Key documents
Institute of Medicine (IOM), Quality of Health Care in America project Report 1
To Err is Human: Building a Safer Health System
[Kohn LT, et al., December 1999, National Academy Press, 283 pages: $45 (prepaid) plus shipping charges of $4.50 for the first copy; 95 cents for each additional copy.] This is a comprehensive overview of medical errors. Full document may be downloaded in pdf. The press release provided below gives a summary of the issues addressed. Go to: "Health and medicine," "Institute of medicine," "Publications," or call 202.334.3313 or 800.624.6242
http://books.nap.edu/catalog/9728.html
Institute of Medicine (IOM), Quality of Health Care in America project Report 2
Crossing the Quality Chasm – A New Health System
for the 21st Century
This follow-up report from the IOM panel recommends a sweeping redesign of the American healthcare system and provides overarching principles for specific direction for policymakers, healthcare leaders, clinicians, regulators, and purchasers. Printed copies are available from the National Academy Press web site or by calling 202.334.3313 or 800.624.6242. It offers:
http://books.nap.edu/catalog/10027.html
Agency for Healthcare Research and Quality (AHRQ), formerly Agency for Health Care Quality and Policy and Research (AHCPR)
Special report
AHRQ released an Evidence Report/Technology Assessment Number 43, "Making Health Care Safer A Critical Analysis of Patient Safety Practices" in July 2001. A summary of the analysis of 79 practices may be reviewed in the Summary report appended here, as well as the Appendix listing all 79 practices tabulated with ratings. The full report is lengthy (2107 KB) and may be downloaded from this Web site. You may also go to the AHRQ link for the report.
Current medical error focus
- Go to: "Research on Medical Errors." Additionally, go to fact sheet: "Reducing Errors in Health Care" four pages, publication number 98-P018.
- Go to: "Quality Interagency Coordination Task Force (QuIC)" fact sheet; describes related initiatives among government agencies.
- Go to: "Centers for Education and Research (CERT)"; describes funding of studies to improve safe and effective use of medical products.
- Go to press releases and, speeches and congressional hearings for current testimony, February 2000
- Go to: "Medical Errors and Patient Safety" and "Patient Safety Task force;" a fact sheet describes the 2001 task force on data (AHRQ, CDC, FDA and CMS/HCFA).
- Go to: "New Federal Patient Safety Data Collection"
Search tool
Locate summaries provided with citation. For example, a search on "medication errors" leads to abstract entitled: "System equipment changes could reduce medication errors;" summary describes issue of adverse drug events as addressed by a series of authors published in JAMA July 5, 1995. Go to: http://www.ahrq.gov.
Quality Interagency Coordination (QuIC) Task Force
within AHRQ
The White House has professed a firm commitment to improving patient safety, and, consistent with the recommendations of the Quality Commission established in 1997, the Quality Interagency Coordination Task Force (QuIC) began to coordinate the Administration’s efforts to improve quality. The Task Force information within AHRQ is on its own Web page with information on the five major themes. Individual work groups have been established to work within these specific areas.
The home page also includes the complete 95-page report to the president, the official response to the IOM-1 report "Doing what counts for patient safety: federal actions to reduce medical errors and their impact." This is a roadmap for implementing the IOM-1 report. The complete report is available and may be downloaded as text or pdf. See also Part 1 and Part 2 to download.
Food and Drug Administration (FDA) MedWatch
MedWatch is supported by over 140 organizations, representing health professionals and industry in partnership to:
- Increase awareness of drug and device-induced disease
- Ease reporting by operating a single system for health professionals to report adverse events and product problems to the agency
- Provide regular feedback to the healthcare community about safety issues involving medical products
- Provide additional directives and guidance to assist in medication error reduction
Center for Medicare and Medicaid Services (CMS),
formerly Health
Care Financing Administration (HCFA)
CMS provides a monthly newsletter in HTML and pdf format. Issues for past two years can be retrieved immediately.
Topics include various broad patient safety issues. Go to "Medicare" and "Provider Update."
CMS Conditions of Participation (COP) for Medicare/Medicaid - 42 CFR 482
The complete CMS conditions of participation (COP) including the patients’ rights revision may be located at the listed web site. This rule introduces a new Patients' Rights Condition of Participation (CoP) that hospitals must meet to be approved for, or to continue participation in, the Medicare and Medicaid programs. The final rule was published December 8, 2006 and is effective February 7, 2007:
- each patient's right to notification of his or her rights;
- the exercise of his or her rights in regard to his or her care; privacy and safety;
- confidentiality of his or her records;
- freedom from restraints used in the provision of acute medical and surgical care unless clinically necessary; and
- freedom from seclusion and restraints used in behavior management unless clinically necessary.
Current regulations are based on original document 51 FR 22042 June 17, 1986 updated October 1 2002. Go to listed site, check box for "Title 42," and then check box for "Volume 3." Enter the following search term: "42.482." Search results for "2002 42CFR482-Part 482-Conditions of Participation for Hospitals." Full document may be downloaded as text or pdf.
http://www.access.gpo.gov/su_docs/fedreg/a061208c.html
Joint Commission (JCAHO)
- Description of JCAHO sentinel event (SE) reporting database, root cause analysis (RCA) and current summary report of findings
- Identification of important unsafe patient care practices; provides "sentinel alerts" on specific issues, such as blood transfusion errors. Go to:" Patient Safety/Sentinel events"
Office of Inspector General (OIG)
Updates on compliance issues and CMS/HCFA –JCAHO Report regarding survey changes. Survey reports may be downloaded at listed web site. Go to: "What’s new" and "Prior years". Locate 07/20/99 and download a series of reports under: "External Review of Hospital Quality."
The patient safety Resources page is a list of web sites that provide additional information on safety management issues. Information found on the Internet does not reflect the opinions or business relationships of Premier.