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DOD Patient Safety Program and Patient Safety Center at AFIP Patient Safety - Why Bother?
Patient Safety Not a New Problem • 1964 - Schimmel (Ann. Int. Med. ) – 20% of Univ. Hospital Admissions Injured • 1981 - Steel (NEJM) – 36% of Teaching Hosp. Admissions Injured • 1989 - Gopher (Proc. Human Factors Society) – 1. 7 errors/day/patient (29% pot. serious) • 1991 - Harvard Practice Study (NEJM) – 4% of Admissions Injured NY State in 1984
National Center for Patient Safety • 1997 – National Patient Safety Partnership (NPSP) – Expert Advisory Panel on Patient Safety System Design • 1998 – NCPS Announced • 1999 - NCPS Formed
NCPS Expert Advisory Panel Recommendations Establish a Voluntary Reporting System – Confidential, De-identified, Non-punitive – Reports Should Emphasize Narratives – Interdisciplinary Review Teams – About Identifying Vulnerabilities NOT Statistics – Prompt Feedback – Open to All Comers
Quality Interagency Coordination Task Force (Qu. IC) • Established in 1998. • Chairs: Sec. of HHS & Depart. of Labor • Members: Departs of Commerce, Defense, H&HS, Labor, Veterans Affairs, BOP, FTC, NHTSA, OMB, OPM, USCG. • Managed by Agency for Healthcare Research and Quality (AHRQ)
Qu. IC Goals 1. To ensure that all Federal agencies that purchase, provide, study, or regulate health care services are working in a coordinated way toward improving the quality of care.
Qu. IC Goals 2. To provide information to help people make choices, to improve the care purchased and delivered by the government, and to develop the infrastructure needed to improve the health care system.
Institute of Medicine (IOM) Report • Published in November 1999 • 7 December - The President directed Qu. IC to evaluate the recommendations in the IOM report & respond with a strategy to identify and reduce medical errors. • Recommended a national goal of reducing the number of medical errors by 50 percent over 5 years
IOM Report Recommendations • Four-tiered Approach – Establish a national focus – Identify & learn from medical errors through mandatory and voluntary reporting systems – Raise standards & expectations – Implement safe practices at delivery level
Qu. IC Report • Doing What Counts For Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact - February 2000 • Endorsed IOM goals • Report can be found at: www. quic. gov/report/index. htm
DOD Patient Safety Working Group • Stood up in January 2000 • Tasked with – assessing DOD patient safety activities – Produce a DOD Patient Safety Instruction
DOD Patient Safety Working Group • Representatives – All Services – Physicians, nurses, pharmacists, lawyers, risk managers, Info Mgt, – OSD/HA, TMA, USU, AFIP, BUMED, VA, AFMC, AFMOA, Naval Safety Center
DOD Patient Safety Working Group • DODI completed 12/00 • Implementation is deferred pending final Congressional action • Pilot program using regional MTFs started 10/00 & ends