patient safety report to congress annual

What is AHRQ publication 22-0009?

AHRQ Publication No. 22-0009. In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress.

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.

WHO reports patient safety to Congress?

Final Report to Congress To Improve Patient Safety Outlines Strategies To Speed Progress. A 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 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 is global patient safety?

Global Patient Safety takes a comprehensive and rigorous approach to pharmacovigilance activities. We are dedicated to establishing, maintaining, and communicating quality safety information throughout the life-cycle of Amgen products.

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.

What is the Cahps survey?

CAHPS® Surveys CAHPS surveys follow scientific principles in survey design and development. The surveys are designed to reliably assess the experiences of a large sample of patients. They use standardized questions and data collection protocols to ensure that information can be compared across healthcare settings.

Is AHRQ part of NIH?

The Agency for Healthcare Research and Quality (AHRQ; pronounced "ark" by initiates and often "A-H-R-Q" by the public) is one of twelve agencies within the United States Department of Health and Human Services (HHS)....Agency for Healthcare Research and Quality.Agency overviewFormed198911 more rows

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 are the 7 National patient safety Goals?

What Are the 7 National Patient Safety Goals for Hospitals in 2021?Identify patients correctly. ... Improve staff communication. ... Use medicines safely. ... Use alarms safely. ... Prevent infection. ... Identify patient safety risks. ... Prevent mistakes in surgery.

What are the 6 International patient safety Goals?

The six International Patient Safety Goals are:Goal 1 - Identify Patients Correctly.Goal 2 - Improve Effective Communication.Goal 3 - Improve the safety of high-Alert Medications.Goal 4 - Ensure correct Site, Correct Procedure, Correct Patient Surgery.Goal 5 - Reduce Risk of Health Care-Associates Infections.More items...•

How is patient safety measured?

There are at least two well-established patient safety measurement systems available for use in the inpatient setting, namely the administrative data-based Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) and the medical record-based National Surgical Quality Improvement Programme ( ...

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 is the IOM report?

Recommendations made by the Institute of Medicine (IOM, now the National Academy of Medicine) in its landmark report To Err Is Human: Building a Safer Health Care System1 (referred to here as the IOM Report) were the impetus for the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act).2 The IOM Report brought attention to the problem of adverse events in the U.S. healthcare system, and it issued a call to action to incorporate safety principles used in other high-risk industries to make healthcare safer.

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 is the IOM report?

Recommendations made by the Institute of Medicine (IOM, now the National Academy of Medicine) in its landmark report To Err Is Human: Building a Safer Health Care System1 (referred to here as the IOM Report) were the impetus for the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act).2 The IOM Report brought attention to the problem of adverse events in the U.S. healthcare system, and it issued a call to action to incorporate safety principles used in other high-risk industries to make healthcare safer.