1. Rosenthal 1 Federal and State Efforts to Improve Patient Safety Jill Rosenthal, MPH National Health Policy Conference February 7, 2006

2. Rosenthal 2 v National Academy for State Health Policy v © Feb 2006 v Medical Errors and Patient Safety Medical errors are a problem of epidemic proportions –44,000 to 98,000 hospitalized patients die per year –Errors in outpatient and nursing home care –Errors of ommission –$17-29 billion from preventable errors Over 1/2 of costs are direct health care –Average increased cost of medication error = $4,700 per admission

3. Rosenthal 3 v National Academy for State Health Policy v © Feb 2006 v Systems Problems Errors occur because of systems problems –Shift focus from blaming individuals to safety improvement Preventing errors means designing safer systems of care

4. Rosenthal 4 v National Academy for State Health Policy v © Feb 2006 v IOM Recommendations National focus on safety Identify and learn from errors Set performance standards and expectations for safety Implement safety systems within health care organizations

5. Rosenthal 5 v National Academy for State Health Policy v © Feb 2006 v Identify and Learn from Errors: Reporting Systems Mandatory –In all states –Smaller number of serious events –Hold institutions accountable Voluntary –Promote existing systems –Larger number of near misses –Identify system weaknesses

6. Rosenthal 6 v National Academy for State Health Policy v © Feb 2006 v Snapshot of Federal response Patient Safety and Quality Improvement Act of 2005 AHRQ Patient Safety Network, Web M&M, grants, conferences VA National Center for Patient Safety DHHS Hospital Compare

7. Rosenthal 7 v National Academy for State Health Policy v © Feb 2006 v Snapshot of state responses Reporting systems and other regulatory approaches Patient safety centers Patient safety coalitions Purchasing for safety

8. Rosenthal 8 v National Academy for State Health Policy v © Feb 2006 v State Reporting Systems 25 states have authorized adverse event reporting programs (Dec 2005) Accountability –Identification of system weaknesses and assurance of corrective actions Facility education –Patient safety alerts –Identification of trends and best practices –Web-based facility comparisons

9. Rosenthal 9 v National Academy for State Health Policy v © Feb 2006 v Reporting System Improvement Maximizing the Use of State Adverse Event Data to Improve Patient Safety –Data coming out is only as good as data going in –Anecdotal vs. epidemiological analysis –Identification of tools, strategies, and shared learning for system improvement NASHP patient safety toolbox for states: www.pstoolbox.org www.pstoolbox.org Supported by The Commonwealth Fund

10. Rosenthal 10 v National Academy for State Health Policy v © Feb 2006 v NASHP resources NASHP website: www.nashp.orgwww.nashp.org –patient safety toolbox for states –adverse event reporting laws –NASHP patient safety news briefs and publications –state resources on patient safety

11. Rosenthal 11 v National Academy for State Health Policy v © Feb 2006 v Todays speakers Vahe Kazandjian, Maryland Patient Safety Center Alan Rabinowitz, Pennsylvania Patient Safety Authority William Weeks, VA National Center for Patient Safety and VA Outcomes Group