Leading patient safety organization(s) | National Patient Safety Agency* | Health Canada (HC); Canadian Institute for Health Information (CIHI) and the Canadian Institutes of Health Research (CIHR); National Steering Committee on Patient Safety (NSCPS) | Australian Council for Safety and Quality in Health Care (ACSQHC); Australian Patient Safety Foundation (APSF) | Agency for Healthcare Research and Quality (AHRQ); National Patient Safety Foundation (NPSF); Joint Commission on Accreditation of Healthcare Organizations (JCAHO) |
Nature | Special health authority set up by the UK government (Statutory Instrument 2001 No. 1743) | HC: Federal Ministry of Health, Canada; CIHI: independent, not-for-profit body for quality health information; CIHR: premier federal agency for health research; NSCPS: an organ of the Royal College of Physicians and Surgeons | ACSQHC: national council set up by the Australian Federal Health Ministers; APSF: non-profit independent organization dedicated to the advancement of patient safety | AHRQ: nationally authorized agency for quality and safety research; NPSF: not-for-profit, multi-disciplinary body; JCAHO: independent, not-for-profit, standards setting and accrediting body in health care |
Web address |
www.npsa.nhs.uk
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www.hc-sc.gc.ca
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www.safetyandquality.org
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www.ahrq.org
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www.cihi.ca
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www.apsf.net.au
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www.npsf.org
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www.cihr.cahttp://rcpsc.medical.org
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www.jcaho.org
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Year national safety program started | July 2001 | May 2002 (CIHI/CIHR hospital safety study funding) | 2000 (ACSQHC); | 2000 (AHRQ); |
| 1989 (APSF) | 1998 (NPSF); |
| | | 1996§; 2002** (JCAHO) |
Mission | To coordinate efforts to learn from adverse events and ‘near misses’ in the NHS; to promote openness and fairness, lead reporting and feedback; to monitor progress; to promote an open and fair culture in the NHS | HC: To coordinate national safety agenda; CIHI/CIHR: To examine the extent of adverse events in Canadian acute care hospitals and availability of data for continuous monitoring and reduction of events; RCPS NSCPS: To develop framework and plan for Canadian patient safety efforts | ACSQHC: To lead a national and collaborative approach to improve safety and quality of patient care; to develop a national framework, put the consumer first and promote research; APSF: To eliminate preventable harm in health care | AHRQ: To support research designed to improve the outcomes and quality of health care, reduce its costs, address patient safety and medical errors; NPSF: To improve patient safety knowledge and awareness JCAHO: To ensure a greater focus on priority safe practices |
Operational mechanism | Establishing and operating a new, mandatory national reporting system for adverse events and “‘near misses”; provision of national leadership and guidance | CIHI/CIHR: Reviewing randomly selected patient hospital records by specially-trained physicians and nurses who belong to the research team | ACSQHC: Using annual action plans to achieve its priority areas; committing to a National Patient Safety Research Centre, a National Centre for Patient Safety Improvement, system capacity building, accreditation and standard setting mechanisms; | AHRQ: Developing error-reduction technologies; conducting safety demonstration projects and error reporting strategies; supporting safety research NPSF: Identifying and applying safety pathways; raising public awareness; JCAHO: Rolling safety goals for accreditation; reporting and analysis of sentinel events |
| | | APSF: Using its Australian Incident Monitoring System |
Remarkable public event(s) on patient safety | Shipman and Ledward affairs;29,
30 high profile intrathecal vincristine deaths,31 etc; Bristol case 1996 (2001 inquiry report);27,
28
An Organization with a Memory, Building a Safer NHS for Patients
8,
9 | Lack of prior nationally coordinated safety initiative; error incidence unknown10,
11 | Incident monitoring in anesthesia (1987/88);43 the Quality in Australian Health Care Study (1995)38 | Harvard Medical Practice studies (1991/1995);36,
37 NPSF’s Annenberg conferences (1996, 1998, 2001, 2002);51 IOM’s report: ‘To Err is Human’ (1999/2000)5 |