Patient Safety Improvement Fact Sheet

The Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System [1999] revealed the following staggering, tragic statistics:

• 4,000-98,000 preventable deaths occur annually due to medical error.
• 7,000 preventable deaths related to medication errors alone.

In July 2004, HealthGrades published a study, Patient Safety in American Hospitals, concluding that there were over one million adverse events associated with Medicare hospitalizations during 2000-2002. And up to 195,000 accidental deaths per year occurred in American hospitals.

The Centers for Disease Control has reported that each year 2,000,000 (2 Million) patients acquire an infection during a hospital stay - and 90,000 of those patients ultimately die from the complications brought on by those infections. The overall impact of hospital acquired infections is an increase in our nation's health costs by over 25 billion dollars.

A conservative average of both the IOM and HealthGrades reports indicates that there have been between 400,000-1.2 million error-induced deaths (and countless errors) during 1996 - 2006. These casualties have been, in part, attributed to:

• Poor communication among care providers;
• Separated / segregated polices, programs and disconnected reporting systems within one hospital;
• Gaps and overlaps of hospital committees and task groups, many under the impression that action is being taken by other groups;
• Insufficient means to identify and measure patient safety improvement initiatives in order to analyze contributory issues and identify improvement strategies.

"What are you doing to improve patient safety? What are you doing to identify and control risks, measure and improve your performance and reduce your legal and regulatory exposure?"

It is not by accident that these are the 2 most challenging questions assessed by all regulators and the insurance companies before they score your hospital's performance. The public information and health care industry literature has confirmed that there is a silent crisis underway in healthcare. This crisis can be calibrated by the increasing frequency of headlines announcing yet another tragic, avoidable death or injury caused by medical errors. The Federal Government, JCAHO, insurance company payers and patient advocacy groups are all watching patient error rates and the hospitals where they occur.

Garry M. Walsh, president of Hospital Policy Net, Inc. also serves in the capacity of expert legal witness for hospitals that must defend appropriate, error-free care when it is questioned during legal proceedings. He knows that the minutia of an organization's policies, procedures, documentation, staff training / competency even remotely related to the suspected error --undergoes a microscopic review. Teams of attorneys and experts review your documentation endlessly, to uncover the basis and cause of suspected error(s).

Then a legal battle is launched to arrive at the facts and the truth. The legal community is also watching medical errors.

We have included 7 specific handouts to help you educate and engage your patients in the practice of safe care. Patients' increasing willingness to participate more actively in their own care is clearly telling us that they, too, are watching.

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How long would it take you right now to assemble your top 60 PS plans, policies, documentation forms, staff training tools and all PS quality indicators that stretch across at least eight (8) departments and divisions? Have you identified at least 130 PS-related aspects of care and service that you can measure and target for improvement?

Our Complete Patient Safety Improvement (PSI) Pack 2 CD-ROM Set catalogues over 60 practical plans, policies, forms and staff training tools. Our PSI tools are cohesively integrated to immediately enable you to:

• Identify of all your hospital' s safety risks;
• Quickly implement the needed planning and training activities;
• Measure all targeted compliance goals;
• Perform common-sense performance analysis;
• Streamline the reporting of patient safety risks, improvement opportunities and accomplishments by one group, be it the CEO Leadership team, the Medical Staff Executive Committee or the Board of Directors, in one report;
• Utilize only the minimal number of hospital leaders to plan, design, implement, measure and act and self-assessment strategies that can be deployed throughout the patient's continuum of care.

Our Patient Safety Improvement (PSI) solutions do not require investment of funds for:

• Medical or computer equipment;
• Facility redesign;
• Recruitment of additional staff.

Our hospital-tested PSI program utilizes existing human and information technology resources to identify-measure-and improve over 130 error-prone activities when it really counts& Before these activities inflict harm on your patients and jeopardize your legal and accreditation standing in your community.

Prior to publishing our PSI Solution Pack (as with all of our health care improvement compendia), we installed and implemented our strategies, programs, plans, policies and documentation forms in hospitals throughout the country to put our work to the real test. To date, there has been no JCAHO recommendation cited against any of our PSI tools. To learn more, please visit On-Site Consulting Success Stories.

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