patient safety report to congress

Full Answer

Where can I find session recordings of the Patient Safety Congress?

Access session recordings: ihi.org/CongressLobby The Institute for Healthcare Improvement (IHI) Patient Safety Congress brings together people who are passionate about ensuring safe, equitable care for all.

What is the IHI Patient Safety Congress?

The Institute for Healthcare Improvement (IHI) Patient Safety Congress brings together people who are passionate about ensuring safe, equitable care for all. This must-attend, virtual event is for those who continue to shape ​​smarter, safer care for patients wherever it’s provided – from the hospital and outpatient settings, to the home.

Where can I find the Patient Safety Act?

View the Patient Safety Act in an on-line version of the United States Code ( 42 U.S.C. sections 299b-21 to 299b-26 ).

What is the patient safety and Quality Improvement Act?

The Patient Safety and Quality Improvement Act (Patient Safety Act) amended Title IX of the Public Health Service Act. The statute provides for the improvement of patient safety and the reduction of the incidence of events that adversely affect patient safety. See GPO.gov for online reference to the Patient Safety Act.

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 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.

What are examples of patient safety events?

Contracting an infection (think for example, of COVID-19) Fall incident, eg because the patient falls out of bed or is not mobile enough for a toilet visit. Wrong diagnosis and/or incorrect treatment plan.

What is AHRQ patient safety?

AHRQ is the lead Federal agency for patient safety research. Our work helps providers make care safer for patients. Connect with Patient Safety. Learn about Patient Safety. Patient Safety and Quality Areas.

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.

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.

What is a safety event report?

Despite its flaws, safety event reporting is an important tool for identifying system hazards and aggregate data, and sharing lessons within and across organizations. Systems can share known fail points in care, which allow other systems to identify that as a potential risk within their own organization.

Which types of events should be reported in a safety report?

Events that affect staff safety should be reported as well. Staff can also report “near miss” or potential events, things that were caught before patients or family members were impacted but that could have been a problem if the staff had not noticed in time.

Where are patient safety indicators reported?

It can be accessed at AHRQ's Quality Indicators Web site (http://www.qualityindicators.ahrq.gov/downloads.htm). The technical report for the third module, entitled Measures of Patient Safety Based on Hospital Administrative Data―The Patient Safety Indicators, is also available on AHRQ's Quality Indicators Web site.

Why is Ahrq important to healthcare organizations?

The Agency for Healthcare Research and Quality's (AHRQ) mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.

What are AHRQ indicators?

AHRQ Quality Indicators (AHRQ QIs) are standardized, evidence-based measures of healthcare quality that can be used with readily available hospital inpatient administrative data to measure and track clinical performance and outcomes.

What Attendees are Saying

"You get the opportunity to hear from those who have been successful in improving patient c​​are,​ specifically patient safety."

Call for Proposals

Highlight the work that you and your organization are doing to improve the safety of patients and those who provide care.

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.

When is the final report required for the Patient Safety Act?

The final report is required to be submitted to Congress no later than December 21, 2021.

What is the Patient Safety Act?

The Patient Safety Act requires the Secretary of the Department of Health and Human Services (HHS), in consultation with the Director of AHRQ, to prepare a draft report on effective strategies for reducing medical errors and increasing patient safety.

When was the Patient Safety and Quality Improvement Act passed?

On July 29, 2005, the President signed the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act, 42 U.S.C. sections 299b-21 to 299b-26) into law.

When is the public comment period for the Federal Register?

The Notice extending the public comment period was published in the Federal Register on March 18, 2021. The public comment period closed on April 5, 2021.

What is the Patient Safety Act?

The Patient Safety Act provides Federal legal privilege and confidentiality protections for information exchanged between healthcare providers and PSOs for the purpose of learning about how to improve patient safety. Patients’ rights to their medical information is not compromised.

What is the Patient Safety and Quality Improvement Act?

The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) was seminal legislation aimed at accelerating the Nation’s efforts to improve patient safety. Among other provisions, it allowed for the establishment of patient safety organizations (PSOs), which work with healthcare providers across organizational ...