Federal and State Efforts to
Improve Patient Safety
Jill Rosenthal, MPH
NATIONAL ACADEMY
for STATE HEALTH POLICY
National Health Policy Conference
February 7, 2006
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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
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Systems Problems

Errors occur because of systems
problems
– Shift focus from blaming individuals to safety
improvement

Preventing errors means designing safer
systems of care
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IOM Recommendations

National focus on safety
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Identify and learn from errors

Set performance standards and
expectations for safety

Implement safety systems within health
care organizations
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Identify and Learn from Errors:
Reporting Systems

Mandatory
– In all states
– Smaller number of
serious events
– Hold institutions
accountable
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Voluntary
– Promote existing
systems
– Larger number of
near misses
– Identify system
weaknesses
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Snapshot of Federal response

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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
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Snapshot of state responses
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Reporting systems and other regulatory
approaches
Patient safety centers
Patient safety coalitions
Purchasing for safety
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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
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Reporting System Improvement

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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:
www.pstoolbox.org
Supported by The Commonwealth Fund
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NASHP resources

NASHP website: www.nashp.org
– patient safety toolbox for states
– adverse event reporting laws
– NASHP patient safety news briefs and
publications
– state resources on patient safety
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Today’s speakers
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Vahe Kazandjian, Maryland Patient Safety
Center
Alan Rabinowitz, Pennsylvania Patient Safety
Authority
William Weeks, VA National Center for
Patient Safety and VA Outcomes Group
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