Internet resources for patient safety

AORN Journal,  August, 2005  by Suzanne C. Beyea

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Since the release of the Institute of Medicine's report, To Err is Human, Building a Safer Health System, (1) a number of organizations have developed Internet-based resources to provide clinicians, researchers, and educators with a variety of helpful materials to guide their patient safety efforts. Using the Internet to obtain information about patient safety can be effective for busy clinicians. This column reviews a number of patient safety web sites. The intent is not to be all inclusive but to provide information about some web sites that have not been featured in earlier columns (2) or that may be recent additions to the vast number of Internet resources.

THE AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)

The AHRQ has added some important safety-related web sites to support its agenda of improving the quality, safety, efficiency, and effectiveness of health care for all Americans. (3) The AHRQ Patient Safety Network (PSNet) at http://psnet.ahrq.gov provides up-to-date information on patient safety, and users of PSNet can subscribe to the PSNet Weekly electronic newsletter to receive updates about the latest literature, news, and conferences on patient safety.

Morbidity and Mortality Rounds on the Web (WebM&M) at http://webmm.ahrq.gov features case studies related to risk management, surgery/anesthesia, medicine, radiology, nursing, and a host of other medical specialties and case commentaries developed by safety experts. The case studies are submitted by clinicians and typically concern medical errors or other patient safety and quality issues. Individuals who submit a case study receive an honorarium if the case is posted, and they can chose to submit the case anonymously. This web site also contains a patient safety glossary, a topic index, a variety of forums and discussion groups, and opportunities to obtain continuing education units.

The AHRQ also offers the National Guidelines Clearinghouse at http://www.guideline.gov. This resource has more than 1,500 evidence-based practice guidelines to help clinicians provide the highest quality care based on research. The availability of these guidelines provides clinicians with another strategy to provide evidence-based, safe care.

THE JOINT COMMISSION

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently launched the Joint Commission International Center for Patient Safety to identify, gather, analyze, and disseminate information about patient safety solutions worldwide. The overall goal of the center is to continuously improve the safety of patient care by providing solutions, procedures, and processes that help reduce medical errors and adverse events in all health care settings? Resources available at http://www.jcipatientsafety.org include information for patients and their family members, health care professionals and providers, and government and business leaders. The web site contains updates about JCAHO's National Patient Safety Goals, Sentinel Event Alerts, news and updates about patient safety topics, networking communities, complimentary safety resources, patient safety products and services, information about upcoming events, and answers to frequently asked questions.

THE INSTITUTE FOR HEALTHCARE IMPROVEMENT (IHI)

The IHI web site at http://www.ihi.org provides users with a vast number of resources focused on advancing the quality, safety, and value of health care. For example, the IHI recently launched the 100K Lives campaign to encourage thousands of US hospitals to commit to implementing six interventions that have been demonstrated to prevent avoidable deaths. These interventions include rapid response teams, reliable evidence-based care for acute myocardial infarctions, and the prevention of adverse drug events, central line infections, surgical site infections, and ventilator-associated pneumonias. (5) Audiovisual materials about the campaign are available, as are discussion groups and a link to Canadian efforts on the same topic.

The IHI web site also has valuable information about a wide variety of quality and safety initiatives, a monthly electronic newsletter, and various products and services. For example, the web site provides a variety of links and resources related to the SBAR (ie, situation, background, assessment, recommendation) communication technique, (6) including a description of the technique, a reference list, a worksheet, and guidelines related to the topic. Other patient safety topics that can be researched here include safety measures, improvement stories, tools, medication systems, and surgical site infections. The web site also provides a variety of links to topics such as leading system improvement, office practice, medical-surgical care, health professions education, and critical care.

VETERANS HEALTH ADMINISTRATION (VHA) NATIONAL CENTER FOR PATIENT SAFETY (NCPS)

Another patient safety resource is provided by the NCPS at http://www.patientsafety.gov. The NCPS describes their program as a "unified and cohesive patient safety program with active participation by all the VA hospitals supported by dedicated patient safety managers." (7) This web site includes a vast number of resources, including VHA Patient Safety Alerts and Advisories, information on how to conduct a root cause analysis or a health care facility's failure mode and effect analysis, a description of the VHA's patient safety curriculum, a number of patient safety resources, and answers to frequently asked questions.