Important Initiatives Taken By Independent Non-governmental Organizations for Patient Safety

ISMP is devoted entirely to medication error prevention and safe medication use. It operates a voluntary “Medication Errors Reporting Program (MERP)” in collaboration with United States Pharmacopoeia to tabulate errors nationally, understand their causes, and share “lessons learnt” with the healthcare community.

In addition, ISMP’s corporate subsidiary, Med-E.R.R.S. (Medical Error Recognition and Revision Strategies), works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading names, labeling, packaging, and device design.

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2. National Patient Safety Foundation (NPSF), USA:

The NPSF was founded in 1996, jointly by the American Medical Association, CNA Health Pro and 3M. Based on the model of the Anesthesia Patient Safety Foundation, the NPSF provides leadership training, research support, and education in patient safety.

3. Joint Commission on Accreditation of Healthcare Organizations (JCAHO):

Founded in 1951, JCAHO is an independent, organization that evaluates and accredits nearly 15,000 health care organizations and programs in the United States.

In 1997, JCAHO began including outcomes and other performance data into the accreditation process (the “ORYX initiative”).

On the basis of that data the Joint Commission has been developing National Patient Safety Goals every year to promote specific improvements in patient safety.

The Commission also created a “do not use” list of abbreviations in 2004 to avoid acronyms and symbols that lead to misinterpretation.

Since 1996, JCAHO has been focusing on identification of sentinel events and analysis of their root causes.

The health care facility experiencing the sentinel event is expected to complete a thorough root cause analysis, make improvements to the underlying processes, and monitor the effectiveness of changes.

JCAHO has also been issuing alerts on events such as wrong site surgery, restraint deaths, medication errors, transfusion errors and patient abductions.

An International Center for Patient Safety was established in 2005 to identify, develop and share safety solutions, conduct joint research, and advocate public policy changes. It also provides educational materials to help patients prevent medical errors.

4. National Quality Forum (NQF), USA:

The NQF was started in 1999 to develop and implement a national strategy for health care quality measurement and reporting. The forum has focused on several areas: Error rates, unnecessary procedures, under treatment, and preventive care.

In 2002, the Forum listed 27 events that should never occur within a health care facility. In 2003, it endorsed a set of 30 safe practices that should be universally utilized in the clinical care settings, as applicable, to reduce the risk of harm to patients.

Six types of “never events” called Serious Reportable Events, as given below, were listed for reporting.

1. Surgical events (e.g., surgery being performed on the wrong patient),

2. Product or device events (e.g., using contaminated drugs),

3. Patient protection events (e.g., an infant discharged to the wrong person),

4. Care management events (e.g., a medication error),

5. Environmental events (e.g., electric shock or burn),

6. Criminal events (e.g., sexual assault of a patient).

5. Leapfrog (USA):

The Leapfrog Group, a group of several large US companies, was officially launched in November 2000 with the aim of reducing preventable medical mistakes.

The Leapfrog Hospital Rewards Program rewards hospitals that implement significant improvements through mandatory practice of Computer Physician Order Entry (CPOE), evidence-based hospital referral, intensive care unit (ICU) staffing by physicians experienced in critical care medicine, and a “Leapfrog Safe Practices Score”, based on the safe practices endorsed by National Quality Forum.

Additional initiatives now include public reporting of health care quality and outcomes (hospital quality ratings) to influence consumers’ choices.

6. United States Pharmacopeia (USP):

The United States Pharmacopeia (USP) promotes patient safety by collecting data about the incidence of medication errors and drug reactions.

USP analyzes the data, develops professional education programs and issues error alerts. The MEDMARX (USP) report released in 2007 analyzed 11,000 medication errors during surgery in 500 hospitals between 1998 and 2005.

7. ECRI Institute (USA):

The ECRI Institute was created in 2008 as a Federal Patient Safety Organization under the Patient Safety and Quality Improvement Act of 2005.

To enable healthcare providers to learn from near miss and adverse events, and to improve patient care, the PSO provides incident report collection and analysis, safety recommendations, best practices library, advisories and publications, and ready-to-use tool kits.

It is also a Collaborating Center for Patient Safety, Risk Management, and Healthcare Technology for the World Health Organization.

8. Texas Medical Institute of Technology (TMIT), USA:

TMIT is a medical research organization founded in 1984. As of 2009, more than 3,100 US hospitals (almost 70% of US acute care), comprise its area of research and study in patient safety. TMIT focuses on adoption of measures that impact patient care.

It co- funded and co-led the development of the National Quality Forum 2009 ‘Safe Practices for Better Healthcare’ that consist of 34 best practices applicable to all US hospitals and most ambulatory care settings.

9. Pittsburgh Regional Health Initiative (PRHI), USA:

The PRHI was the first regional consortium of medical, business and civic leaders who came together to address the issues of healthcare safety and quality improvement.

PRHI offers clinicians and other healthcare professional’s necessary tools, expertise, education, models and networks to perfect patient care and safety in their organizations.

It has developed ‘Perfecting Patient Care’, a program of quality improvement in clinical care and has, over the years, imparted training to thousands of health care professionals.

10. Other Initiatives:

Besides the above, many other useful initiates have been started such as the Institute for Safety in Office-Based Surgery (ISOBS), Boston, USA, the American Society of Medication Safety Officers (ASMSO) for promoting safe medication and safety in pharmacy and the Safe Care Campaign to help eradicate hospital acquired infections through improvement in hand hygiene.