Patient safety improved quality healthcare

Wreathall, J, Nemeth, C, 2004, Assessing risk the role of probabilistic risk assessment in patient safety improvement, Quality and safety in healthcare, 13 206-2. 

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. 

Woods, D.D. 2000a. Behind human error human factors research to improve patient safety. National Summit on Medical Errors and Patient Safety Research, Quality Interagency Coordination Task Force and Agency for Healthcare Research and Quality, September 11, 2000. www.apa.org/ppo/issues/shumfactors2.html. 

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,... 

In addition, the U.S. Department of Health and Human Services (HHS) and other federal agencies formed the Quality Interagency Coordination Task Force in 2000 and issued an action plan for reducing medical errors. In 2001, former HHS Secretary Tommy G. Thompson announced a Patient Safety Task Force to coordinate a joint effort to improve data collection on patient safety. The lead agencies are the FDA, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality. 

SIG (prescription instructions), and RxNorm (standard name, dose, and form availability) were not considered ready for implementation because of numerous approaches used in these three areas across health information technology. Electronic prescribing is not required under MMA, but plans are to have it available should providers choose to use it. As standards are developed, the adoption of e-prescribing is expected to improve patient safety by reducing prescribing and dispensing errors (Agency for Healthcare Research Quality, 2007). 

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. 

Since its establishment in 1989, AHRQ has sponsored and conducted research to improve the quality of health care, reduce its cost, and increase access. It also supports research to address patient safety issues and medication errors. AHRQ s goal is to provide information that allows people to make better decisions about healthcare. 

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. 

Healthcare, as with many other industries, is notorious for coming up with new initiatives which, on closer inspection, turn out to be remarkably similar to the old initiatives but with a new label. Some of the core ideas and concepts of patient safety could certainly be identified in earlier writings from the quality pioneers, though often in rather embryonic form. Safety however, did enrich the quality movement by bringing new force, new ideas and new approaches to bear on the shared quest to improve healthcare. Most importantly, we began to realize that patients were suffering much more than had previously been... 

Nieva, V.F. and Sorra, J. (2003) Safety culture assessment a tool for improving patient safety in healthcare organizations. Quality and Safety in Health Care, 12(Suppl. II), iiI7-ii23. 

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. 

DeRosier, J, Stalhandske, E, Bagain, J, Nudell, T, 2002, Using healthcare failure mode and effect analysis the VA national center for patient safety s prospective risk analysis system. Joint commission journal on quality improvement, 28 248-267. 

Berni, J., Koutantji, M., Wallace, L., Spurgeon, R, Rejman, M., Healey, A. and dncent, C. 2009. Feedback from incident reporting Information and action to improve patient safety. Quality and Safety in Healthcare, 18,11-20. 

While the focus of almost all studies included in this chapter was the adaptation of a patient safety cUmate measure from the USAto their own national and healthcare contexts, maity of the questions we will have to answer in future might be better addressed at a cross-national level. At the level of the survey instmment this would require a certain amount of consistency regarding the use of terminology and the addition or removal of items - a minimal shared item set. Taking cross-national similarities and differences into account (especially with regard to internal consistencies of the various safety climate dimensions) might help to improve further the overall quality of the HSPSC and to further our understanding of factors at the level of healthcare systems that may have a considerable impact on safety climate. 

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