A
new National Patient Safety Foundation (NPSF) report follows up on the Institute of Medicine’s (IOM) landmark 2000 publication, To Err Is Human:
Building a Safer Health System.
Top 5 in the News
eds Target Drug-Resistant TB The White House in December released the National
Action Plan to Combat Multidrug-Resistant Tuberculosis (MDR TB). In 2014 nearly 10 million people became ill with TB, resulting in 1.5 million deaths. MDR TB is a strain of TB resistant to at least two of the fi drugs used to treat TB, and is now found in every country in the world.
The National Action Plan is an effort to articulate a comprehensive strategy, mobilize political will, and
spur additional fi and in-kind commitments
The 2000 IOM report raised awareness of medical
errors and patient safety events among health care providers and the public. The new NPSF report, titled Free from Harm: Accelerating Patient Safety
Improvement Fifteen Years After To Err Is Human, indicates that patient safety events remain a serious public health problem that require a more pervasive response to address. According to NPSF, this response should include a total systems approach to patient safety.
NPSF makes eight recommendations for achieving total system safety and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation. The eight recommendations are as follows:
Ensure that leaders establish and sustain a safety culture.
Create centralized and coordinated oversight of patient safety.
Create a common set of safety metrics that reflect meaningful outcomes.
Increase funding for research in patient safety and implementation science.
Address safety across the entire care continuum.
Support the health care workforce.
Partner with patients and families for the safest care.
Ensure that technology is safe and optimized to improve patient safety A panel of preeminent experts brought together by NPSF in 2015 assessed
the state of the patient safety field and set the stage for future patient safety improvement efforts. The panel was led by cochairs Donald M. Berwick, MD, MPP, president emeritus and senior fellow at the Institute for Healthcare Improvement (IHI) and lecturer in the Department of Health Care Policy at
Harvard Medical School, and Kaveh G. Shojania, MD, director of the Centre for Quality Improvement and Patient Safety at the University of Toronto. The report and the executive summary are available for download at http://w w w
The report notes that much of the work done in patient safety to date addresses hospital care, whereas most care today is provided outside of hospitals. Moreover, while deaths from medical errors make headlines, morbidity—in the form of lasting effects of harm, additional care, or lengthier hospitalizations—also demands attention. The report argues for centralized oversight of patient safety, in part to facilitate sharing best practices and knowledge.
Joint Commission Leadership (LD) standards require accredited health care organizations to have an organizationwide, integrated patient safety system within their performance improvement activities, as well as an organizationwide culture of safety. The “Patient Safety Systems” (PS) chapter of the Comprehensive Accreditation Manual for Hospitals contains a framework for designing and implementing such systems. TS
_for_tuberculosis_20151204_fi to download
the plan.
oint Commission and AABB Partner on Blood Management The AABB (formerly the
American Associations of Blood Banks) and The Joint Commission have announced a partnership to provide a voluntary, joint hospital certifi for patient blood management. An evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion, patient blood management encompasses all aspects of patient evaluation and clinical management surrounding the transfusion decision-making process.
oint Commission Center Leader Writes on High Reliability The January/February 2016
issue of Healthcare Executive magazine features an article by Erin S. DuPree, MD, chief medical offi and vice president of the Joint Commission Center for Transforming Healthcare, on the path to high reliability. Visit http://www.jointcommission.org
/assets/1/18/HC_Exec_article.pdf
DC: Opioid-Related Deaths Rose in 2014
Opioid overdose deaths, including both opioid pain relievers and heroin, hit record levels in 2014, with an alarming 14% increase in just one year, according to new data recently published in the US Center for Disease Control and Prevention’s Morbidity and Mortality Weekly Report. The most commonly prescribed opioid pain relievers, those classifi as natural or semisynthetic opioids such as oxycodone and hydrocodone, continue to be involved in more overdose deaths than any other opioid type. These deaths increased by 9% (813 more deaths in 2014 than 2013). Visit http://www.cdc.gov/mmwr/preview/mmwrhtml
/mm6450a3.htm?s_cid=mm6450a3_w for more
rightStar Care Recognized for High-
Quality Home Care The Joint Commission has presented the 2015 Enterprise Champion for Quality Award to BrightStar Care, recognizing the national private duty home care and medical staffi franchise for its efforts to promote the delivery of high-quality care to its franchisees through Joint Commission accreditation. This is the third consecutive year the award was given to BrightStar Care, which has more than 300 locations that provide skilled and nonmedical home care to families and staffi services to health care facilities. For more information about the Enterprise Champion for Quality award, visit www.jointcommission.org/accreditation/home
Page 9 Copyright 2016 The Joint Commission The Source, February, Volume 14, Issue 2