patient safety report congress

What does patient safety stand for?

What does Patient safety mean? Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often leads to adverse healthcare events.

What are the JCAHO patient safety guidelines?

The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable.

What is the goal of national patient safety?

The seven 2019 National Patient Safety Goals for hospitals provide a guideline to combat those issues that stood out most recently. 2019 Patient Safety Goals. National patient safety goals for hospitals that became effective in January of 2019 include: Improving patient identification; Cultivating communication among caregivers

How to ensure patient safety in a healthcare setting?

• providing global leadership and fostering collaboration between Member States and relevant stakeholders
• setting global priorities for action
• developing guidelines and tools
• providing technical support and building capacity of Member States
• engaging patients and families for safer health care
• monitoring improvements in patient safety

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Who provides a report of patient safety to Congress?

the U.S. Department of Health and Human ServicesA final report (PDF, 1.16 MB) on strategies to improve patient safety and reduce medical errors has been delivered to Congress by the U.S. Department of Health and Human Services in consultation with AHRQ.

What is a patient safety report?

Patient Safety Reporting (PSR) gives military treatment facility personnel the ability to anonymously report medical events that impact the safety of patients.

What is the Patient Safety and Quality Improvement Act of 2005?

The Patient Safety and Quality Improvement Act of 2005 (PSQIA) establishes a voluntary reporting system designed to enhance the data available to assess and resolve patient safety and health care quality issues.

What is a federal patient safety organization?

The Patient Safety Organization (PSO) program established federally recognized PSOs to work with health care providers to improve the safety and quality of patient care. The program also creates the first and only comprehensive, nationwide patient safety reporting and learning system in the United States.

Why must a SI report be?

It is important that any incident suspected as a SI is notified to the Patient Safety Team as soon as possible. The notification ensures communication of incidents and the mobilisation of help and support. Even when it is decided an incident is not a SI the notification can be very valuable.

Why is patient safety reporting important?

It helps identify root causes: All healthcare incidents have a cause. The root causes must be identified—and corrected—to try to prevent adverse events from recurring. A patient incident report is a detailed, written account of the chain of events leading up to an adverse event.

Is the Patient Safety and Quality Improvement Act a federal law?

The Patient Safety and Quality Improvement Act signifies the Federal Government's commitment to fostering a culture of patient safety. It creates Patient Safety Organizations (PSOs) to collect, aggregate, and analyze confidential information reported by health care providers.

What reports are encouraged as a result of the Patient Safety and Quality Improvement Act?

What reports are encourage as a result of the patient safety and quality improvement act? near misses, unsafe conditions, adverse events, events the threaten patient safety.

Is Patient Safety a right or privilege?

Medical Malpractice and Professional Liability Defense To further this goal, Congress passed the Patient Safety and Quality Improvement Act of 2005 (“PSA”), which provides the protection of privilege to documents created as part of patient safety efforts in patient safety organizations.

What organization is responsible for patient safety?

A Patient Safety Organization (PSO) works with healthcare providers to help them improve patient safety and healthcare quality and encourage a culture of safety.

What organizations are leading the charge for patient safety?

The Agency for Healthcare Research and Quality (AHRQ) is the lead federal agency charged with improving the quality and safety of America's health-care system.

What organizations are involved with patient safety?

Patient Safety Organizations (PSOs) collect and analyze data voluntarily reported by healthcare providers to help improve patient safety and healthcare quality. PSOs provide feedback to healthcare providers aimed at promoting learning and preventing future patient safety events.

What is the Patient Safety Act?

The Patient Safety Act requires the Secretary of HHS to create and maintain a network of patient safety databases (NPSD) that provides an interactive, evidence-based resource for providers, PSOs, and other entities with the capacity to accept, aggregate, and analyze nonidentifiable patient safety work product voluntarily reported by PSOs, providers, and other entities. The statute also addresses data standards and use of data. It authorizes the Secretary to develop common formats, including common and consistent definitions, so that data collected from different sources can be aggregated for analysis of national and regional statistics, including trends and patterns of healthcare errors. Information resulting from the analyses is available to the public.

What is the Patient Safety and Quality Improvement Act?

As required by the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), the Secretary of the Department of Health and Human Services (the Secretary), in consultation with the Director of the Agency for Healthcare Research and Quality (AHRQ), has prepared this draft report on effective strategies for reducing medical errors and increasing patient safety. The report also includes measures to encourage the appropriate use of such strategies. The Patient Safety Act specified that the draft report be made available for public comment and review by the Institute of Medicine, now the National Academy of Medicine.

What are high reliability organizations?

Organizations that consistently avoid accidents despite operating in complex, high-risk environments are described as “high-reliability organizations (HROs).”18 Industries that exemplify high reliability include commercial aviation and nuclear power. These industries share several characteristics that help them maintain safety. Among them is a preoccupation with failure. Because they operate in environments where inattention to safety threats can have catastrophic effects, HROs are exceptionally vigilant, always scanning the environment for any sign of a problem. They treat every incident and close call as an opportunity to learn, and they encourage reporting of errors. A well-functioning safety culture, including a clear and just process for distinguishing between unintentional errors and blameworthy conduct, is a prerequisite to high reliability.19

What is the system approach to safety?

The basic premise of a systems approach13 to safety is that accidents and errors stem from a combination of human and system failures. While humans are fallible, the systems in which they operate can either contribute to or help prevent human error and associated harm. The key to prevention, then, is to identify and address factors in the system that contribute to or fail to prevent adverse events or to mitigate harm when adverse events do occur. Applied to healthcare, the systems approach expands the focus of analysis beyond the provider when an adverse event occurs to include an examination of flaws in the surrounding system that facilitated or failed to prevent the adverse event.

What is a PSO?

The Patient Safety Act establishes the process for entities to be certified and listed as PSOs. The statute details the types of entities excluded from becoming listed as a PSO and the requirements an entity must meet to become a PSO, or to form a component PSO, and to maintain its Federal listing. For initial listing, the entity must have policies and procedures to perform defined patient safety activities and must meet certain criteria. For example, the entity’s mission and primary activity must be to conduct activities that improve patient safety and quality of healthcare delivery, and it must have an appropriately qualified workforce, including licensed or certified medical professionals. During its period of listing, a PSO must meet additional requirements, such as certifying within specified timeframes that it has at least two bona fide contracts with providers. The statute specifies the process the Secretary must follow in making listing decisions, addressing PSO deficiencies, and when necessary, revoking a PSO’s listing. It also addresses public notice requirements and issues related to disposition of protected data when a PSO is no longer listed.

How does clinical encounters generate data?

Every day, clinical encounters generate data pertaining to healthcare procedures and patient outcomes. When these data are systematically collected and analyzed, the results can point to risks and hazards in healthcare delivery and contribute to the evidence on safe practices. In a learning health system, that evidence is aligned with safety culture and the mission of healthcare organizations to drive improvements in clinical practice. Figure 2 illustrates the continuous feedback loop wherein data generates evidence, evidence informs practice, and ongoing research supports the cycle of improvement.

What are the strategies and practices used in the provision of care?

The strategies and practices presented in this section are defined as “discrete and clearly recognizable structures and/or processes used during the provision of care that are intended to mitigate the effects” of various threats to patient safety.58 All were evaluated for effectiveness based on the quality and extent of the evidence as published in peer-reviewed journals and other relevant literature in one or more of AHRQ's three MHS reviews, published in 2001, 2013, and 2020. This body of work has collected, critically reviewed, and in 2013 and 2020, provided selected updates on the existing evidence base for many of the strategies and practices that are in use to reduce medical error and increase patient safety. These reports, while not all-inclusive, together create a compendium that captures and addresses many of the patient safety strategies and practices in use and have been the subject of a systematic review for evidence of effectiveness. Patient safety experts and stakeholders assisted with topic selection for each report.

What is the purpose of reporting patient safety events?

The reporting of all patient safety events, even those that don’t reach the patient, allows the DoD PSP to identify, analyze and learn from the sequence of events that may potentially lead to errors before they affect patients.

What is the DoD PSP?

The DoD PSP's Patient Safety Analysis Center, analyzes the reported data and additional data sources to provide cumulative data reports and feedback to the military treatment facilities through the services. These analyses are then used to design and develop programs and tools to assist the MTFs in reducing preventable harm and improve safety throughout the direct care system.

How to access PSLC?

To access in the PSLC, log into LaunchPad and search “PSLC” in the upper right corner search bar. Choose “PSLC Home” from the results list. Then click “Patient Safety Resources” from the left menu on the PSLC landing page. From the Resources page, click “Joint Patient Safety Reporting” under the Equip column.

Public Comment Period Extended for Strategies To Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine

This table of contents is a navigational tool, processed from the headings within the legal text of Federal Register documents. This repetition of headings to form internal navigation links has no substantive legal effect.

AGENCY

Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (HHS).

SUMMARY

As required by the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act), the Secretary of HHS (the Secretary) is making this draft report on effective strategies for reducing medical errors and increasing patient safety available to the public for review and comment. Through this notice the comment period is extended.

ADDRESSES

The draft report, Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine, can be accessed electronically at the following HHS website: https://pso.ahrq.gov/​legislation/​act. Comments on the draft report must be submitted by email to PSQIA.RC@ahrq.hhs.gov.

SUPPLEMENTARY INFORMATION

The Secretary, in consultation with the Director of AHRQ, has prepared a draft report on effective strategies for reducing medical errors and increasing patient safety as required by the Patient Safety Act.