Patient Safety Practices

Patient Safety Practices are available for the sole purposes of providing general educational information on patient safety and medical quality-related issues. Always seek the advice of your physician before beginning any new treatment or if you have any questions regarding a medical condition. The Tennessee Improving Patient Safety (TIPS) Coalition adopted the Patient Safety Practices in 2003 and recommended to many health organizations in Tennessee to support or endorse.

Seven Components of Abuse Prevention
Wrong Site Surgery
Medication Errors (10 Confusing Abbreviations to Avoid)
Medication Errors (15 Ways to Lower your Dose of Medication Errors)
Effective and Underused Safety Practices
Falls Tool Kit
Ensuring Correct Surgery
Choking

Patient Safety Best Practices

Patient Safety Best Practices comprise the department's effort to supply providers with information which can help providers furnish a higher quality of care to the citizens of Tennessee.  Best Practices will be added to and updated as needed.

Public/Private Patient Safety Initiatives

It is acknowledged that there is no single entity that has the only solution or approach to improving patient safety. There are a number of organizations, both governmental, private, and/or not-for-profit, that are engaged in patient safety initiatives. These organizations and their efforts are summarized below. Links to their websites are also provided to enable access to information, as well as numerous references on the topic of medical errors and patient safety. Note: Organization descriptions were obtained from individual websites.

Agency for Healthcare Research and Quality
National Center for Patient Safety (NCPS)
National Patient Safety Foundation (NPSF)
Commonwealth Fund (CMWF)
National Quality Forum (NQF)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
The Institute for Safe Medication Practices (ISMP)
AARP Research Center
Leapfrog Group

Agency for Healthcare Research and Quality (www.ahrq.gov)

The Agency for Healthcare Research and Quality, the health services research arm of the U.S. Department of Health and Human Services, is the lead agency charged with supporting research designed to improve the quality of healthcare, reduce its cost, improve patient safety, decrease medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use, and access. The information helps healthcare decisionmakers - patient and clinicians, health system leaders, and policymakers - make more informed decisions and improve the quality of healthcare services.

This web site provides important clinical information and information on medical errors and patient safety.

National Center for Patient Safety (NCPS) (www.patientsafety.gov)

The National Center for Patient Safety (NCPS) embodies the Department of Veterans Affairs' (VA) uncompromising commitment to reducing and preventing adverse medical events while enhancing the care given to patients. The NCPS represents a unified and cohesive patient safety program, with active participation by all of the 172 VA hospitals supported by dedicated patient safety managers. The Center's program is unique in healthcare; they focus on prevention not punishment, applying human factor analysis and the safety research of high reliability organizations (aviation and nuclear power) targeted at identifying and eliminating system vulnerabilities.

This web site offers monthly TIPS (Topics in Patient Safety) newsletters.

National Patient Safety Foundation (NPSF) (www.npsf.org)

The National Patient Safety Foundation was founded in 1996 by the American Medical Association, CNA HealthPro, 3M, and contributions from the Schering-Plough Corporation. The NPSF is an independent, nonprofit research and education organization. It is an unprecedented partnership of health care practitioners, institutional providers, health product providers, health product manufacturers, researchers, legal advisors, patient/consumer advocates, regulators, and policy makers committed to making health care safer for patients. Through leadership, research support, and education, the NPSF is committed to making patient safety a national priority.

The mission of the National Patient Safety Foundation (NPSF) is to improve measurably patient safety in the delivery of health care by its efforts to:

  • Identify and create a core body of knowledge;
  • Identify pathways to apply the knowledge;
  • Develop and enhance the culture of receptivity to patient safety;
  • Raise public awareness and foster communications about patient safety; and
  • Improve the status of the Foundation and its ability to meet its goals.
  • This site offers information on education and research programs related to patient safety.

Commonwealth Fund (CMWF) (www.cmwf.org)

The Commonwealth Fund is a private foundation that supports independent research on health and social issues and makes grants to improve health care practice and policy. The Fund is dedicated to helping people become more informed about their health care, and improving care for vulnerable populations such as children, elderly people, low-income families, minority Americans, and the uninsured. The Fund's two national program areas are improving health insurance coverage and access to care and improving the quality of health care services. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. In its own community, New York City, the Fund makes grants to improve health care and enhance public spaces and services.

This website offers reports related to health care quality, such as "Room for Improvement: Patients Report on the Quality of Their Health Care."

National Quality Forum (NQF) (www.qualityforum.org)

The National Forum for Health Care Quality Measurement and Reporting (National Quality Forum or NQF) is a not-for-profit membership organization created in 1999 to develop and implement a national strategy for health care quality measurement and reporting. A shared sense of urgency about the impact of health care quality on patient outcomes, workforce productivity, and health care costs prompted leaders in the public and private sectors to create the NQF as a mechanism to bring about national change. Established as a public-private partnership, the NQF has broad participation from all parts of the health care system; including national, state, regional, and local groups representing consumers, public and private purchasers, employers, health care professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in health care research or quality improvement. Together, the organizational members of the NQF will work to promote a common approach to measuring health care quality and fostering system-wide capacity for quality improvement.

This web site provides project summaries of NQF's work in medical error reporting ( " Never Events " Project, "Serious Reportable Events in Healthcare " Report); patient safety ( " Safe Practices " Project) and hospital quality performance measures (" Hospital Measures " Project).

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)(www.jointcommission.org/)

The Joint Commission evaluates and accredits nearly 16,000 health care organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation's predominant standards-setting and accrediting body in health care. Since 1951, the Joint Commission has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks. The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in healthcare organizations.

There are revisions to Joint Commission Standards, effective July 1, 2001, in support of patient safety and medical error reduction. Thesenew standards are available on this JCAHO web site.

JCAHO has expanded it's national patient safety awareness campaign to focus on ambulatory care. This campaign is entitled "Speak Up." It encourages patients to become active, involved and informed participants on the health care team. Research has shown that patients who take part in decisions about their health care are more likely to have better outcomes.

In addition, the Joint Commission publishes, Sentinel Event Alert. This is a newsletter that identifies the most frequently occurring sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future. Sentinel Event Alertshave been issued on various events.

The Institute for Safe Medication Practices (ISMP) (www.ismp.org)

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia (USP) in the USA. Information from the reports may be used by USP to impact on drug standards. All information derived from the MERP is shared with the U.S. Food and Drug Administration (FDA) and pharmaceutical companies whose products are mentioned in reports.

The Institute is an FDA MEDWATCH partner and regularly communicates with the FDA to help to prevent medication errors. The Institute encourages the appropriate reporting of medication errors to the MEDWATCH program.

ISMP is dedicated to the safe use of medications through improvements in the drug distribution, naming, packaging, labeling, and delivery system design. The organization has established a national advisory board of practitioners to assist in problem solving.

The ISMP publishes the ISMP Medical Safety Alert which provides information on medication errors and provides "safe practice " recommendations. This web site provides recent articles from the ISMP Medication Safety Alert.

AARP Research Center (https://www.aarp.org/research/)

There is a high incidence of preventable medical treatment-related injuries among patients age 65 and older. AARP initiated research to identify the nature and extent of preventable medical injuries among patients age 65 and older, to determine how and why their patterns of injury differ from those of younger patients, and to suggest some ways that iatrogenic injury can be addressed.

Jeffrey M. Rothschild, M.D., Harvard School of Medicine and Lucian L. Leape, M.D., Harvard School of Public Health conducted this research. This website contains their important findings relating to reducing preventable medical injuries in the following areas:

  1. Adverse Drug Events (ADEs);
  2. Falls
  3. Noscomial Infections;
  4. Pressure Sores;
  5. Delirium; and
  6. Surgical Complications

Leapfrog Group (www.leapfroggroup.org)

Composed of more than 100 public and private organizations that provide health care benefits, The Leapfrog Group works with medical experts throughout the U.S. to identify problems and propose solutions that it believes will improve hospital systems that could break down and harm patients. Representing more than 31 million health care consumers in all 50 states.

The Leapfrog Group was created to help save lives and reduce preventable medical mistakes by mobilizing employer purchasing power to initiate breakthrough improvements in the safety of health care and by giving consumers information to make more informed hospital choices. It is a voluntary program aimed at mobilizing large purchasers to alert the healthcare industry that big leaps in patient safety and customer value will be recognized and rewarded with preferential use and other intensified market reinforcements.

The Leapfrog Group was founded by the Business Roundtable, a national association of Fortune 500 CEOs.

On this website, The Leapfrog Group describes 3 initiatives that are being advanced by Leapfrog purchasers to improve patient safety: 1. Computer Physician Order Entry CPOE); 2. Evidence-based Hospital Referral (EHR); and 3. ICU Physician Staffing (ICU).