Related Public/Private Initiatives

The IOM Report acknowledged that there is no single entity with any single solution (or approach) to improving patient safety. Accordingly, there are a number of organizations, both governmental and private, not-for-profit, that are engaged in patient safety initiatives. These organizations, and their corresponding efforts, are summarized below. Cross links to their web sites are also provided to enable access to "best practice " information as well as numerous references on the topic of medical errors and patient safety. Note: Organizational descriptions were obtained from individual web sites.

AARP Research Center (www.research.aarp.org)

There is a substantial evidence that older patients (defined as those age 65 and older) are at substantially greater risk for iatrogenic (treatment or procedure-related) medical injury than other age groups are. Because older patients have special problems and may require special measures to achieve acceptable levels of safety in health care, there is concern that they may not fully benefit from the safety improvements being designed.

AARP initiated research to identify the nature and extent of preventable medical injury among patients age 65 and older, to determine how and why their patterns of injury differ from those of younger patients, and to suggest some ways that iatrogenic injury among older patients can be addressed.

Jeffrey M. Rothschild, M.D., Harvard School of Medicine and Lucian L. Leape, M.D., Harvard School of Public Health conducted this research. This web site contains their important findings relating to reducing preventable medical injuries in the following areas:

  1. Adverse Drug Events (ADEs);
  2. Falls;
  3. Noscomial Infections;
  4. Pressure Sores;
  5. Delirium; and
  6. Post-Operative Complications.
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Agency for Healthcare Research and Quality (www.ahrq.gov)

Agency for Healthcare Research and Quality, the health services research arm of the U.S. Department of Health and Human Services, is the lead agency charged with supporting research designed to improve the quality of healthcare, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. The information helps healthcare decisionmakers - patient and clinicians, health system leaders, and policymakers - make more informed decisions and improve the quality of healthcare services.

This web site provides important clinical information and information on medical errors and patient safety.

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Commonwealth Fund (CMWF) (www.cmwf.org)

The Commonwealth Fund is a private foundation that supports independent research on health and social issues and makes grants to improve health care practice and policy. The Fund is dedicated to helping people become more informed about their health care, and improving care for vulnerable populations such as children, elderly people, low-income families, minority Americans, and the uninsured. The Fund's two national program areas are improving health insurance coverage and access to care and improving the quality of health care services. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. In its own community, New York City, the Fund makes grants to improve health care and enhance public spaces and services.

This website offers reports related to health care quality, such as "Room for Improvement: Patients Report on the Quality of Their Health Care."

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Institute for Healthcare Improvement (IHI) (www.ihi.org)

The Institute for Healthcare Improvement (IHI) is a Boston-based, not-for-profit organization created to help lead the improvement of health care systems, to increase continuously their quality and value. The institute's measures of improvement include improved health status, better clinical outcomes, lower cost, broadened access, greater ease of use, and higher satisfaction for individuals and their communities.

This web site is an excellent resource tool on patient safety and provides an annotated bibliography listing several of the most important books and articles on patient safety.

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Institute for Safe Medication Practices (ISMP) (www.ismp.org)

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia (USP) in the USA. Information from the reports may be used by USP to impact on drug standards. All information derived from the MERP is shared with the U.S. Food and Drug Administration (FDA) and pharmaceutical companies whose products are mentioned in reports.

The Institute is an FDA MEDWATCH partner and regularly communicates with the FDA to help to prevent medication errors. The Institute encourages the appropriate reporting of medication errors to the MEDWATCH program.

ISMP is dedicated to the safe use of medications through improvements in the drug distribution, naming, packaging, labeling, and delivery system design. The organization has established a national advisory board of practitioners to assist in problem solving.

The ISMP publishes the ISMP Medical Safety Alert which provides information on medication errors and provides "safe practice " recommendations. This web site provides recent articles from the ISMP Medication Safety Alert.

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IPRO (www.ipro.org)

IPRO is an independent, not-for-profit organization, providing a full spectrum of health care assessment and improvement services to government agencies and corporate clients. IPRO's highly qualified professional staff includes more than 300 physicians, registered nurses, epidemiologists, biostatisticians, data analysts, health policy experts, programmers, medical record personnel and systems analysts, as well as a network of more than 300 board-certified physician consultants.

Since 1989, IPRO has served as the Quality Improvement Organization for New York State under contract with the federal government. IPRO has major contracts with the New York State Department of Health and serves as the External Quality Review Organization for New Mexico, Pennsylvania and Rhode Island. IPRO is also licensed to conduct independent audits of managed care organizations' HEDIS® performance measures and was one of the first organizations to receive URAC accreditation as an Independent Review Organization. IPRO partners with the New York Business Group on Health in sponsoring the New York State Health Accountability Foundation, a public-private consortium with initiatives that focus on providing consumers with timely information on health care quality, access and consumer satisfaction; promoting value-based health care purchasing; and providing the health care community with "best practices" information.

In the fall of 2003, IPRO became certified to ISO 9001:2000, an international quality management standard and framework for business-to-business dealings, focusing on meeting customer quality and applicable regulatory requirements, enhancing customer satisfaction and continually improving business performance.

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Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (www.jcaho.org)

The Joint Commission evaluates and accredits nearly 18,000 health care organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation's predominant standards-setting and accrediting body in health care. Since 1951, the Joint Commission has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks. The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in healthcare organizations.

There are revisions to Joint Commission Standards, effective July 1, 2001, in support of patient safety and medical error reduction. These new standards are available on this JCAHO web site.

JCAHO has expanded it's national patient safety awareness campaign to focus on ambulatory care. This campaign is entitled "Speak Up." It encourages patients to become active, involved and informed participants on the health care team. Research has shown that patients who take part in decisions about their health care are more likely to have better outcomes.

In addition, the Joint Commission publishes, Sentinel Event Alert. This is a newsletter that identifies the most frequently occurring sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future.

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Leapfrog Group (www.leapfroggroup.org)

Comprised of more than 100 public and private organizations that provide health care benefits, The Leapfrog Group works with medical experts throughout the U.S. to identify problems and propose solutions that it believes will improve hospital systems that could break down and harm patients. Representing more than 31 million health care consumers in all 50 states.

The Leapfrog Group was created to help save lives and reduce preventable medical mistakes by mobilizing employer purchasing power to initiate breakthrough improvements in the safety of health care and by giving consumers information to make more informed hospital choices. It is a voluntary program aimed at mobilizing large purchasers to alert the healthcare industry that big leaps in patient safety and customer value will be recognized and rewarded with preferential use and other intensified market reinforcements.

The Leapfrog Group was founded by The Business Roundtable, a national association of Fortune 500 CEOs.

On this web site, the Leapfrog Group describes 3 initiatives that are being advanced by Leapfrog purchasers to improve patient safety: 1. Computer Physician Order Entry (CPOE); 2. Evidence-based Hospital Referral (EHR); and 3. ICU Physician Staffing (ICU).

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National Center for Patient Safety (NCPS) (www.patientsafety.gov)

The National Center for Patient Safety (NCPS) embodies the Department of Veterans Affairs' (VA) uncompromising commitment to reducing and preventing adverse medical events while enhancing the care given our patients. The NCPS represents a unified and cohesive patient safety program, with active participation by all of the 172 VA hospitals supported by dedicated patient safety managers. The Center's program is unique in healthcare; they focus on prevention not punishment, applying human factor analysis and the safety research of high reliability organizations (aviation and nuclear power) targeted at identifying and eliminating system vulnerabilities.

This web site offers monthly TIPS (Topics in Patient Safety) newsletters.

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National Patient Safety Foundation (NPSF) (www.npsf.org)

The National Patient Safety Foundation was founded in 1996 by the American Medical Association, CNA HealthPro, 3M, and contributions from the Schering-Plough Corporation. The NPSF is an independent, nonprofit research and education organization. It is an unprecedented partnership of health care practitioners, institutional providers, health product providers, health product manufacturers, researchers, legal advisors, patient/consumer advocates, regulators, and policy makers committed to making health care safer for patients. Through leadership, research support, and education, the NPSF is committed to making patient safety a national priority.

The mission of the National Patient Safety Foundation (NPSF) is to improve measurably patient safety in the delivery of health care by its efforts to:

  • Identify and create a core body of knowledge;
  • Identify pathways to apply the knowledge;
  • Develop and enhance the culture of receptivity to patient safety;
  • Raise public awareness and foster communications about patient safety; and
  • Improve the status of the Foundation and its ability to meet its goals.

This site offers information on education and research programs related to patient safety.

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National Quality Forum (NQF) (www.qualityforum.org)

The National Forum for Health Care Quality Measurement and Reporting (National Quality Forum or NQF) is a not-for-profit membership organization created in 1999 to develop and implement a national strategy for health care quality measurement and reporting. A shared sense of urgency about the impact of health care quality on patient outcomes, workforce productivity, and health care costs prompted leaders in the public and private sectors to create the NQF as a mechanism to bring about national change. Established as a public-private partnership, the NQF has broad participation from all parts of the health care system; including national, state, regional, and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement. Together, the organizational members of the NQF will work to promote a common approach to measuring health care quality and fostering system-wide capacity for quality improvement.

This web site provides project summaries of NQF's work in medical error reporting ( " Never Events " Project, "Serious Reportable Events in Healthcare " Report); patient safety ( " Safe Practices " Project) and hospital quality performance measures (" Hospital Measures " Project).

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