who gives report on patient safety each year to congress

What has the agency done to advance patient safety?

Following are some highlights of the Agency's contributions in advancing patient safety during the past decade. These highlights are organized by year and by three key, ongoing challenges: Develop a solid evidence base. Design and evaluate useful strategies and tools. Disseminate information and tools for implementation.

What is the National Summit on medical errors and patient safety?

Later in 2000, under AHRQ leadership, that task force held a National Summit on Medical Errors and Patient Safety. The meeting focused on multistakeholder collaboration and input to be used by AHRQ in setting its patient safety research agenda.

What is who doing to improve patient safety?

WHO's work on patient safety began with the launch of the World Alliance for Patient Safety in 2004 and this work has continued to evolve over time. WHO has facilitated improvements in the safety of health care within Member States through establishment of Global Patient Safety Challenges.

What is the hospital survey on patient safety culture?

To assist organizations and their units in improving patient safety culture, AHRQ developed and releaed the Hospital Survey on Patient Safety Culture, a psychometrically tested and well-received survey instrument.

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 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.

Which government Agency is responsible for research into healthcare safety?

The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of healthcare for all Americans.

Which government Agency has a patient safety network?

AHRQ's Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits, opportunities for free CME and trainings.

Which governmental Agency monitors safety practices in the healthcare environment?

The FDA is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics, and products that emit radiation.

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.

Which level of government provides services for public health and safety?

The states have the primary constitutional responsibility and authority for the protection of the health, safety and general welfare of the population, and much of this responsibility falls on the state health departments.

Who is responsible for the oversight of healthcare facilities in the United States?

The federal agency that oversees CMS, which administers programs for protecting the health of all Americans, including Medicare, the Marketplace, Medicaid, and the Children's Health Insurance Program (CHIP).

Who runs Agency for Healthcare Research and Quality?

United States Department of Health and Human ServicesAgency for Healthcare Research and QualityAgency overviewAgency executivesRobert Otto Valdez, Director Dr. David Meyers, Deputy DirectorParent departmentUnited States Department of Health and Human ServicesParent agencyUnited States Public Health ServiceWebsitewww.ahrq.gov8 more rows

Who created patient safety organizations?

Joe KianiThe organization was founded in 2012 by Joe Kiani and is based in Irvine, California. Over the last 7 years, PSMF has gathered 4,710 hospitals over 46 countries.

What is the name of the committee that a hospital has to ensure patient safety in research projects?

the National Steering Committee for Patient SafetyAHRQ is co-leading the National Steering Committee for Patient Safety, which includes members from two dozen organizations that are joining together to create a national action plan to accelerate progress in reducing patient harm.

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.

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.

How many grants were awarded to lay the groundwork for reducing harm to patients?

With the research agenda and evidence report serving as points of departure, extensive work began to compile needed evidence. Nearly 100 grants were awarded to lay the groundwork for reducing harm to patients. The focus of these grants was to:

What is the Patient Safety and Quality Handbook?

Given the central role that nurses serve in patient care and the likelihood that they are among the first health care professionals to recognize errors and prevent harm to patients, the Agency teamed with the Robert Wood Johnson Foundation to develop and distribute a handbook for nurses entitled Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Even though working conditions may be less than optimal and the needs of patients are quite diverse, the opportunities for patient safety and quality improvement are clearly addressed. More than 22,000 copies of the three-volume handbook have been distributed to nursing schools and clinicians in the field.

What is AHRQ Advances in Patient Safety?

AHRQ released Advances in Patient Safety: From Research to Implementation as a way to share the progress occurring in the first half of the decade. The four-volume publication, comprising 140 articles, sought to bridge the gap between the research underway and its integration into practice. The compendium covered a wide range of research paradigms, clinical settings, patient populations, reporting systems, measurement and taxonomy issues, tools and technology, implementation challenges, safety culture, and organizational considerations. The volumes helped fuel efforts to improve patient safety and provided a measure of progress. More importantly, they also provided a sense of remaining challenges.

What is AHRQ grant?

AHRQ 's initial grants helped build a patient safety knowledge base and informed the Agency's thinking about the next steps it needed to take. As the knowledge base continued to evolve, it became clear that AHRQ needed to produce sound research studies and to ensure that the information, educational content, new approaches, and tools it provided were relevant to providers as they initiated their own patient safety improvement efforts. What follows is a brief description of some of the projects that were carefully designed, developed, and evaluated.

What is a PSIC?

In response to the need to expand the patient safety knowledge and skills of midlevel professionals responsible for investigating medical errors and initiating improvements, AHRQ partnered with the Department of Veterans Affairs' National Center for Patient Safety and began the first of four 9-mont h Patient Safety Improvement Corps (PSIC) training programs. Participants received training on tools and topics including analyzing root causes, analyzing health care failure modes and effects, applying human factors principles, assessing patient safety culture, and making a business case for patient safety. By the program's end, teams had been trained in every State, as well as the District of Columbia and Puerto Rico. Feedback the Agency received that PSIC graduates were, in turn, training their own personnel in patient safety principles acquired from the program provided evidence that this program represented a significant step in disseminating patient safety knowledge throughout the country.

What is the most common complication of hospital care?

Data indicate that health care-associated infections (HAIs) are the most common serious complication of hospital care, striking nearly 2 million U.S. hospital patients, resulting in an estimated 99,000 deaths, and costing the health care system up to $20 billion each year, according to the Centers for Disease Control and Prevention (CDC). The most common HAI is methicillin-resistant Staphylococcus aureus (MRSA). With some MRSA-related projects already underway, Congress directed AHRQ to work with its Federal partners at the CDC and the Centers for Medicare & Medicaid Services to develop an action plan to identify and help reduce the spread of MRSA and related HAIs. The action plan is designed to:

What is AHRQ in healthcare?

Given that consumers can be an important source of information for understanding patient safety events and health care system failures, AHRQ, in another patient safety event reporting project, is developing specifications for the future development of consumer reporting systems.