Discussion: National Patient Safety Goals

Discussion: National Patient Safety Goals ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Discussion: National Patient Safety Goals I need an explanation for this Psychology question to help me study. Discussion: National Patient Safety Goals The groundbreaking report, To Err Is Human , provided alarming data regarding the impact of medical errors in health care. Many health care organizations are actively working toward improving the quality and safety of care provided to their patients through various programs and initiatives. Discussion: National Patient Safety Goals For this discussion, research the Joint Commission’s NPSGs. Choose a health care setting from the 2019 NPSG Program Links on the web page. Follow the link and read through the goals related to that setting. Choose one of the goals to build your discussion around. In your post, explain why the goal is important, what its purpose is, and why you feel it should be a targeted area for improvement. Cite your sources using current APA style. 300-400 words. err_.pdf THE NATIONAL ACADEMIES PRESS This PDF is available at http://nap.edu/9728 SHARE ? ? ? ? To Err Is Human: Building a Safer Health System (2000) DETAILS 312 pages | 6 x 9 | HARDBACK ISBN 978-0-309-06837-6 | DOI 10.17226/9728 CONTRIBUTORS GET THIS BOOK Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine FIND RELATED TITLES SUGGESTED CITATION Institute of Medicine 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. https://doi.org/10.17226/9728. Visit the National Academies Press at NAP.edu and login or register to get: – Access to free PDF downloads of thousands of scienti?c reports – 10% off the price of print titles – Email or social media noti?cations of new titles related to your interests – Special offers and discounts ?? ? Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press. (Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences. Copyright © National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System To Err Is Human Building a Safer Health System Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors Committee on Quality of Health Care in America INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.Discussion: National Patient Safety Goals The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by The National Research Council and The Commonwealth Fund. The views presented in this report are those of the Institute of Medicine Committee on the Quality of Health Care in America and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data To err is human : building a safer health system / Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, editors. p. cm Includes bibliographical references and index. ISBN 0-309-06837-1 1. Medical errors—Prevention. I. Kohn, Linda T. II. Corrigan, Janet. III. Donaldson, Molla S. R729.8.T6 2000 362.1—dc21 99-088993 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055; call (800) 624-6242 or (202) 334-3313 in the Washington metropolitan area, or visit the NAP on-line bookstore at www.nap.edu. The full text of this report is available on line at www.nap.edu/readingroom. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Discussion: National Patient Safety Goals Dr. Bruce M. Discussion: National Patient Safety GoalsAlberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council. Copyright National Academy of Sciences. All rights reserved.Discussion: National Patient Safety Goals To Err Is Human: Building a Safer Health System Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. Kellogg Foundation, Battle Creek, MI DONALD M. BERWICK, President and CEO, Institute for Healthcare Improvement, Boston J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta LONNIE R. BRISTOW, Past President, American Medical Association, Walnut Creek, CA CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy Initiatives, General Electric Company, Fairfield, CT CHRISTINE K. CASSEL, Professor and Chairman, Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City MARK R. CHASSIN, Professor and Chairman, Department of Health Policy, Mount Sinai School of Medicine, New York City MOLLY JOEL COYE, Senior Vice President and Director, West Coast Office, The Lewin Group, San Francisco DON E. DETMER, Dennis Gillings Professor of Health Management, University of Cambridge, UK JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management Corporation, Boston BRENT JAMES, Executive Director, Intermountain Health Care, Institute for Health Care Delivery Research, Salt Lake City, UT DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health Plan, Inc., Oakland, CA LUCIAN LEAPE, Adjunct Professor, Harvard School of Public Health ARTHUR LEVIN, Director, Center for Medical Consumers, New York City RHONDA ROBINSON-BEALE, Executive Medical Director, Managed Care Management and Clinical Programs, Blue Cross Blue Shield of Michigan, Southfield JOSEPH E. SCHERGER, Associate Dean for Clinical Affairs, University of California at Irvine College of Medicine ARTHUR SOUTHAM, Partner, 2C Solutions, Northridge, CA MARY WAKEFIELD, Director, Center for Health Policy and Ethics, George Mason University GAIL L. WARDEN, President and CEO, Henry Ford Health System, Detroit v Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System Study Staff JANET M. CORRIGAN, Director, Division of Health Care Services, Director, Quality of Health Care in America Project MOLLA S. DONALDSON, Project Co-Director LINDA T. KOHN, Project Co-Director TRACY McKAY, Research Assistant KELLY C. PIKE, Senior Project Assistant Auxiliary Staff MIKE EDINGTON, Managing Editor KAY C. HARRIS, Financial Advisor SUZANNE MILLER, Senior Project Assistant Copy Editor FLORENCE POILLON vi Copyright National Academy of Sciences. All rights reserved. Discussion: National Patient Safety Goals To Err Is Human: Building a Safer Health System Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the review of this report: GERALDINE BEDNASH, Executive Director, American Association of Colleges of Nursing, Washington, DC PETER BOUXSEIN, Visiting Scholar, Institute of Medicine, Washington, DC JOHN COLMERS, Executive Director, Maryland Health Care Cost and Access Commission, Baltimore JEFFREY COOPER, Director, Partners Biomedical Engineering Group, Massachusetts General Hospital, Boston ROBERT HELMREICH, Professor, University of Texas at Austin vii Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System viii REVIEWERS LOIS KERCHER, Vice President for Nursing, Sentara-Virginia Beach General Hospital, Virginia Beach, VA GORDON MOORE, Associate Chief Medical Officer, Strong Health, Rochester, NY ALAN NELSON, Associate Executive Vice President, American College of Physicians/American Society of Internal Medicine, Washington, DC LEE NEWCOMER, Chief Medical Officer, United HealthCare Corporation, Minnetonka, MN MARY JANE OSBORN, University of Connecticut Health Center ELLISON PIERCE, Executive Director, Anesthesia Patient Safety Foundation, Boston Although the individuals acknowledged have provided valuable comments and suggestions, responsibility for the final contents of the report rests solely with the authoring committee and the Institute of Medicine. Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System Preface T o Err Is Human: Building a Safer Health System. The title of this report encapsulates its purpose. Discussion: National Patient Safety Goals Human beings, in all lines of work, make errors. Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing. Cars are designed so that drivers cannot start them while in reverse because that prevents accidents. Work schedules for pilots are designed so they don’t fly too many consecutive hours without rest because alertness and performance are compromised. In health care, building a safer system means designing processes of care to ensure that patients are safe from accidental injury. When agreement has been reached to pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the best chance possible of achieving the desired outcome. This report describes a serious concern in health care that, if discussed at all, is discussed only behind closed doors. As health care and the system that delivers it become more complex, the opportunities for errors abound. Correcting this will require a concerted effort by the professions, health care organizations, purchasers, consumers, regulators and policy-makers. Traditional clinical boundaries and a culture of blame must be broken down. But most importantly, we must systematically design safety into processes of care. This report is part of larger project examining the quality of health care ix Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System x PREFACE in America and how to achieve a threshold change in quality. The committee has focused its initial attention on quality concerns that fall into the category of medical errors. There are several reasons for this. First, errors are responsible for an immense burden of patient injury, suffering and death. Second, errors in the provision of health services, whether they result in injury or expose the patient to the risk of injury, are events that everyone agrees just shouldn’t happen. Third, errors are readily understandable to the American public. Fourth, there is a sizable body of knowledge and very successful experiences in other industries to draw upon in tackling the safety problems of the health care industry. Discussion: National Patient Safety Goals Fifth, the health care delivery system is rapidly evolving and undergoing substantial redesign, which may introduce improvements, but also new hazards. Over the next year, the committee will be examining other quality issues, such as problems of overuse and underuse. The Quality of Health Care in America project is largely supported with income from an endowment established within the IOM by the Howard Hughes Medical Institute and income from an endowment established for the National Research Council by the Kellogg Foundation. The Commonwealth Fund provided generous support for a workshop to convene medical, nursing and pharmacy professionals for input into this specific report. The National Academy for State Health Policy assisted by convening a focus group of state legislative and regulatory leaders to discuss patient safety. Thirty-eight people were involved in producing this report. The Subcommittee on Creating an External Environment for Quality, under the direction of J. Cris Bisgard and Molly Joel Coye, dealt with a series of complex and sensitive issues, always maintaining a spirit of compromise and respect. Additionally the Subcommittee on Designing the Health System of the 21st Century, under the direction of Donald Berwick, had to balance the challenges faced by health care organizations with the need to continually push out boundaries and not accept limitations. Lastly, under the direction of Janet Corrigan, excellent staff support has been provided by Linda Kohn, Molla Donaldson, Tracy McKay, and Kelly Pike. At some point in our lives, each of us will probably be a patient in the health care system. It is hoped that this report can serve as a call to action that will illuminate a problem to which we are all vulnerable. William C. Richardson, Ph.D. Chair November 1999 Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System Foreword T his report is the first in a series of reports to be produced by the Quality of Health Care in America project. The Quality of Health Care in America project was initiated by the Institute of Medicine in June 1998 with the charge of developing a strategy that will result in a threshold improvement in quality over the next ten years. Discussion: National Patient Safety Goals Under the direction of Chairman William C. Richardson, the Quality of Health Care in America Committee is directed to: • review and synthesize findings in the literature pertaining to the quality of care provided in the health care system; • develop a communications strategy for raising the awareness of the general public and key stakeholders of quality of care concerns and opportunities for improvement; • articulate a policy framework that will provide positive incentives to improve quality and foster accountability; • identify characteristics and factors that enable or encourage providers, health care organizations, health plans and communities to continuously improve the quality of care; and • develop a research agenda in areas of continued uncertainty. This first report on patient safety addresses a serious issue affecting the xi Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System xii FOREWORD quality of health care. Future reports in this series will address other qualityrelated issues and cover areas such as re-designing the health care delivery system for the 21st Century, aligning financial incentives to reward quality care and the critical role of information technology as a tool for measuring and understanding quality. Additional reports will be produced throughout the coming year. The Quality of Health Care in America project continues IOM’s longstanding focus on quality of care issues. The IOM National Roundtable on Health Care Quality described how variable the quality of health care is in this country and highlighted the urgent need for improving it. A recent report issued by the IOM National Cancer Policy Board concluded that there is a wide gulf between ideal cancer care and the reality that many Americans experience with cancer care. The IOM will continue to call for a comprehensive and strong response to this most urgent issue facing the American people. This current report on patient safety further reinforces our conviction that we cannot wait any longer. Kenneth I. Shine, M.D. President, Institute of Medicine November 1999 Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System Acknowledgments T he Committee on the Quality of Health Care in America first and foremost acknowledges the tremendous contribution by the members of two subcommittees. Both subcommittees spent many hours working through a set of exceedingly complex issues, ranging from topics related to expectations from the health care delivery system to the details of how reporting systems work. Although individual subcommittee members raised different perspectives on a variety of issues, there was no disagreement on the ultimate goal of making care safer for patients. Discussion: National Patient Safety Goals Without the efforts of the two subcommittees, this report would not have happened. We take this opportunity to thank each and every subcommittee member for their contribution. SUBCOMMITTEE ON CREATING AN ENVIRONMENT FOR QUALITY IN HEALTH CARE J. Cris Bisgard (Cochair), Delta Air Lines, Inc.; Molly Joel Coye, (Cochair), The Lewin Group; Phyllis C. Borzi, The George Washington University; Charles R. Buck, Jr., General Electric Company; Jon Christianson, University of Minnesota; Charles Cutler, formerly of The Prudential HealthCare; Mary Jane England, Washington Business Group on Health; George J. Isham, HealthPartners; Brent James, Intermountain Health Care; Roz D. xiii Copyright National Academy of Sciences. All rights reserved. To Err Is Human: Building a Safer Health System xiv ACKNOWLEDGMENTS Lasker, New York Academy of Medicine; Lucian Leape, Harvard School of Public Health; Patricia A. Riley, National Academy of State Health Policy; Gerald M. Shea, American Federation of Labor and Congress of Industrial Organizations; Gail L. Warden, Henry Ford Health System; A. Eugene Washington, University of California, San Francisco School of Medicine; and Andrew Webber, Consumer Coalition for Health Care Quality. SUBCOMMITTEE ON BUILDING THE 21ST CENTURY HEALTH CARE SYSTEM Don M. Berwick (Chair), Institute for Healthca … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10