Doing What Counts for Patient Safety:

Contents

Quality Interagency Coordination Task Force

Executive Summary and Actions

A National Problem of Epidemic Proportion
The Clinton–Gore Administration's Commitment to Improving Patient Safety
Institute of Medicine Recommendations
A Road Map for Action: The Federal Response
Creating a National Focus to Enhance the Knowledge Base on Patient Safety
Setting Performance Standards and Expectations for Safety
Implementing Safety Systems in Health Care Organizations
Additional Federal Actions to Improve Patient Safety
Conclusion

Compendium of Action Items

Introduction—Errors: Part of a Broader Quality Agenda

The IOM Report
The President’s Directive

Growing Concerns About Medical Errors
Definitions and Context

Figure 1. Framework for Identifying Errors
A Framework for Thinking About Errors

Lessons from other industries
Unique aspects of health care errors
Impact of organizational and professional culture
A global challenge

Evidence of Errors

The epidemiology of medical errors
Adverse events and medical products use or misuse
Current programs to prevent errors
Accomplishments of programs to prevent medical errors
Insufficiency of existing programs

Chapter 2—Federal Response to the IOM Report

National Focus and Leadership

Center for Patient Safety-- Actions
Research Planning-- Actions
Identifying and Learning From Errors

Accountability-- Actions
Learning from Errors
Characteristics of an Ideal Reporting System for Learning-- Actions
Analysis and Feedback
Peer Review Protections --;Actions
Setting Performance Standards and Expectations for Safety

Raising the Standards for Health Care Organizations-- Actions
Raising the Standards for Health Care Professionals-- Actions
Safe Use of Drugs and Devices-- Actions
Implementing Safety Systems in Health Care Organizations-- Actions
Framework for Reporting Systems

Building Public Awareness of Medical Errors-- Actions
Building Purchasers’ Awareness of the Problem-- Actions
Working with Providers to Improve Patient Safety-- Actions
Using Decision-support Systems and Information Technologies-- Actions
Using Standardized Procedures, Checklists, and the Results of Human Factors Research-- Actions

Standards --; Actions
Data Integration--Actions

References

Glossary

Organization and Acronym Guide
Glossary of Terms