We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published byJayden Bryant
Modified over 2 years ago
Rosenthal 1 Federal and State Efforts to Improve Patient Safety Jill Rosenthal, MPH National Health Policy Conference February 7, 2006
Rosenthal 2 v National Academy for State Health Policy v © Feb 2006 v Medical Errors and Patient Safety Medical errors are a problem of epidemic proportions –44,000 to 98,000 hospitalized patients die per year –Errors in outpatient and nursing home care –Errors of ommission –$17-29 billion from preventable errors Over 1/2 of costs are direct health care –Average increased cost of medication error = $4,700 per admission
Rosenthal 3 v National Academy for State Health Policy v © Feb 2006 v Systems Problems Errors occur because of systems problems –Shift focus from blaming individuals to safety improvement Preventing errors means designing safer systems of care
Rosenthal 4 v National Academy for State Health Policy v © Feb 2006 v IOM Recommendations National focus on safety Identify and learn from errors Set performance standards and expectations for safety Implement safety systems within health care organizations
Rosenthal 5 v National Academy for State Health Policy v © Feb 2006 v Identify and Learn from Errors: Reporting Systems Mandatory –In all states –Smaller number of serious events –Hold institutions accountable Voluntary –Promote existing systems –Larger number of near misses –Identify system weaknesses
Rosenthal 6 v National Academy for State Health Policy v © Feb 2006 v Snapshot of Federal response Patient Safety and Quality Improvement Act of 2005 AHRQ Patient Safety Network, Web M&M, grants, conferences VA National Center for Patient Safety DHHS Hospital Compare
Rosenthal 7 v National Academy for State Health Policy v © Feb 2006 v Snapshot of state responses Reporting systems and other regulatory approaches Patient safety centers Patient safety coalitions Purchasing for safety
Rosenthal 8 v National Academy for State Health Policy v © Feb 2006 v State Reporting Systems 25 states have authorized adverse event reporting programs (Dec 2005) Accountability –Identification of system weaknesses and assurance of corrective actions Facility education –Patient safety alerts –Identification of trends and best practices –Web-based facility comparisons
Rosenthal 9 v National Academy for State Health Policy v © Feb 2006 v Reporting System Improvement Maximizing the Use of State Adverse Event Data to Improve Patient Safety –Data coming out is only as good as data going in –Anecdotal vs. epidemiological analysis –Identification of tools, strategies, and shared learning for system improvement NASHP patient safety toolbox for states: Supported by The Commonwealth Fund
Rosenthal 10 v National Academy for State Health Policy v © Feb 2006 v NASHP resources NASHP website: –patient safety toolbox for states –adverse event reporting laws –NASHP patient safety news briefs and publications –state resources on patient safety
Rosenthal 11 v National Academy for State Health Policy v © Feb 2006 v Todays speakers Vahe Kazandjian, Maryland Patient Safety Center Alan Rabinowitz, Pennsylvania Patient Safety Authority William Weeks, VA National Center for Patient Safety and VA Outcomes Group
1 Why Not The Best: The Commonwealth Fund Benchmarking Website to Track and Facilitate Performance Improvement Anne-Marie J. Audet, M.D., Sc.M., S.M. Academy.
Families USA Health Action Conference, 2010 State Opportunities in Health Reform Sonya Schwartz Program Director National Academy for State Health Policy.
THE COMMONWEALTH FUND Exhibit 1. National Health Expenditures per Capita, 1980–2007 Data: OECD Health Data 2009 (June 2009).
MRSA: A Learning and Networking Session Program Overview July 30, 2007 Paula Griswold, Executive Director
Compiled by Kaye Culberson Wilkie, RN, BSN Autopsy to Determine if Heparin Overdose Killed Texas Newborn Multiple cancer patients killed by improperly.
February 13, 2007 Page 1 HIT 4 QI Convergence of Quality and Health Information Technology: The Opportunities That Lie Ahead National Health Policy Conference.
A dialogue document July The Challenge In a country that expects the best of everything we fail to achieve the best in health. What must be.
Value Based Purchasing In the Traditional Medicare Fee-for- Service Program The National Pay for Performance Summitt March 10, 2009 Jeffrey B Rich, MD.
1 Health Research & Educational Trust January 8, 2009.
1 Performance Measurement Workgroup Meeting 3/17/2014 New All-Payer Model Monitoring Measures.
1 A Regional Public Health System in NH What Do We Have Now? Why Regionalize? How Do We Make a Case for Regional Public Health in a State Like NH? What.
The Crisis of Non-Reporting: Where does this go JH Lange - Presenter Co-authors/contributors Luca Cegolon Giuseppe Mastrangelo.
E-Health Networks The New Shape of Public Health NGA State Alliance for e-Health 2nd Annual State Learning Forum Stephen Goldsmith Daniel Paul Professor.
Fall Meeting AAOS Orthopaedic Surgery Safety Update 2012 William J Robb III MD Chair AAOS Orthopaedic Surgery Safety Summit AAOS Patient Safety Committee.
Mental Health Americas Regional Policy Council Forum at the National Press Club Washington, DC December 12, 2003 Charles Curie, The Curie Group, LLC Presenter.
Thanks to Migrant Clinics Network, Institute for Health Care Improvement, Marc Williams- Intermountain Healthcare & Mike Hindmarsh MacColl Institute for.
An Imperative for Performance Improvement Neil G. Jaymalin, RN, MBAH, CQA February 26, 2010.
1 Updates in Patient Safety Helen Burstin, MD, MPH Senior Vice President, Performance Measures National Quality Forum Academy Health June 8, 2008.
Cheryll D. Lesneski, DrPH Clinical Assistant Professor Gillings School of Global Public Health, UNC Chapel Hill Consultant, US DHHS.
Leading the Health System through Policy Development New Roles for Public Health.
© Joint Commission International Med Health Cairo March Ashraf Ismail, MD, MPH, CPHQ Managing Director, Middle East Region Joint Commission.
1 Patient Safety: New Trends and Strategies for Implementation Canadian College of Health Service Executives March 2006.
Public Reporting of Quality in Healthcare: The Power of Transparency Alliance for Health Reform Briefing April 27, 2011 Gerry Shea, AFL-CIO.
HEALTHY WORK ENVIRONMENTS QWQHCS 2010 SUMMIT Healthy Workplaces in Action: Working to Delivery Quality Care February 25, 2010.
TEAMWORK AND COMMUNICATION TRAINING. WHY WE CARE: IMPACT OF PATIENT ERROR 98,000 Americans die each year as a result of preventable medical errors*
National Public Health Performance Standards Program Orientation to the Essential Public Health Services.
Welcome Laerdal SUN 2009 Dallas, Texas. Brief Introduction Susan Lucot, MSN, RN – Nurse Educator, SimMedical Laura Mosesso – Project Manager, SimMedical.
Sigma Theta Tau International, Inc. Lambda Rho Chapter-at-large Jacksonville, Florida 2012 Nursing Research Conference March 3, 2012 Diane Brady Schwartz.
The Patient-Centered Medical Home (PCMH): Building a Better Health Care Model.
No-Charge Policy for Serious Adverse Events An AHA Member Teleconference Series.
© 2016 SlidePlayer.com Inc. All rights reserved.