Patient Safety

Prepared by Alice Lam, Intern in the Department of Medical Economics Medical Society of the District of Columbia.

Special thanks to the National Patient Safety Foundation, whose web site provided the basis for this list.  Also, thanks to Terry Smith of MEDSTAT Group, Inc. for her contributions to the list.  The organizations listed here are involved with the issues of errors in medicine and patient safety. MSDC does not endorse these web sites or their sponsoring organizations, but provides them here for your information.  If you have questions or feedback, please contact Dianne Bricker.

Agency for Healthcare Research and Quality Medical Errors Research Page-AHRQ
AHRQ provides evidence-based information on: health care outcomes; quality; and cost, use, and access. Information from AHRQ’s research helps people make more informed decisions and improves the quality of health care services. The web site includes a variety of materials on medical errors, including press releases, text from Congressional hearings, speeches, and other documents.

American Society of Health-System Pharmacists - ASHP
ASHP's "Medication Misadventures Resource Center" provides comprehensive information on medication errors and adverse drug events. It includes articles, a message board for public exchange, and an amazing list of resources.

American Society of Healthcare Risk Management – ASHRM
ASHRM is a professional membership organization devoted to identification, evaluation and control of risks that could cause injury to the patient and financial loss to the institutions they represent.  It provides a variety of products and resources on patient safety.

Anesthesia Patient Safety Foundation – APSF
The mission of the APSF is to make sure that patients are not harmed by anesthesia. The purposes of the foundation are: to foster investigations that will provide a better understanding of preventable anesthetic injuries; encourage programs that will reduce the number of anesthetic injuries; and promote national and international communication of information and ideas about the causes and prevention of anesthetic injuries.

Anonymous Critical Incidents Reporting System - CIRS©
Based on the experiences from the Australian-Incident-Monitoring-Study, this site supports an international forum where information on critical incidents – that happen in daily anesthetic practice – are collected. This program not only allows the submission of critical incidents, but also serves as a teaching instrument. CIRS© is anonymous.

Australia Patient Safety Foundation - APSF
The APSF promotes the Australian Incident Monitoring System (AIMS) which provides a mechanism for any incident or accident in the health care system to be reported using a standard single form. Their site includes news, reporting forms, and the patient safety projects they have undertaken in ten specialties.

Best Practice Network

Enhancing Patient Safety and Reducing Errors in Health Care
This site provides information from the second in a series of conferences held at the Annenberg Center for the Health Sciences to address issues vital to enhancing patient safety and reducing errors in health care. The syllabus from the meeting serves as a useful tool to identify individuals and organizations actively involved in the patient safety movement.

Food and Drug Administration FDA MedWatch
MedWatch is an initiative designed to educate all health professionals about the critical importance of being aware of, monitoring for, and reporting adverse events and problems, and to facilitate reporting to the Agency. A site with extensive information on safety information, reporting problems to the FDA, and a collection of downloadable publications.

Human Factors and Ergonomics Society - HFES
The society's mission is to look at how the design of systems and devices interact with the humans that use them.  It directly relates to issues of device effectiveness in medicine. This site provides interesting and relevant information not only on medical errors but also on engineering and design and the considerations needed for human interaction.

Institute for Healthcare Improvement – IHI
An organization hosting both seminars and a collaborative approach to reducing errors in health care. One noted publication on their site is Reducing Adverse Drug Events: Lessons from a Breakthrough Series Collaborative. They have also produced other practical and user-friendly guides based on the real-life experiences of health care organizations that have made dramatic changes.

Institute for Safe Medication Practices - ISMP
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. Their biweekly newsletter, ISMP Medication Safety Alert, brings you vital and potentially life-saving information about medication and device errors and adverse drug reactions.

Institute of Medicine
The mission of the Institute of Medicine is to advance and disseminate scientific knowledge to improve human health. The Institute provides objective, timely, authoritative information and advice concerning health and science policy to government, the corporate sector, the professions and the public. They publish landmark reports, such as To Err is Human: Building A Safer Health System (Medical Errors), which has prompted increased investigation into the matter of patient safety.

Joint Commission on Accreditation of Healthcare Organizations - JCAHO
The Joint Commission is a nationally recognized accreditation agency for hospitals, managed care entities and other types of health care facilities. This page hosts a `sentinel events' section with a newsletter called Sentinel Event Alert, a glossary, a list of educational programs and an annotated bibliography.

Latiolais Leadership Program
This web site supports a program from the Ohio State School of Pharmacy looking at the safety of intravenous drug systems.

Massachusetts Coalition for the Prevention of Medical Errors
The Massachusetts Coalition for the Prevention of Medical Errors was established to develop and implement a statewide initiative to improve patient safety and minimize medical errors. Their publications, accessible on their website, include recommendations to reduce medical errors and patient guidelines for safe medication use.

MDSR
MDSR is a repository of medical device incident and hazard information independently examined by ECRI, a nonprofit health services research agency. MDSR is a collective look at the types of problems that have occurred with medical devices and lessons learned over the past three decades.

National Association of Health Data Organizations

National Committee for Quality Assurance - NCQA
Provides information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed decisions. They publish annual reports on the state of health care and offer educational conferences to help organizations meet their quality goals, comply with accreditation or certification requirements or simply deliver better care and service.

National Guideline Clearinghouse
A database of clinical practice guidelines and other documents. This site allows many search types and comparison of guidelines.

National Patient Safety Foundation – NPSF
The mission of the National Patient Safety Foundation (NPSF) is to improve measurably patient safety in the delivery of health care. They provide extensive literature and offer Listserv on patient safety.

National Safety Council - NSC
Their mission is "to educate and influence society to adopt safety, health and environmental policies, practices and procedures that prevent and mitigate human suffering and economic losses arising from preventable causes." Their Safety and Health section gives information on adverse drug effects as well as news and research.

Partnership for Patient Safety

Quality Interagency Coordination Task Force

Risk Management Foundation of Harvard Medical School
RMF provides claims management and services related to loss prevention, quality improvement, underwriting, and related research for Controlled Risk Insurance Company (CRICO) insureds.  Their website includes legal resources, risk management guides, and newsletters. Forum, the bi-monthly newsletter of the Risk Management Foundation, supplies in-depth analyses of specific medical malpractice claims and issues along with practical loss prevention advice and case abstracts

"Take Time to Care" Initiative - TTTC
This FDA Office of Women's Health program has developed tools to reach women, who are the primary users of medications and who often administer them for family members, more aware of safe medication use.

US Pharmacopoeia - USP
USP promotes public health by establishing and disseminating officially recognized standards of quality and authoritative information for the use of medicines and other health care technologies by health professionals, patients and consumers. The page provides access to the USP Medication Errors Reporting (MEP) program, which facilitates the reporting of actual or potential medication errors.

VA Healthcare Network Upstate New York: Integrated Patient Safety/Risk Management Program
This program helps to establish network policy to define and outline procedures and responsibilities for reviewing, reporting, tracking and trending patient incidents as well as other safety related events. Includes many handy documents on reporting and other patient safety issues.

VA Palo Alto/Stanford Patient Simulator
An example of an educational tool that has resulted in the reduction of error. This project does so by placing medical students in critical situations through the use of a detailed simulation in the operating room, and then reviewing the results of the actions of the team.

Veterans Administration Virtual Learning Center - VLC
The Virtual Learning Center was designed to provide a mechanism for individuals to post "lessons learned" and share knowledge. In particular, a section here is devoted to "Patient Safety" where the sharing of lessons learned from adverse events, or from proactive actions aimed at preventing future occurrences, is encouraged.