Patient safety organization


A patient safety organization is an organization that seeks to improve medical care by advocating for the reduction of medical errors. Common functions of patient safety organizations include health care data collection, reporting and analysis on health care outcomes, educating providers and patients, raising funds to improve health care, and advocating for safety-oriented policy changes. In the United States, the term typically refers only to PSOs that have been formally recognized by the Secretary of Health and Human Services and listed with the Agency for Healthcare Research and Quality. A federally-designated PSO differs from a typical PSO in that it provides health care providers in the U.S. privilege and confidentiality protections in exchange for efforts to improve patient safety.
In the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable errors and deficiencies in health care, among them adverse events and complications arising from poor infection control. In the United States, a 1999 report from the Institute of Medicine called for a broad national effort to prevent these events, including the establishment of patient safety centers, expanded reporting of adverse events, and development of safety programs in healthcare organizations. Although many PSOs are funded and run by governments, others have sprung from private entities such as industry, professional, health insurance providers, and consumer groups.

Functions

The functions of a PSO can be diverse, but the United States government formally defines "patient safety activities" as:
  1. Efforts to improve patient safety and the quality of health care delivery.
  2. The collection and analysis of patient safety work product.
  3. The development and dissemination of information with respect to improving patient safety, such as recommendations, protocols, or information regarding best practices.
  4. The utilization of patient safety work product for the purposes of encouraging a culture of safety and of providing feedback and assistance to effectively minimize patient risk.
  5. The maintenance of procedures to preserve confidentiality with respect to patient safety work product.
  6. The provision of appropriate security measures with respect to patient safety work product.
  7. The utilization of qualified staff.
  8. ''Activities related to the operation of a patient safety evaluation system and to the provision of feedback to participants in a patient safety evaluation system.''

    Governmental organizations

World Health Organization

World Alliance for Patient Safety

In response to a 2002 World Health Assembly Resolution, the World Health Organization launched the World Alliance for Patient Safety in October 2004. The goal was to develop standards for patient safety and assist UN member states to improve the safety of health care. The Alliance raises awareness and political commitment to improve the safety of care and facilitates the development of patient safety policy and practice in all WHO Member States. Each year, the Alliance delivers a number of programs covering systemic and technical aspects to improve patient safety around the world.
At the Fifty-Ninth World Health Assembly in May 2006, the Secretariat reported that the Alliance held patient safety meetings in five of the six WHO regions and 40 technical workshops in 18 countries. Since the launch of the Alliance in October 2004, significant progress was achieved in six areas:
  1. The First Global Patient Safety Challenge, which for 2005–2006 developed the WHO Guidelines on Hand Hygiene in Health Care.
  2. A patient involvement group, Patients for Patient Safety, built networks of patients’ organizations from around the world, through regional workshops.
  3. A patient safety taxonomy was developed to classify data on patient safety problems.
  4. Prevalence studies conducted on patient harm in ten developing countries.
  5. A WHO Collaborating Centre was established to develop and disseminate safety solutions.
  6. The WHO Draft Guidelines on Adverse Event Reporting and Learning Systems.

    Patients for Patient Safety (PFPS)

Patients for Patient Safety is part of the World Alliance for Patient Safety launched in 2004 by the WHO. The project emphasizes the central role patients and consumers can play in efforts to improve the quality and safety of healthcare around the world. PFPS works with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programs, both within countries and in the global programs of the World Alliance for Patient Safety.

Australia and New Zealand

Therapeutic Goods Administration and Adverse Drug Reactions Advisory Committee

The Therapeutic Goods Administration is a unit of the Australian Government Department of Health and Ageing. The TGA approves and monitors prescription and non-prescription drugs, medical supplies and devices and blood and biological products. Risks to users are assessed prior to product introduction, and manufacturers are regularly audited for efficacy, quality and safety. Manufacturers are required to report adverse drug effects to the Adverse Drug Reactions Advisory Committee of the TGA; reporting by medical professionals and consumers is voluntary. ADRAC notifies medical professionals and the public through recalls and alerts on its website and publications.
In December 2003, the Australian and New Zealand Governments signed an agreement to establish a joint regulatory organisation for therapeutic products. The Australia New Zealand Therapeutic Products Authority will replace the Australian Therapeutic Goods Administration and the New Zealand Medicines and Medical Devices Safety Authority, and be accountable to the Australian and New Zealand Governments. Implementing legislation is scheduled for introduction into both countries' parliaments in July 2006.
On 16 July 2007, the New Zealand State Services Minister Annette King announced that "The Government is not proceeding at this stage with legislation that would have enabled the establishment of a joint agency with Australia to regulate therapeutic products." She further advised that "The Government does not have the numbers in Parliament to put in place a sensible, acceptable compromise that would satisfy all parties at this time. The Australian Government has been informed of the situation and agrees that suspending negotiations on the joint authority is a sensible course of action."

Australian Commission on Safety and Quality in Health Care

The Australian Commission on Safety and Quality in Health Care was established by the Australian, State and Territory Governments to lead and coordinate national improvements in safety and quality. The Commission replaced the Australian Council for Safety and Quality in Health Care in 2006.
The Commission engages in collaborative work in patient safety and healthcare quality that benefits from national coordination. This includes the development of the Australian Charter of Healthcare Rights and the National Safety and Quality Health Service Standards, improving areas such as patient identification, medication safety, clinical handover and open disclosure, and reducing healthcare associated infection. The commission has also developed the National Safety and Quality Framework to improve the safety and quality of the Australian health system.
Other key areas of work for the Commission include National Health Service accreditation, recognising and responding to clinical deterioration, patient centred care, safety and quality in mental health and primary care and the development of national safety and quality indicators as part of the information strategies activity.
In its role primarily as a coordination and facilitation body, the Commission utilises evidence and data and the experience, enthusiasm and commitment of consumers, clinicians, managers and other stakeholders to influence the system to make changes for the safety and quality of health care in Australia.

New Zealand Health Quality & Safety Commission

The New Zealand Health Quality & Safety Commission was established in November 2010 as a Crown entity under the New Zealand Public Health and Disability Act 2000 to lead and co-ordinate work across the health and disability sector for the purposes of:
  • monitoring and improving the quality and safety of health and disability support services
  • helping providers across the whole sector to improve the quality and safety of services.
The Commission aims to reduce avoidable deaths and harm, reduce wastage, and make the best use of the health dollar. It works towards the New Zealand Triple Aim for quality improvement:
  • improved quality, safety and experience of care
  • improved health and equity for all populations
  • best value for public health system resources.
Commission programs include medication safety, infection prevention and control, reportable events, consumer engagement and participation, and mortality review committees.

United Kingdom

National Patient Safety Agency

The National Patient Safety Agency is an NHS special health authority created in July 2001 to improve patient safety within the National Health Service by encouraging voluntary reporting of medical errors, conducting analysis and initiating preventative measures. Since 2005, the NPSA has also been responsible for: safety aspects of hospital design, cleanliness and food; safe research practices through the National Research Ethics Service ; and the performance of individual doctors and dentists, through the National Clinical Assessment Service. The NPSA identifies patient safety deficiencies with the input of clinical experts and patients, develops solutions and monitors results of corrections within the NHS. Initiatives and alerts include hand hygiene, information for doctors and patients on steps to reduce the risk of error, vaccine safety and disclosure of errors to injured patients. In addition, the National Reporting and Learning System allows NHS employees to provide the NPSA with reports anonymously.