Patient safety reports

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. 

In addition to being reviewed by interested groups, departments, or committees, the knowledge gleaned from patient safety reports is used in a variety of other ways ... 

Use an organizationwide data warehouse to study the epidemiology of patients at risk for accidents. The Children s system has plans to analyze patient safety reports for the information they can offer about how characteristics specific to a patient can increase the likelihood of risk-prone conditions in the environment. For example, the data warehouse can track patients ages, diagnoses, and admission times. Thus, if the data show that staff members report more concerns when patients who have complex, multiple diagnoses are admitted on weekends, then protocols and procedures for those patients can be modified to prevent harm. 

A strong system of reporting, crucial to the success of SATs, includes the patient safety report. The report is a narrative, text-based report that encourages staff members to identify errors and latent conditions in the environment before they manifest in an accident. The Office of Patient Safely receives reports and screens them to identify those requiring an immediate response. Reports are entered into a database and distributed to SATs for review, discussion, and action. All safety reports are entered into a safety database, so that the data can be analyzed for detection of patterns and identification of trends. These analyses inform organizational priorities. 

EMDICATOR S-l Total system-wide patient safety reports submitted electronically. 

DEFINITION— includes all locations. Includes aU types of patient safety reports. 

Patient Safety Reporting System (PSRS) (6) A prototype blameless reporting system established in 2000 by NASA and the Veterans Administration. The PSRS emphasizes the reporting of near misses (see definition above). 

Safety, patient safety, sentinel event, medical accident, near miss, good catch, Office of Patient Safety, JCAHO, focused event analysis, disclosure, peer review, confidentiality, maltreatment of minors, root cause analysis, patient safety report, accident, documentation... 

The Patient Safety Reporting System (PSRS) is a program modeled on the Aviation Safety Reporting System and developed by the U.S. Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports. 

Patient Safety Reporting System. Online at http //www.psrs.arc.nasa.gov/programoverview/ index.html... 

External Patient Safety Review (Robson Report) - June 2004. http //www. calgaryhealthregioaca/qshi/patientsafety/reports/patient safety reports.htm, accessed 6 January 2006. 

Health (Quality Council of Alberta (HQCA) (2004). Review of Best Practices for HandhngPotassium Chloride ContainingProducts inHospitals, and the Preparation of Batch Amounts of Dialysis Solutions for Continuous Renal Replacement Solutions, Health Quality Council of Alberta http //www.calgaryhealthregion.ca/ qshi/patientsafety/reports/patient safety reports.htm, Accessed 6 January 2006. 

Nesiritide has been shown to improve symptoms of dyspnea and fatigue. In a randomized clinical trial, the safety and efficacy of adding nesiritide to standard care was compared to placebo and nitroglycerin.53 Nesiritide was found to significantly decrease PCWP more than nitroglycerin and placebo over 3 hours. Nesiritide improved patients self-reported... 

All health care personnel should be strongly encouraged to receive the influenza vaccine yearly in order to prevent transmission of influenza within the health care facility and to decrease employee absenteeism for influenza-related reasons. The vaccine should be made available to employees at the workplace, free of charge. Employees should be asked to sign a declination if refusing to receive the influenza vaccine. Additionally, health care facilities should report the number of health care personnel receiving influenza vaccine as a patient safety measure.19... 

The number on the outside of the case is required to be numeric or alphanumeric, not the name of the patient. Patient names are not permitted to be publicly disclosed in the context of a MedWatch report according to 21 CFR 21.63(f). The initial report is the first reported information received by the company about an individual s adverse drug experience. There must be a prompt attempt to obtain follow-up information about each initial report. The attempt(s) are made according to the company s written procedures. If the written safety procedures are not followed, the safety reports are not appropriately submitted, or the safety records are not appropriately kept, FDA has the authority under Section 80 of Part 315 to withdraw the market NDA. The follow-up report is the format for submitting additional information about an experience. Each case regards only one individual unless the experience is both temporally and clinically unrelated to a second event experienced by the same person taking the same drug product. 

QulC, Report of the Quality Interagency Coordination Task Force (QulC) to the President. Doing What Counts for Patient Safety Federal Actions to Reduce Medical Errors and Their Impact, February 2000, Rockville, MD (http //www.quic.gov/report). 

Prevention of medication errors is the primary objective of the USP Medication Errors Reporting Program. It collects and analyzes potential and actual medication errors submitted by health care practitioners. The program affords health care professionals the opportunity to report medication errors and thereby contribute to improving patient safety by sharing their experiences. 

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. 

Safety and efficacy Expansion of the trial outlined above to six children affected by early onset ADA-SCID All patients were reported to be alive and healthy in the absence of enzyme replacement therapy. The degree of myelosuppression after conditioning ranged from mild (Pt2, Pt4 and Pt6) to short-term neutropenia (Ptl and Pt5), or more prolonged thrombocytopenia and neutropenia (Pt3). None of the patients experienced severe infections or adverse events 668664... 

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. 

Stelfox HT, Palmisani S, Scurlock C, et al. 2006. The To Err is Human report and the patient safety literature. 

Accuracy of the final study report—The role of CQA is essential at this phase of trial activity. The final study report must be audited for accuracy and consistency against a broad body of data. If a study is terminated early or extended beyond the protocol period, the final report must reflect all the safeguards employed to ensure both patient safety and data integrity. 

Lead CRA—The lead contract research associate is usually responsible for interfacing with field monitors and addressing investigator non-compliance. They review field reports provided by field staff- and determine adequate follow-up to problems that have been identified by the field staff"as well as investigators. Clinical QA must ensure that the lead CRA is adequately trained to respond comprehensively and in a timely manner. It must also be formally trained on the notification process required when patient safety or data integrity is in question. 

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. 

National Patient Safety Agency (2008) Rapid Response Report (NPSA/2008/ RRR001) Risks of incorrect dosing of oral anti-cancer medicines, 22 January. 

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