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Public reports - Patient Safety: details of reports
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 [2006 ] (pre-publication)
Preventing Medication Errors
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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]
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 [2005]
Patient Safety in Denmark - Past, current and future activities.
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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.)
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 [2005]
UK National Audit Office.
A Safer Place for Patients:
Learning to improve patient safety.
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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."
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 [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.
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"
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 ...
"
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| 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 |
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"
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."
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 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 |
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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.
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| 2004 Food and Drug Administration (FDA) White Paper: Protecting and Advancing Consumer Health and Safety |
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Executive Summary [extracts]:
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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".
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2003 HIMSS Patient Safety Survey 2003
(sponsored by McKesson Corporation) |
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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.
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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."
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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]
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| 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.
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| 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.
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
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;
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| 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".
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
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[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.
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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."
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| 2001 A Spoonful of Sugar - Medicines Management in NHS Hospitals |
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"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" ...
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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."
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| 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.
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 2001
Patientensicherheit: Für ein sicheres Gesundheitssystem
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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
 Expertengruppe «Patientensicherheit »:
Für ein sicheres Gesundheitssystem. Vorschlag für ein
nationales Programm zur Erhöhung der Patientensicherheit. (Übersetzung des englischen).
Executive Summary, Luzern, 9. April 2001.
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
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| 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. |
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| 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.
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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.
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| acknowledgements |
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| page history |
Entry on OpenClinical: 2003
Last main updates: 05 April 2006; 30 August 2006 |
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Complete Report