Send this page to a friend

Posted December 8, 2004

Agency for Healthcare Research and Quality (AHRQ) – AHRQ is the federal agency primarily charged with coordinating research and implementation of patient safety initiatives.

• AHRQ is part of a federal Patient Safety Task Force that collects and analyzes patient safety data.
• AHRQ backs several large research projects designed to develop patient safety systems that can be implemented nationwide.

American Osteopathic Association (AOA) Healthcare Facilities Accreditation Program (HFAP) – The AOA is a private organization that sets and enforces quality and safety standards for many hospitals in the U.S.

• Most hospitals must pass an AOA or other accreditation inspection every three years, and are subject to surprise inspections (see Joint Commission on Accreditation of Healthcare Organizations below).

Computerized physician order entry – Automated systems that allow physicians to order medicines and other hospital care directly, rather than writing notes and orders on patient charts that must be relayed by nurses or others.

• Studies show that computerized physician order entry systems can significantly reduce medication and other care errors resulting from illegible, lost or mis-communicated orders.

Correct site surgery – A process for ensuring that the correct surgical procedure is performed on the correct body site of the correct patient.

• Surgeons now mark the surgery site before surgery and double-check patient identity.
• The incidence of wrong-site surgery has declined significantly in recent years, according to JCAHO data.

Health care error – A health care error is a defect in the delivery of care to a patient.

• Most health care errors are minor and do not result in patient injuries. However, errors can and do result in patients suffering injuries, infections or even death.
• Designing health care systems to reduce the chances of health care errors is the goal of the patient safety movement.

Hospital quality improvement committees – State and federal law require that every hospital maintain teams of doctors, nurses and other health care professionals dedicated to improving health care quality and safety. These teams are generally known as quality improvement committees. These committees:

• Design care processes to ensure they are effective and safe.
• Monitor the quality of care and patient outcomes.
• Investigate unexpected adverse outcomes, deaths and other evidence of medical errors. When a weakness in a hospital process is found to be the cause, these teams re-design the process to help prevent future errors.

Institute of Medicine (IOM) – A unit of the National Academies, the Institute of Medicine is an independent organization chartered by Congress to analyze and develop health policy recommendations.

• A 1999 IOM report drew national attention to patient safety by estimating that somewhere between 44,000 and 98,000 patients die in the U.S. health system each year as a result of errors in care.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – The JCAHO is a private organization sponsored by medical and hospital groups that sets and enforces quality and safety standards for most hospitals in the U.S.

• The Joint Commission publishes detailed guidelines and goals for monitoring and improving hospital safety.
• Most hospitals must pass a Joint Commission or other accreditation inspection every three years, and are also subject to surprise inspections.
• Most states and the federal Medicare and Medicaid programs require hospitals to be accredited by the Joint Commission or the American Osteopathic Association, (see above) or pass an equivalent inspection by federal agents.

Leapfrog Group – A coalition of about 140 large businesses dedicated to improving health system safety and quality. Because of its economic clout, the Leapfrog Group is considered a major force in the patient safety movement.

• The Leapfrog Group encourages hospitals and health systems to adopt what they consider key patient safety systems and technologies.
• The group surveys hospitals on whether they make use of these techniques and publishes the results.

Medication errors – Medication errors are the most common medical errors. Doctors and patients can help avoid medication errors by double checking that medicines taken are those prescribed. Medication errors can involve:

• Dosage. Make sure you are taking no more and no less than the doctor orders.
• Type of medicine. Make sure you received what the doctor ordered, and not something with a similar name.
• Mistaken identity. Make sure the prescription you receive is the one prescribed to you, and not someone with the same or similar name.
• Timing. Make sure you take your medicine at the times prescribed, and do not double up for skipped doses unless your doctor says it’s OK.

Patient safety – The term “patient safety” has several important meanings:

• It is a general concept that hospital and other health care services should be designed and organized to reduce hazards for patients, health care workers and visitors.
• It is a societal movement backed by health care, government, business and consumer interests to promote health system changes that reduce the chances of patients being accidentally harmed.
• Most importantly, it is a broad range of activities by hospitals and other health care providers to protect patients. These include the careful design and continual improvement of health care processes to minimize opportunities for medication errors, infections or surgical injuries.

Universal precautions – Guidelines used by hospitals, health care professionals and home care givers to prevent the spread of infectious diseases. They include:

• Using gloves and other protective clothing when exposed to patients’ body fluids or mucous membranes, or handling clothes or bedding soiled by patients
• Utilizing surgical masks for patients with coughs, sneezing or other respiratory symptoms, and for staff treating them
• Hand washing before and after touching patients
• Special safe disposal receptacles for needles and other sharp items
• Sterilization and disinfection of equipment and furniture between patients

> Return to Campaign Overview