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Public reports - Patient Safety: details of reports
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EU [2007]   eHealth for Safety: Impact of ICT on Patient Safety and Risk Management

"The eHealth for Safety study takes a broad look at the information and communication technology (ICT) tools that can lead to higher quality of care, increased patient safety, and better risk management in health services and healthcare in Europe. It does so through a mix of desk research and provision of empirical evidence. It brings together into this mix the views of leading researchers and practitioners from around the globe from a series of high-level discussions and workshops.

"As a result, this report outlines the whole field of ICT and patient safety as seen from our holistic vision. It includes appropriate definitions, gathers and analyses factual data, describes the main workshop outcomes, and then makes a definitive set of recommendations for future research on ICT and patient safety. Among the consistent roadmapping that is currently being undertaken in relation to European research, this report provides yet another vision of important, possible research directions.

"The study examines the complementarities and overlap among patient safety, risk management, the study of medical errors, and quality assurance. It outlines the reality of patient risk and patient safety in practice. Based on a considerable stream of seminal clinical research, the twenty-first century began with the launch of two groundbreaking reports from the United States Institute of Medicine alerting the public to the deplorable state of patient safety and submitting recommendations for action. Internationally, these reports have formed the backbone of the rationale for global attention to the potential risks that patients run when they receive treatment in a country’s health system or service. The influence of these reports has been substantial, and their figures and statistics are easily translatable into a European context.

[...]

"A key barrier to the wider diffusion of patient safety ICT tools is user acceptance. Understanding better the sophisticated cognitive and socio-technical characteristics implicit in healthcare processes would result in designing safer workflows and healthcare systems for a wide range of healthcare professionals that would support improved clinical and organisational outcomes. ICT tools are enablers. As a fundamental component of a safer healthcare environment, they can support transforming healthcare processes.

"However, Europe also needs a holistic vision. A strategy is required that can take into account the complex, organisational elements of Europe’s health systems. Safety for all is an imperative, whether we apply it to healthy citizens or to patients undergoing treatment. Research and development in ICT can contribute fundamentally to finding solutions to these demanding questions that challenge the safety of our people."


 bullet  eHealth for Safety: Impact of ICT on Patient Safety and Risk Management
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USA  [2006 ]  (pre-publication)   Preventing Medication Errors

Pre-publication report. Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors. Preventing Medication Errors: the fourth report published in the Institute of Medicine's Quality Chasm Series launched in 1996. The programme is focused on assessing and improving the [US] nation's quality of health care.

The book sets out "action agendas detailing the measures needed to improve the safety of medication use [in the USA] in both the short- and long-term" in an effort to deal with "medication errors [which] injure 1.5 million people and cost billions of dollars annually".

Proposed IT solutions include electronic prescribing:
    "New computerized systems for prescribing drugs and other applications of information technology show promise for reducing the number of drug-related mistakes, the report says. Studies indicate that paper-based prescribing is associated with high error rates. Electronic prescribing is safer because it eliminates problems with handwriting legibility and, when combined with decision-support tools, automatically alerts prescribers to possible interactions, allergies, and other potential problems, the committee found. While it acknowledged that significant regulatory issues and problems with automated alerts still need to be worked out, the committee said that by 2008 all health care providers should have plans in place to write prescriptions electronically. By 2010 all providers should be using e-prescribing systems and all pharmacies should be able to receive prescriptions electronically. The Agency for Healthcare Research and Quality (AHRQ) should take the lead in fostering improvements in IT systems used in ordering, administering, and monitoring drugs." [Press Release]

 bullet  Complete Report  bullet  Press Release (20 July 2006)  bullet  Crossing the Quality Chasm: The IOM Health Care Quality Initiative  bullet   "The Chasm in Quality: Select Indicators from Recent Reports" [IOM]
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Denmark  [2005]   Patient Safety in Denmark - Past, current and future activities.

Patient Safety in Denmark - Past, current and future activities. Published by the Danish Society for Patient Safety, Copenhagen Hospital Corporation, the Danish Regions, the National Board of Health, the Ministry of the Interior and Health. November 2005.

Patient Safety became a national issue following the publication of The Danish Adverse Event Study in September 2001. "Based on a review of 1,097 patient records, the study found that 9 percent of patients admitted to a Danish hospital were exposed to an adverse event. 40 percent of the adverse events were preventable, and the remaining 60 percent were classified as complications. The adverse events resulted in an average of 7 days prolonged hospital stay." The Study was the main instigation of the creation of the Danish Society for Patient Safety.

"The publication describes the learning-oriented reporting system for adverse events, the work carried out at regional and national level, the background to the development of the reporting system etc." [Danish Society for Patient Safety].

Current and planned Danish safety-related activities in healthcare including
  • National adverse event reporting system (2004+)
  • Implementation of the Personal Electronic Medication Profile (PEM) (2004+)
  • Implementation of electronic medical records (the aim is to achieve full national coverage including data access interopability between systems by 2008.)


 bullet  Complete report (Ministry of the Interior and Health)  bullet  Schioler T, Lipczak H, Pedersen BL, et al. Danish Adverse Event Study. [Incidence of adverse events in hospitals. A retrospective study of medical records] Ugeskr Laeger. 2001 Sep 24;163(39):5370-8. Danish. [PubMed - abstract in English]  bullet  Danish Society for Patient Safety  bullet  Danish National Board of Health  bullet  Danish Regions  bullet  Ministry of the Interior and Health  bullet  National reporting system  bullet  Personal Electronic Medication Profile  bullet  Danish Electronic Health Record Observatory
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UK [2005]   UK National Audit Office. A Safer Place for Patients: Learning to improve patient safety.

The UK National Audit Office (NAO) report reviews progress made by the NHS in reducing unintentional harm to patients in hospitals.

The report states that more than 2,000 deaths occurred in NHS hospitals over the period April 2004 to March 2005 as a result of patient safety incidents. About 980,000 patient safety incidents (including medication errors, equipment defects and patient accidents ...) and near misses were reported - some two thirds of incidents resulted in no long-term harm. Around a half of incidents in which NHS hospital patients were unintentionally harmed could have been avoided, if lessons from previous incidents had been learned. The cost of mistakes to the NHS was estimated to be £2bn a year in lost bed days on top of the costs of litigation.

"A retrospective study of patient records in two English hospitals found that just over 10 per cent of patients experienced an ‘adverse event’. Around half of these (5.2 per cent) were judged to have been preventable. Responses to the NAO survey showed that, in 2004-05, trusts recorded some 2,081 deaths as a result of patient safety incidents, but it is widely acknowledged that there is significant under-reporting of deaths and serious incidents. Other estimates of deaths range from 840 to 34,000 but, in reality, the NHS simply does not know."

"Reducing unintentional harm to patients in NHS hospitals is a central tenet in the management of healthcare quality and risk. Two factors are crucial to this: the establishment of a culture in which incidents can be reported easily, honestly and without fear of blame; and the ability to ensure that lessons learned from these incidents are successfully promulgated to NHS staff both locally and nationally. What today’s report shows is that the Department of Health and the NHS have made some progress in both of these areas – but not enough."

Note: "A patient safety incident is defined as any unintended or unexpected event that causes death, disability, injury, disease or suffering for one or more patients. The most common incidents reported were: patient injury (due to falls), followed by medication errors, equipment-related incidents, record documentation error and communication failure."

 


 bullet  Report  bullet  UK National Audit Office  bullet  Press release 03 November 2005 (NAO)  bullet  England and Wales NHS National Patient Safety Agency (NPSA)  bullet  NPSA National Reporting and Learning System (NRLS) for patient safety
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Australia [2005]   Achieving Safety and Quality Improvements in Health Care – Sixth Report to the Australian Health Ministers’ Conference. Australian Council for Safety and Quality in Health Care.

" This sixth report is the last formal report to Health Ministers as the Australian Council for Safety and Quality in Health Care’s (Council) agreed extended term will finish in June 2006 prior to that year’s mid-year Health Ministers’ meeting. It is set against a background of the Ministerial Review of future governance arrangements for safety and quality in health care. Ministers clearly see safety and quality as important and have had the foresight to plan to take this agenda forward before the Council’s term ends. The Council has taken a strong interest in informing this Review, and listening to stakeholders who have made their views known through this Review, to inform Council’s directions for its remaining term and the broader landscape of safety and quality in the future.

In this context, this report builds on all fi ve previous reports to Australian Health Ministers, provides a summary of achievements since Council’s inception in 2000 and identifi es the foundation for future directions in safety and quality in Australia that has been built with the active support of many stakeholders ... "

 


 bullet  Complete report  bullet  Australian Commission on Safety and Quality in Health Care (succeeded the Australian Council for Safety and Quality in Health Care on 1 January 2006)
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Australia  2005   National Arrangements for Safety and Quality of Health Care in Australia. The Report of the Review of Future Governance Arrangements for Safety and Quality in Health Care. 28 July 2005

" National action should seek to operationalise safety and quality at all levels of the health system and achieve measurable improvement in the safety and quality of care. Informed by the Review consultation process, the Review Team believes that achieving this transformation will require:

  • a new national safety and quality body with clearly defined functions;
  • a quality improvement focus across the continuum of health care;
  • public reporting on the progress of safety and quality improvement as a key driver for change;
  • clearly defined functions to be performed by jurisdictions, including responsibility for implementation; and
  • a National Strategic Framework which promotes coordinated action from all key players.
The functions proposed by the Review Team for the new national safety and quality body are:
  • lead and coordinate improvements in safety and quality in health care in Australia by identifying issues and policy directions, recommending priorities for action, disseminating knowledge, and advocating for safety and quality;
  • report publicly on the state of safety and quality including performance against standards;
  • recommend national data sets for safety and quality, working within current multilateral governmental arrangements for data development, standards, collection and reporting;
  • provide strategic advice to Health Ministers on ‘best practice’ thinking to drive quality improvement, including implementation strategies; and
  • recommend nationally agreed standards for safety and quality improvement."


 bullet  Complete report  bullet  Introduction on health.gov.au  bullet  Press release  bullet  Australian Council For Safety and Quality in Health Care
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Canada  2004  Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170(11):1678-86

Summary: This was the first national study of patient safety in Canadian hospitals. The report estimates that 7.5 per cent of people hospitalized in Canada in the year 2000 (=185,000) experienced an adverse event as a result of their care and that around 70,000 of these adverse events were potentially preventable.


 bullet  Complete report- CMAJ (Canadian Medical Association Journal)  bullet  Press Release - Canadian Institutes of Health Research (24 May 2004)  en français  Communiqué de presse - Instituts de recherche en santé du Canada (21 mai 2004)
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USA  2004  Food and Drug Administration (FDA) White Paper: Protecting and Advancing Consumer Health and Safety

Executive Summary [extracts]: " Consumer health and safety form the core of FDA’s mission to protect and advance the public health... ... [T]he Agency has developed a core set of consumer-focused goals – including ... improved patient and consumer safety...." The document includes strategies to help reduce "preventable medical errors".


 bullet  Complete report- FDA  bullet  FDA Press Release - Jan 2004
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USA   2003  HIMSS Patient Safety Survey 2003 (sponsored by McKesson Corporation)

Executive Summary [extracts]: "The 2003 HIMSS Patient Safety Survey, sponsored by the Information Solutions division of McKesson Corporation suggests that nurses play a critical role in promoting patient safety in healthcare. Nearly all of the respondents who indicated that their facility had a formal patient safety committee indicated that at least one member of the nursing department sat on the committee. Further, nurse executives and patient safety officers were identified as most likely to lead the patient safety initiative at their organization.

Other key findings of the survey include:

...
  • Technology and Patient Safety: Nearly all respondents indicated that technology can address at least one patient safety issue, and 93 percent reported that technology is likely to play a role in reducing medication errors. Despite this, only 41 percent of respondents indicated that a member of the IT department participates on their organization’s patient safety committee.
  • ...
  • Decision to Implement Patient Safety Tools: Survey respondents are most likely (70 percent) to report that their organization’s strategic mission drives decisions to implement patient safety tools. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and Institute of Medicine reports ranked second and third as factors influencing these decisions.
  • ...
  • Measuring Patient Safety: Respondents most frequently identified a decrease in medication errors as the metric that will be used to measure patient safety. It was identified by 81 percent of respondents.
  • "


     bullet  Complete report- HIMSS

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    USA  2003  Patient Safety: Achieving a New Standard for Care
    Philip Aspden, Janet M. Corrigan, Julie Wolcott, Shari M. Erickson (Editors) (Committee on Data Standards for Patient Safety). Patient Safety: Achieving a New Standard for Care. Board on Health Care Services, Institute of Medicine, November 2003.

    This report is a result of the third phase of the IOM’s Quality Initiative started in 1996 with the aim of improving the quality of care in the USA. This phase is focused on "operationalizing the vision of a future health system described in the Quality Chasm report". [IOM]  The report advocates nationwide implementation of computerized information systems.

    The " report ... describes a detailed plan to facilitate the development of data standards applicable to the collection, coding, and classification of patient safety information.

    [It] "addresses key areas related to the establishment of a national health information infrastructure, including: a process for the ongoing promulgation of data standards; the status of current standards-setting activities in health data interchange, terminologies, and medical knowledge representation; as well as the need for comprehensive patient safety programs in health care organizations. Recommendations are made for an applied research agenda on patient safety. " [IOM]


     bullet  Complete report - free, browsable Open Book page image presentation framework  bullet  Press release, 20 November 2003  bullet  National Academies Press  bullet  The National Academies  bullet  IOM's Quality of Care Initiative
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    Australia  2003   Patient Safety: Towards Sustainable Improvement
    Patient Safety: Towards Sustainable Improvement – 4th Annual Report to Australian Health Ministers, July 2003.

    The report is accompanied by 8 papers including National Action Plan Update , Safety and Quality and the Health Reform Agenda; Standards Setting and Accreditation Systems in Health; 10 Tips for Safer Health Care? What Everyone Needs to Know. The report details the developments achieved to date by the Australian Council For Safety and Quality in Health Care and includes strategies for driving long-term sustainable improvements in patient safety.


     bullet  Executive Summary  bullet  Australian Council For Safety and Quality in Health Care
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    Canada  2002   Patient Safety and Healthcare Error in the Canadian Healthcare System
    Baker GR, Norton P. Patient Safety and Healthcare Error in the Canadian Healthcare System. A Systematic Review and Analysis of Leading Practices on Canada with Reference to Key Initiatives Elsewhere. A Report to Health Canada. Ottawa: Health Canada, 2002.

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    en français  Baker GR, Norton P. La sécurité des patients et les erreurs médicales dans le système de santé canadien : un examen et une analyse systématiques des principales initiatives prises dans le monde

    en français  Sommaire des recommandations: Accroître la sensibilisation et établir des priorités en vue d'améliorer la sécurité des patients au Canada; Mettre sur pied des systèmes de déclaration plus efficaces; Acquérir des compétences, diffuser le savoir et mettre en œuvre des systèmes visant à améliorer la sécurité; Mettre en place des mesures organisationnelles et stratégiques encourageant les initiatives dans le domaine de la sécurité des patients; [Santé Canada]

    Appendices include: Appendix D: how data on adverse events and errors are collected and used by canadian healthcare organizations;


     bullet  Complete report - pdf en français  Rapport complet version PDF  bullet  Health Canada | Santé Canada
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    Canada  2002  Governments and Patient Safety in Australia, the United Kingdom and the United States A Review of Policies, Institutional and Funding Frameworks, and Current Initiatives
    J. Paul Gardner, G. Ross Baker, Peter Norton, Adalsteinn D. Brown. Governments and Patient Safety in Australia, the United Kingdom and the United States A Review of Policies, Institutional and Funding Frameworks, and Current Initiatives. Prepared for the Advisory Committee on Health Services Working Group on Quality of Health Care Services. Final Report August 2002.

    Quoted from the section of the report Evaluations of Strategies :

    "Most patient safety initiatives are in their infancy, having been started in 2001 or 2002, or being currently piloted. There has been no evaluation of any of the three countries' overall efforts. None of the governments seem to have undertaken any evaluation, or if they have, made it public.

    "It may be necessary to have a fully developed incident reporting system in place for several years before results can be evaluated.

    "Two evaluations of the effectiveness of clinical patient safety measures in the U.S. are described in the appendix".

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    en français   J. Paul Gardner, G. Ross Baker, Peter Norton, Adalsteinn D. Brown. Les gouvernements et la sécurité du patient en Australie, au Royaume-Uni et aux États-Unis Examen des politiques, des cadres institutionnels et de financement et des initiatives en cours Préparé pour le Comité consultatif sur les services de santé Groupe de travail sur la qualité des services de santé Rapport définitif août 2002

     bullet  Complete report en français  Rapport complet version PDF
    USA [2002]   Kathleen Covert Kimmel, Joyce Sensmeier. A Technological Approach to Enhancing Patient Safety. White paper released by The Healthcare Information and Management Systems Society (HIMSS) and sponsored by Eclipsys Corporation.

    From CONCLUSIONS/RECOMMENDATIONS/POSITION STATEMENT:

    "... The Healthcare Information and Management Systems Society (HIMSS) is advocating ... the use of information technology including point-of-care, unit-of-use bar coding to reduce medical errors and improve productivity. ... The American Medical Informatics Association ... contends that errors can be prevented by computer systems that provide electronic patient records, physician order entry, practice standards, medical vocabularies, and computerized decision support.

    "Technology is rapidly progressing. Electronic medical records with decision support at the time of order entry are improving each year in their features, functions, and capabilities. These systems are justifying themselves in saving lives and money.

    "Accessibility to mobile computing devices at the point of care is evolving. Wireless computing devices enable physicians, other ordering clinicians, and nurses to enter patient data at the patient bedside. Use of bar coding in combination with decision support assures that patients are receiving the correct medication or treatment. Utilizing CPOE, physicians are able to review up-to-date patient test results and other pertinent data prior to writing orders, as well as receive decision support while processing them.

    "Now is the time for a call to action for all healthcare stakeholders. Health plans need to provide the ordering physician with information on disease state management, efficacy of various drugs, and treatments at various stages of the clinical condition. The reference laboratory must supply results that offer guidance in the interpretation of the test and support the physician in selecting additional tests or proper treatment. A four-way cooperative alignment between the ordering physician and the three major purveyors of information — the health plan, the reference laboratory, and pharmaceutical companies — is required. This can only be achieved when this information is available through decision support capabilities at the time of order entry. Orders may be entered using a hand-held device, wireless tablet, laptop, or desktop PC. Orders and results need to be immediately available to the physician, as well as to the entire treatment team at the hospital. This patient care team also needs to include the patient. Patients must be informed decision makers and active participants in their care. When all healthcare stakeholders recognize their responsibility and work together to address the patient safety issues, healthcare in this nation and all over the world will be vastly improved."

     


     bullet  Report [Eclipsys Corporation]  bullet  Healthcare Information and Management Systems Society (HIMSS)
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    UK  2001   A Spoonful of Sugar - Medicines Management in NHS Hospitals

    "Abstract: Medicines management is central to the quality of healthcare, and underpins many of the specific objectives set out in The NHS Plan. However, a combination of factors means that hospitals do not always manage their medicines to best effect. This report has been written to help hospital trusts identify how well they manage medicines. It addresses the main strategic challenges and issues facing hospitals in improving the effectiveness of their medicines' management, and suggests ways in which potential barriers can be met and overcome."

    Some main points:

  • "Medication errors alone cost the NHS about £500 million a year in additional days spent in hospital"
  • "Most errors are caused by the prescriber not having immediate access to adequate information"
  • "The core curricula at medical schools do not provide a thorough knowledge of safe medicines prescribing and administration"
  • "Computerised systems containing rules to prevent incorrect or inappropriate prescribing have reduced the incidence of errors and increased the appropriateness of medical treatment" ... " many errors could be eliminated through the use of computer technology and automation – a national approach is needed to introduce these systems."
  • "One quarter of hospital readmissions are because of non-compliance with medicines regimes"

    Recommendations include:

  • "The establishment of standard nationwide definitions and categories of medication errors and ‘nearmisses’ should be an early priority for the new National Patient Safety Agency."
  • "The DoH and the National Assembly for Wales should commission a specification for automated dispensary systems and consider the provision of earmarked funds to roll-out the introduction of these systems to all hospitals."
  • "A standard national system for the coding of medicines and barcodes should be introduced across the whole NHS to support the development of electronic prescribing systems and automated dispensing systems. Earmarked funds should be made available to enable hospitals to comply with the targets set in the IM and T strategy. Central guidance on systems specification and screen layouts should also be considered."


  •  bullet  Full report  bullet  Audit Commission Briefing, December 2001. in Healthcare
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    Australia  2001  Safety in Practice: Making Health Care Safer
    Australian Council for Safety and Quality in Healthcare (ACSQHC). Safety in Practice: Making Health Care Safer. Second Report to the Australian Health Ministers' Conference, 2001.


     bullet  Full report  bullet  Australian Council for Safety and Quality in Healthcare
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    Switzerland  2001   Patientensicherheit: Für ein sicheres Gesundheitssystem
    H. H. Brunner, D. Conen, P. Günter, M. von Gunten, F. Huber, B. Kehrer, A. Komorowski, M. Langenegger, D. Scheidegger, R. Schneider, P. Suter, C. Vincent, O. Weber (Hrsg.), Towards A Safe Healthcare System Proposal For A National Programme On Patient Safety Improvement For Switzerland

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    Auf Deutsch  Expertengruppe «Patientensicherheit »: Für ein sicheres Gesundheitssystem. Vorschlag für ein nationales Programm zur Erhöhung der Patientensicherheit. (Übersetzung des englischen). Executive Summary, Luzern, 9. April 2001.

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    en français  Renforcer la securite du systeme de soins de santé. Proposition d'un programme national d'amelioration de la securite des patients en Suisse. Version provisoire de la traduction de l'anglais. Lucerne, 9 avril 2001


     bullet  Report in German, French and Englaish  bullet  Stiftung für Patientensicherheit - Patient Safety Foundation, Switzerland  bullet  swiss-q.org
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    UK  2001  Building A Safer NHS For Patients
    Building A Safer NHS For Patients: implementing an organisation with a memory. London: Department of Health, 2001.

    "Building A Safer NHS For Patients sets out the Government's plans for promoting patient safety following the publication of the report An Organisation with a Memory and the commitment to implement it in the NHS Plan. It places patient safety in the context of the Government's NHS quality programme and highlights key linkages to other Government initiatives. Central to the plan is the new mandatory, national reporting scheme for adverse health care events and near misses within the NHS. This will enhance existing mechanisms for improving quality of care and promoting patient safety by harnessing learning throughout the NHS when something goes wrong...." [DOH]

    The England and Wales NHS National Patient Safety Agency was created in 2001, and has incorporated a national patient safety reporting system - a world first.


     bullet  Complete report  bullet  NHS Plan  bullet  UK Department of Health  bullet  Seven steps to patient safety - A guide for NHS staff (National Patient Safety Agency 2003)  bullet  NHS National Patient Safety Agency
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    UK  2000   An organisation with a memory
    An organisation with a memory. Report of an expert group on learning from adverse events in the NHS, chaired by the Chief Medical Officer. London: Department of Health, 2000.


    Four key areas are highlighted for targeted action by the NHS. The need to develop: unified mechanisms for reporting and analysis when things go wrong; a more open culture, in which errors or service failures can be reported and discussed; mechanisms for ensuring that, where lessons are identified, the necessary changes are put into practice; a much wider appreciation of the value of the system approach in preventing, analysing and learning from errors.

    This report led directly to the setting up the the the England and Wales NHS National Patient Safety Agency and its national patient safety reporting system - a world first.


     bullet  Complete report  bullet  UK Department of Health  bullet  NHS National Patient Safety Agency
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    USA   1999  To Err Is Human: Building a Safer Health System

    Kohn LT, Corrigan JM, Donaldson MS, Eds. To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine, 1999.

    This document reported that that a large number of people (possibly up to 98,000, reperesenting over 1% of all admissions) lose their lives as a result of errors that occur in hospitals in the USA - many of which could have been prevented. The report highlighted the disparity between people's perceptions of medical errors and the reality. It placed the responsiblity for this on systems rather than people and set out a four-pronged national agenda for reducing errors and improving patient safety through the design of a safer health system.


     bullet  Complete Report  bullet  Press Release (Nov. 29 1999)  bullet  Institute of Medicine of the National Academies  bullet  IOM's Quality of Care Initiative  bullet   Medical Errors: The Scope of the Problem: Fact sheet, Publication No. AHRQ 00-P037. Agency for Healthcare Research and Quality, Rockville, MD.  bullet   Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact - Report from the Quality Interagency Coordination Task Force (QuIC) established by President Clinton and tasked to evaluate the recommendations in To Err is Human and respond with a strategy to identify prevalent threats to patient safety and reduce medical errors  bullet  Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005 May 18;293(19):2384-90.
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    Entry on OpenClinical: 2003
    Last main updates: 05 April 2006; 30 August 2006
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