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IHC Work Plan Description — Patient Safety (pg. 1)
Executive Summary
"First do no harm" is a prime directive in healthcare. Despite the best intentions, adverse events and medical errors occur in every health care setting in every community in this country. Patient safety is the prevention of harm to patients. Although simple in definition, the road to ensuring patient safety is complex and replete with obstacles.
Modern healthcare is a highly complex, high-risk, and error-prone activity. Not surprisingly, adverse healthcare events are a leading cause of death and injury. Despite remarkable advances in healthcare technology and delivery, too many patients die or are disabled as a result of adverse healthcare events. Adverse healthcare events occur in all settings: hospitals, clinics, nursing homes, urgent care centers, and surgery centers.
- The Institute of Medicine's report, To Err is Human, has estimated that between 44,000 and 98,000 deaths occur annually due to preventable medical errors in our hospitals.
- This estimate of 98,000 deaths ranks medical errors as the fifth leading cause of death in the United States – higher than motor vehicle accidents (43,458), breast cancer (42,397), or AIDS (16,516).
- Preventable injury resulting from medical errors costs the economy from $17 billion to $29 billion annually, half of which are healthcare costs.
Healthcare organizations should focus on patient safety by establishing comprehensive patient safety programs with defined executive responsibility and trained personnel. The Iowa Healthcare Collaborative is committed to illuminating the issue of Patient Safety, promoting the spread of best practice, and engaging the healthcare community.
National Quality Forum's Safe Practices
The National Quality Forum (NQF), with support from the Agency from Healthcare Research and Quality (AHRQ), has identified 30 safe practices that can work to reduce or prevent adverse events and medical errors. NQF strongly urges that these 30 safe practices be universally adopted by all applicable healthcare settings to reduce the risk of harm to patients.
In 2004, IHC worked to introduce the 30 safe practices to Iowa hospitals and physicians. IHC conducted a baseline survey to assess the level of priority and deployment of these practices in Iowa. Response and engagement was outstanding with 100 of 116 Iowa hospitals completing the initial survey.
In 2005, IHC partnered with the Texas Medical Institute of Technology (TMIT) to assist Iowa hospitals on patient safety initiatives. TMIT surveys hospitals from around the country on the NQF safe practices to evaluate their performance and construct strategies for improvement. Iowa hospitals were asked to complete a web-based self-assessment survey on the deployment of 27 of the 30 NQF safe practices. Response and engagement were again outstanding, with 113 of 116 Iowa hospitals completing this survey. Iowa aggregate information from this survey was used to educate providers and construct toolkits to address identified opportunities.
In 2006, IHC used results from the TMIT survey to build specific patient safety interventions in Iowa. The first Patient Safety Conference was held in March of 2006. Four toolkits were then constructed to promote awareness of the issues, spread best practice, and engage Iowa providers and patients in improvement.
The NQF edited their safe practices document in 2006. The new safe practices are more refined and have better definitions and metrics. They will serve as the basis of another statewide assessment in 2007.
Anticoagulation Initiative
Anticoagulation therapy is a complex and labor-intensive intervention. Success depends upon correct dosing decisions, close attention to many details, and good communication among all parties involved. In a recent study, anticoagulants were responsible for 121 of 1,523 adverse drug events. A third of these were considered preventable.
In a recent TMIT survey conducted by IHC, 116 Iowa hospitals rated anticoagulation as an extremely relevant problem within the state. Recognizing this problem, IHC produced an Anticoagulation Toolkit for healthcare providers. The objective of this initiative is to ensure effective and safe long-term anticoagulation therapy in all care settings in Iowa.
A project team from 11 healthcare providers participated in the development of the toolkit. The team gathered information on current anticoagulation processes from anticoagulation clinics in Iowa and nationally. Following the American College of Chest Physicians (ACCP) Guidelines, the team has posted protocol examples for healthcare providers focusing on improvement of anticoagulation monitoring and treatment. These resources include all of the data elements necessary to successfully manage patient anticoagulation therapy according to the National Quality Forum Safe Practices and the ACCP Anticoagulation Management Guidelines.
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