Fact Sheet

Patient Safety Task Force

The Patient Safety Task Force was established to coordinate the integration of data collection on medical errors and adverse events, coordinate research and analysis efforts, and promote collaboration within the Department of Health and Human Services to improve healthcare quality by preventing complications and injuries associated with healthcare delivery.

Background

In discussing how to reduce the incidence of error as described in the Institute of Medicine's (IOM's) 1999 report To Err is Human: Building a Safer Health System, the Department of Health and Human Services (HHS) realized the importance of coordinating existing and planned reporting systems, to establish a more useful database for information on patient safety and medical errors that is simpler to use and which reduces the burden of reporting on healthcare facilities and providers.

Federal agencies, States, accrediting bodies, and other organizations are already collecting data that can provide important insights into patient safety and the prevention of medical errors, and many of these groups have plans to expand their data collection systems independently. By coordinating these data collection initiatives, the Patient Safety Task Force will reduce the duplication of effort and the unnecessary burden on those who are providing information to these systems, thus encouraging more complete and comprehensive reporting of data.

To facilitate this coordination, HHS has established a Patient Safety Task Force to:

• Coordinate integrating data collection on medical errors and adverse events.
• Coordinate research and analysis efforts.
• Promote collaboration on reducing the occurrence of injuries that result from medical errors.

The activities of the Patient Safety Task Force will contribute to the Nation's efforts in reducing the number of medical errors.

Task Force Composition

The Patient Safety Task Force will serve as a special task force under the HHS Secretary's Quality Improvement Initiative. The Patient Safety Task Force consists of representatives from:

• Agency for Healthcare Research and Quality (AHRQ).
• Centers for Disease Control and Prevention (CDC).
• Food and Drug Administration (FDA).
• Centers for Medicare & Medicaid Services (CMS).

Mission

The mission of the Task Force is to partner with other Federal agencies, States, and private-sector organizations to develop information that will help to avert risks to patients. The Task Force will:

• Coordinate collection and analysis of data from existing and developing Federal systems that will help avert risks to patient safety.
• Communicate with other initiatives regarding reporting systems and safe practices.
• Provide the results of its analyses to the health care community, so that it can reduce errors and improve patient safety while still maintaining confidentiality of information.
• Conduct research, demonstration projects, and quality improvement programs aimed at promoting patient safety.
• Promote effective patient safety programs and strategies to the public and the health care community.
• Monitor rates of risk factors and actual patient harm.

A Coordinated Reporting System

The Patient Safety Task Force will work to eliminate the barriers to partnership and collaboration. A goal of this effort is to minimize the burden of reporting adverse events and errors by supporting the development of:

• Appropriate computer networks.
• User-friendly reporting systems.
• Standards for coding the content of the reports.

The Patient Safety Task Force will spearhead the development of a coordinated system for collecting data to reduce patient risk. Collection of two kinds of data is currently anticipated:

• First, AHRQ will support a series of demonstration projects to identify the causes of errors and to develop evidence-based systems for reducing errors and mitigating potential harm when they do occur.
• Second, data on adverse events from CDC's National Healthcare Safety Network and FDA's reports on adverse events will be part of the coordinated system.

To ensure minimal burden, the coordinated data collection system should:

• Be easy to use. The system should be manageable and feature a uniform data collection method, so that those being asked to report are not frustrated by cumbersome and inconsistent formats. Frustration could lead to underreporting, and the health care system will show little gain for the expense of creating the system.
• Provide reliable, valid information. The system should facilitate Federal agencies, States, and private-sector organizations in fulfilling their missions. If they receive inaccurate or incomplete information, or it does not meet their needs, they may seek to develop new systems that fragment national efforts to improve patient safety.
• Maintain confidentiality. The confidentiality of individual patients and providers in the reported information should be paramount.

Patient Safety Programs

Patient safety programs will build on the information gained from the national database and other resources and will identify and promote practices that prevent errors and protect patients. These programs will include:

• Patient Safety Demonstration Projects. These demonstration projects will help identify the best methods to detect errors and adverse events, encourage accurate reporting, determine the underlying causes of errors, evaluate the impact of errors on patients, and evaluate the most successful strategies to help clinicians and health care agencies prevent errors.

  This information is essential to ensure a scientific basis for strategies and tools to reduce errors and adverse events, and minimize their impact on patients if they do occur. Lessons learned from these projects will be widely disseminated to other facilities through CMS's Peer Review Organizations (PROs) and other mechanisms.

• National Benchmarks and Other Comparative Data for Patient Safety Promotion. These projects initially will develop accurate assessments of certain classes of adverse events. In the longer term, this project aims to collect reliable rates of patients' risks of errors, which can be used for comparing progress in error reduction among similar facilities. Such comparisons will alert facilities whether they need to improve their error reduction efforts and help integrate patient safety into their general quality improvement program.

Products

To achieve its mission, the Task Force will create:

1. A coordinated reporting system that is easy to use for the person reporting errors and adverse events.
2. A common vocabulary that enables data to be shared, compared, analyzed, and evaluated.
3. A network for reporting that retains confidentiality of clinicians and patients and that allows access by each agency or organization that needs to use the reported information.
4. An analysis and research function that allows the reports of errors to be evaluated, safety hazards to be identified, and safety improvements to be evaluated for their effectiveness.
5. Information on the implementation of patient safety best practices within Federal programs.
6. Information dissemination and technical assistance to public- and private-sector organizations that use this information to improve patient safety.
7. A report that evaluates the Task Force's progress toward meeting its mission.

For More Information

To obtain more information about the Patient Safety Task Force and its activities, contact:

James B. Battles, Ph.D.
Senior Service Fellow for Patient Safety
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
(301) 427-1332 voice
(301) 427-1341 fax
JBattles@ahrq.gov

To obtain more information about specific programs at participating agencies, contact the following agency representatives:

AHRQ
Dan Stryer, M.D.
Acting Director, Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
(301) 427-1300 voice
DStryer@ahrq.gov

CDC
Steven L. Solomon, M.D.
Acting Director, Division of Health Care Quality Promotion
Centers for Disease Control and Prevention
1600 Clifton Road
Mail Stop A-07
Atlanta, GA 30333
(404) 498-1175
ssolomon@cdc.gov

FDA
Chris Bechtel R.N., M.S.N.
Science Policy Analyst
Office of Executive Programs
CDER/FDA
HFD-006 c/o Parklawn Building
5600 Fishers Lane
Rockville, MD 20857
(301) 594-5458
bechtelc@cder.fda.gov

CMS
Stephen F. Jencks, M.D., M.P.H.
Director, Quality Improvement Group
Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services
Mail Stop S3-02-01
7500 Security Blvd.
Baltimore, MD 21244-1850
(410) 786-6508
SJencks@hcfa.gov

Current as of July 2003

Internet Citation:

Patient Safety Task Force. Fact Sheet. July 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/taskforce/psfactst.htm

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