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Issue 2 (18th April 2002)

A L Scheffler

Agency for Healthcare Research and Quality (US)
Quality of health care: Q-Pack
( groups AHRQ�s quality and safety materials for consumers, including Spanish-language versions. In AHRQ focus on research: patient safety (, 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 (, 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" (

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 ( A PDF version is also available (

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?
( 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 A web cast and transcript of the hearing are available at

Medicare Payment Advisory Commission (US)
MedPAC�s report to the US Congress, Applying quality improvement standards in Medicare, (, 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 ( 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 ( 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 ( A current literature review is also available (

Patient Safety Reporting System (US)
The Veterans Health Administration (VHA) is rolling out a medical incident reporting system ( 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" (

Scottish Executive (UK)
The right medicine: a strategy for pharmaceutical care in Scotland
( 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 (
 "Accountability in Clinical Research: Balancing Risk & Benefit" � Indianapolis, 24�26 April 2002 ( 
"The Changing Health Care System: An Anglo-American Dialogue" � New York City, 25�26 April 2002 ( 
"National Human Research Protections Advisory Committee" � Washington, DC, 29�30 April 2002 ( 
"Patient Safety: Are We Doing Enough?" � Fremantle, Western Australia, 2�3 May 2002 ( 
"Institute of Medicine Committee on Patient Safety Data Standards" � Washington, DC, 6 May 2002 ( 
"Who�s in the Driver�s Seat? Leading Efforts in Consumer-Centered Care" � Washington, DC, 15 May 2002 ( 
"Chaos Collaboration Change: Improving Quality in Health Care" � Minneapolis, 16�17 May 2002 ( 
"International Summit on Innovations in Patient Safety" � Salt Lake City, 12�14 June 2002 ( 
"Using Measurement and Evidence-Based Strategies to Improve Health Care" �
Copenhagen, 19�21 June 2002 ( 
"10th Cochrane Colloquium" � Stavanger, Norway, 31 July�3 August 2002 ( 
"International Conference on Communication in Healthcare" � Warwick University, 18�20 September 2002 ( 
"2ndAsia Pacific Forum on Quality Improvement in Health Care" � Singapore, 11�13 September 2002 ( 
"Partnership Symposium 2002: Smart Designs for Patient Safety" � Washington, DC, 14�16 October 2002 ( 
"19th International Conference of the International Society for Quality in Health Care" � Paris, 5�8 November 2002 ( 
"14th National Forum on Quality Improvement in Health Care" � Orlando, 8�11 December 2002 (

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 (

Broken links
tries to ensure that featured links (URLs) are working at the time of publication. However, sites change their content frequently; resources are moved, deleted, or go private; servers crash; and we make editorial mistakes. Please let us know about any broken or incorrect links you encounter 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}