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Issue 2 (18th April 2002)
Agency for Healthcare Research and Quality (US)
Quality of health care: Q-Pack (http://www.ahrq.gov/consumer/pathqpack.htm)
groups AHRQ�s quality and safety materials for consumers, including
Spanish-language versions. In AHRQ focus on research: patient safety (http://www.ahrq.gov/news/focus/ptsafety.htm),
the agency updates its patient safety portfolio.
Commonwealth Fund (US)
A new report by Karen Davis et al, Room for improvement: patients report
on the quality of their health care (http://www.cmwf.org/programs/quality/davis_improvement_534.pdf),
estimates that 8.1 million American households have at least one member who has
experienced a serious medical or drug error. That figure is based on a survey of
6722 adults in 2001. The report states that "the Institute of Medicine
report on medical errors, To Err Is Human: Building a Safer Health System,
which reported 44,000 to 98,000 deaths annually, may be only the tip of the
iceberg concerning the adverse health consequences for patients resulting from
medical errors." See also from Reuters Health: "Missed opportunities,
errors undermine health care" (http://www.reutershealth.com/archive/2002/04/16/eline/links/20020416elin039.html).
ECRI (US)
ECRI, with support from the American Association of Health Plans (AAHP) and
Pfizer, Inc., has published Should I enter a clinical trial? A patient
reference guide for adults with a serious or life-threatening illness (http://www.ecri.org/documents/bctoc2.html).
A PDF version is also available (http://www.aahp.org/InternalLinks/CT_book.pdf).
European Forum
The "7th European Forum on Quality Improvement in Health Care"
(organized by the BMJ Publishing Group and the Institute for Healthcare
Improvement) took place in Edinburgh in March. In his closing keynote, IHI
President Donald Berwick challenged delegates to develop interdisciplinary
scientific centres worldwide "to study the sources of hazard and
risk."
Institute of Medicine (US)
The anthrax vaccine: is it safe? Does it work? (http://www.nap.edu/catalog/10310.html)
provides an expert assessment of the efficacy and safety of current US anthrax
vaccine stores.
Legislative hearing (US)
On 7 March, the House Health Subcommittee held a hearing on "Health
Quality and Medical Errors." Most members did not attend, and the hearing
adjourned abruptly because of a competing vote on the House floor. The prepared
testimonies of Donald Berwick of IHI, Karen Wolk Feinstein of the Pittsburgh
Regional Healthcare Initiative, and other witnesses are archived at http://waysandmeans.house.gov/health/107cong/hl-13wit.htm.
A web cast and transcript of the hearing are available at http://www.kaisernetwork.org/health_cast/hcast_index.cfm.
Medicare Payment Advisory Commission (US)
MedPAC�s report to the US Congress, Applying quality improvement
standards in Medicare, (http://www.medpac.gov/publications/congressional_reports/jan2002_QualityImprovement.pdf),
concludes that Medicare "has multiple tools to stimulate quality
improvement efforts. It can: act as a regulator and establish standards and
measures; act as a purchaser and reward high performance; act as an advisor and
help plans and providers measure and improve care; and act as a researcher,
either alone or in coordination with others such as the Agency for Healthcare
Research and Quality (AHRQ), to further develop the science of quality
improvement."
National Patient Safety Agency (UK)
The NPSA (http://www.npsa.org.uk/) was
officially launched at a reception on 20 March. In a remark reminiscent of the
late John Eisenberg, Lord Hunt (Under Secretary of State for Health) stated:
"The National Patient Safety Agency is here to help."
National Quality Forum (US)
NQF (http://www.qualityforum.org/)
is inviting public comment on two draft reports: Making healthcare safer for
patients: evidence-based practices, and Nursing home performance measures.
The site also provides an order blank for Serious reportable events in
healthcare.
National Surgical Infection Program (US)
The Centers for Medicare & Medicaid Services (CMS) and the Centers for
Disease Control and Prevention (CDC) are developing a national healthcare
quality improvement project to prevent postoperative infections (http://www.surgicalinfectionprevention.org/).
A current literature review is also available (http://www.surgicalinfectionprevention.org/literature.html).
Patient Safety Reporting System (US)
The Veterans Health Administration (VHA) is rolling out a medical incident
reporting system (http://psrs.arc.nasa.gov/)
that adapts methodology developed for aviation by NASA�s Ames Research Center
in California. A brochure describes PSRS as a voluntary "learning
program" that VHA staff may use to report "close calls,"
"unexpected serious occurrences that involved a death, physical injury, or
psychological injury of a patient or employee," and "lessons learned
or safety ideas" (http://psrs.arc.nasa.gov/web_docs/PSRS_Brochure.pdf).
Scottish Executive (UK)
The right medicine: a strategy for pharmaceutical care in Scotland (http://www.scotland.gov.uk/library3/health/pcis-00.asp)
sets out a four-year action plan to modernise pharmacy services in Scotland.
Plans for 2002 include establishing a Scottish Centre for Adverse Drug Reactions
Reporting, and exploring "effective strategies to empower and inform
patients and the public about medicines."
Upcoming meetings
"Patient Safety: Let�s Get Practical" � Indianapolis, 22�24
April 2002 (http://www.mederrors.org/).
"Accountability in Clinical Research: Balancing Risk & Benefit"
� Indianapolis, 24�26 April 2002 (http://www.researchsafety.org/).
"The Changing Health Care System: An Anglo-American Dialogue" � New
York City, 25�26 April 2002 (http://www.nyam.org/events/hcaresystem.shtml).
"National Human Research Protections Advisory Committee" �
Washington, DC, 29�30 April 2002 (http://ohrp.osophs.dhhs.gov/nhrpac/mtg04-02/agen0402.pdf).
"Patient Safety: Are We Doing Enough?" � Fremantle, Western
Australia, 2�3 May 2002 (http://www.archi.net.au/conferencediary/FinalMay_Prog0404.pdf).
"Institute of Medicine Committee on Patient Safety Data Standards" �
Washington, DC, 6 May 2002 (http://www4.nas.edu/webcr.nsf/MeetingDisplay1/HCSX-H-01-05-A?OpenDocument).
"Who�s in the Driver�s Seat? Leading Efforts in Consumer-Centered
Care" � Washington, DC, 15 May 2002 (http://www.facct.org/invite.htm).
"Chaos � Collaboration �
Change: Improving Quality in Health Care" � Minneapolis, 16�17 May
2002 (http://www.icsi.org/colloq/intro.htm).
"International Summit on Innovations in Patient Safety" � Salt Lake
City, 12�14 June 2002 (http://www.ihi.org/conferences/summit/pssummitindex.asp).
"Using Measurement and Evidence-Based Strategies to Improve Health
Care" � Copenhagen, 19�21 June 2002 (http://www.jcrinc.com/education.asp?durki=573).
"10th Cochrane Colloquium" � Stavanger, Norway, 31 July�3
August 2002 (http://www.cochrane.no/colloquium/).
"International Conference on Communication in Healthcare" � Warwick
University, 18�20 September 2002 (http://www.each2002.com/).
"2ndAsia Pacific Forum on Quality Improvement in Health
Care" � Singapore, 11�13 September 2002 (http://web3.bma.org.uk/forms.nsf/confweb/JBEY-566EDN).
"Partnership Symposium 2002: Smart Designs for Patient Safety" �
Washington, DC, 14�16 October 2002 (http://www.p4ps.org/symposium2002.html).
"19th International Conference of the International Society for Quality in
Health Care" � Paris, 5�8 November 2002 (http://www.isqua.org.au/isquaPages/Conferences.html#Anchor-PARIS-11481).
"14th National Forum on Quality Improvement in Health Care" �
Orlando, 8�11 December 2002 (http://www.ihi.org/conferences/natforum/justfacts02.asp).
Update
We were confused last issue in citing the work of the Australian Council for
Safety and Quality in Health Care. The report published by the Council in August
2001 is Safety in practice: making health care safer (http://www.safetyandquality.org/articles/publications/cfsafety.pdf).
Broken links
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in this issue.
Adam L Scheffler is a freelance writer and policy researcher based in Chicago. He can be contacted at a-scheffler-1{at}alumni.uchicago.edu.