-30. 

Human Investigation Review Board Infection Control Patient Safety and Quality Pharmacy and Therapeutics... 

In a double-bUnd, randomized, placebo-controlled, crossover study of a single oral dose of sparfloxacin in 15 healthy volunteers, prolongation of the QT interval was about 4% greater with sparfloxacin than with placebo (10). An independent Safety Board concluded from the results of various phase I and phase II studies that the increase in the QT . interval associated with sparfloxacin is moderate, averaging 3%, and that the few serious adverse cardiovascular events that have been reported during postmarketing surveillance all occurred in patients with underlying heart disease (11). 

Significant deficiencies in the security and control of samples have been well documented. " " In fact, it has been estimated that just over half of samples actually reach patients. Samples may be used by prescribers and staff, or they may be diverted. Personal use of drug samples by physicians and other healthcare providers raises ethical concerns and is not without risk." Limaye and Paauw described three medical residents who self-prescribed antimicrobials and were subsequently diagnosed with Clostridium difficile infection." Tong and Lien reported self-medication with samples and distribution of samples to nonphysicians by almost 60% of pharmaceutical representatives surveyed at a Canadian family practice office. A contributing factor to some of these issues is that institutional or facility sample policy and procedures are often absent, or compliance is poor. One institution found only 10% compliance when the inventory of samples was compared with the required written documentation. Even after an educational program in which the policy was explained to the house staff, a second audit found only 26% compliance. " Poor compliance with policy and procedure may jeopardize patient safety, as well as put the institution at risk for JCAHO recommendations or Board of Pharmacy penalties. 

In 1999, the Board of Commissions established an Oversight Task Force for the Accreditation Process Improvement (API) Initiative. The purpose is to oversee the continuous improvement in the accreditation process. The resulting changes are intended to enhance the evaluation of critical patient safety and patient care functions and to achieve an accreditation process that remains consultative and focused on performance improvement. A white paper was published outlining a future operational model that will continue to build and expand on technology, performance data, presurvey self-assessments, a fully automated interface with JCAHO, increased surveyor development, and a more continuous accreditation process. Instead of a once every 3 years site visit, two 18-month site visits would occur that evaluate select standards. In addition, since health care entities are so diverse, there is a desire to create a model that is more data driven, less predictable, and more customized to an individual organization. 

Create an accoimtability system (such as reports to the board) for patient safety. 

Chapter Four returns to the patient safety manifesto and continues with the committment Assume executive responsibility. This chapter focuses on what it looks like to accept responsibility on a personal and organizational level, whether in a clinical discipline, a department, a clinic, a single hospital, a large system of care, in the academic health sciences, or on a governing board. 

Routinely bring patient safety matters, trending data, and specific cases to the board and other hospital leadership committees. 

Accountability to patients and families in the face of medical accident is a hallmark of a safety culture. The organization committed to creating a patient safety culture, through its board and its CEO, has in place pohcies, processes, and... 

The board of directors endorsed a policy of full disclosure to families as part of the overall patient safety agenda. The policy states, Children s Hospitals and... 

Timeline for Event Analysis. The determination of a sentinel event must be initiated within the first forty-eight hours after notification of the accident/event has taken place and the initial fact finding has commenced. The causal analysis needs to be completed as soon as possible, to preserve an accurate account of events, discover the multiple factors contributing to the accident, and decrease system vulnerabilities for other patients. Generally, the initial summary report to the professional executive council, the patient safety steering committee, the board of directors, and the quality oversight committee should be completed within thirty days, but not later than forty-five days after notification of the event. 

Board of Directors. The Office of Patient Safety notifies the chief executive officer, who communicates to the board of directors aU sentinel events. This communication is privileged under the board of directors responsibility for overall quality of care at TTte Healih Care Organization. 

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