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1、Initiatives to Improve Quality and Safety in Health Care,Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality 5th Annual Colorado Patient Safety Conference November 11, 2005,Medical Errors in History,“In my opinion, physicians kill as many people as we generals.” - Napoleon Bona
2、parte“The physician can bury his mistakes, but the architect can only advise his client to plant vines.” - Frank Lloyd Wright, New York Times, 1953,To Err Is Human - 6 years later AHRQ role and resources Where we are today Federal initiatives Safety in numbers collaboration and communication,Patient
3、 Safety Initiatives,To Err Is Human,Landmark 1999 Institute of Medicine report elevated national awareness on issue of patient safety Two key conclusions - Traditional “name, blame and shame” response ineffective in improving safety Safe, high quality care requires a team effort and significant comm
4、unication and collaboration,Progress Since 1999,Regulation: JCAHO safe practices; standardization of practices A- Workforce and Training: PSIC; maintenance of certification; leadership training B Error Reporting Systems: C Information Technology: B- Malpractice: D+ R Wachter. The end of the beginnin
5、g: patient safety five years after To Err is Human. Health Affair 2004; W4: 534-545.,More Medical Errors in U.S.,Any medical mistake, medical error or test error in last 2 years,2005 Commonwealth Fund International Health Policy Survey,Incorrect Lab/Diagnostic Test,Percent reporting either lab test
6、error,2005 Commonwealth Fund International Health Policy Survey,or Delay in Receiving Abnormal Test Result, Past 2 years,Mistake/Medication Error/Lab Error,2005 Commonwealth Fund International Health Policy Survey,By Number of Doctors Seen in Past 2 Years,Percent,Major Finding: Patients face a signi
7、ficant risk for preventable adverse events and serious medical errors in hospital critical care units In a study of patients admitted to intensive care units: 20% had an adverse event 45% of the adverse events were preventable Over 90% of incidents occurred during routine care,AHRQ Research Study: C
8、ritical Care Safety,JM Rothschild, CP Landrigan, JW Cronin, et al., The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care, Critical Care Medicine. 33(8):1694-1700, August 2005.,Medical Errors and Nurse Fatigue,“Patients are more at ri
9、sk when nurses work long hours. A tired nurse is more likely to miss subtle changes, have more difficulties concentrating, and may not catch their own or others errors.”Ann Rogers, Ph.D. R.N.University of Pennsylvania,AHRQ-funded grant HS11963,ICU Infections Down Nearly 80%,Keystone initiative signi
10、ficantly reduced infections at 77 Michigan hospitals Simple interventions: hand washing reminders and elevating a patients head while on a ventilator Project so successful that 68 ICUs had no infections or ventilator-associated pneumonias during the 18 months of the project,AHRQ-supported Pronovost
11、study, 10/05,Colorado Physician and Public Agreement on Medical Errors,Source: Robinson AR, et al., Arch Intern Med, 2002; 162:2186-2190,Major Themes Identified at National Research Summit,Epidemiology of Errors Infrastructure to Improve Patient Safety Information Systems Knowing Which Interventions
12、 Should Be Adopted Facilitating the Implementation of What is Shown to Work in Improving Safety Disseminating Information to Clinicians, Policymakers, Patients, and Others,To Err Is Human - 6 years later AHRQ role and resources Where we are today Federal initiatives Safety in numbers collaboration a
13、nd communication,Patient Safety Initiatives,AHRQs Mission,Improve the quality, safety, efficiency and effectiveness of health care for all Americans,HHS Organizational Focus,NIH Biomedical research to prevent, diagnose and treat diseases,NIH Biomedical research to prevent, diagnose and treat disease
14、s,CDC Population health and the role of community-based interventions to improve health,HHS Organizational Focus,NIH Biomedical research to prevent, diagnose and treat diseases,CDC Population health and the role of community-based interventions to improve health,AHRQ Long-term and system-wide improv
15、ement of health care quality and effectiveness,HHS Organizational Focus,AHRQ and Patient Safety,Identify medical errors and other threats to patient safety and understand why they occur Advance knowledge of practices that will reduce or eliminate the occurrence of medical errors and minimize risk of
16、 patient harm Develop, assemble and disseminate information on how to implement best practices for patient safety Enable providers to monitor and evaluate threats to patient safety and the progress being made,Safety Research & Training,Funded over 225 patient safety and related health information technology projects since 2001 Awarded over $8 million in funding for 15 Partnerships in Implementing Safety Patient Safety Improvement Corps New curriculum under development by AHRQ, Department of Defense, CMS and Quality Improvement Organizations,
