report on status of patient safety to congress

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. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine.

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What is the Patient Safety Act?

What is the Patient Safety and Quality Improvement Act?

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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.

Which entity is mandated to provide a report on the status of patient safety to Congress each year?

Congress vested the authority for implementing the Patient Safety Act with AHRQ by incorporating its provisions into AHRQ's authorizing statute. As the lead Federal agency for patient safety research, AHRQ is an appropriate partner for PSOs and healthcare providers.

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 are the 5 factors to be crucial to patient safety?

5 Factors that can help improve patient safety in hospitalsUse monitoring technology. ... Make sure patients understand their treatment. ... Verify all medical procedures. ... Follow proper handwashing procedures. ... Promote a team atmosphere.

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.

Which created patient safety organizations PSOs to collect aggregate and analyze confidential information reported by health care providers?

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.

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.

How do you write a patient report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

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.

How can we improve patient safety?

Hospitals can ensure patient safety and prevent untoward harm to patients who seek treatment with these steps.Enforce strict disinfection protocols. ... Use advanced monitoring equipment. ... Verify all medical procedures. ... Observe care in handling medicines. ... Review staffing policies. ... Work with trusted providers.

What are examples of patient safety?

The Nurse's Role in Patient SafetyIdentify “wrong site, wrong procedure, wrong patient” errors. High quality hospitals view nurses as the physician's partner in avoiding errors such as these. ... Catch medication mistakes. ... Educate patients about their medications. ... Reduce patient falls. ... Monitor patients for deterioration.

How can we improve safety and quality of care?

5 Patient-Centered Strategies to Improve Patient SafetyAllow patients access to EHR data, clinician notes. ... Care for hospital environment. ... Create a safe patient experience. ... Create simple and timely appointment scheduling. ... Encourage family and caregiver engagement.

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.