Finding patient safety Internet resources - Research Corner

Suzanne C. Beyea

One approach to learning more about patient safety issues and strategies to prevent medical errors and adverse events is searching the Internet. Many organizations and groups have developed web sites that can assist both clinicians and patients. Many of these web sites provide up-to-date, helpful information and clinical alerts.

Exploring web sites such as these can help nurses learn about the problem of medical errors and prepare to address issues in their facilities. Many web sites provide information that clinicians can use to support their efforts to improve clinical processes and, thus, ensure high quality, cost-effective patient outcomes. Many of these web sites also provide access to discussion groups or links to additional resources.

This column provides an overview of many safety-related web sites (Table 1). This listing and description is not intended to be inclusive. It simply is meant to highlight some frequently mentioned web sites. Readers are encouraged to explore a variety of web sites and identify those that will be most helpful to their specific specialty and clinical issues.

GOVERNMENT RESOURCES

The Agency for Healthcare Research and Quality site is a helpful web resource that provides a collection of documents, press releases, workshops, speeches, congressional hearings, and information related to the Quality Interagency Coordination Task Force. Both consumer and professional information is provided, including "Twenty tips to help prevent medical errors: Patient fact sheet" and "Reducing medical errors in healthcare: Fact sheet." The Institute of Medicine's report on medical errors also may be found on this site.

Another helpful government web resource is the Veterans Health Administration's Virtual Learning Center. This web page lists frequently asked questions along with answers and provides brief lessons on patient safety that users can search or browse. Each lesson discusses a specific clinical alert, recommended interventions, and reference materials.

The National Center for Patient Safety embodies the Department of Veterans Affairs' (VA) commitment to reducing and preventing adverse medical events. This web site includes information about the VA's patient safety program and provides information about the culture of safety to which the VA system ascribes. This culture includes a focus on prevention and not punishment, applying human factor analysis, and the safety research of reliable organizations targeted at identifying and eliminating system problems.

Another government resource is the Quality Interagency Coordination Task Force web site. The purpose of the task force is to ensure that all federal agencies involved in purchasing, providing, studying, or regulating health care services work in a coordinated fashion to improve health care quality. Typical resources on this site include "Five steps to safer health care: Patient fact sheet" and "Report to the president on medical errors."

ORGANIZATIONS AND GROUPS

One organization at the fore-front of gathering and providing information on patient safety is the Leapfrog Group for Patient Safety. The Leapfrog Group is a coalition of more than 90 public and private organizations that provide health care benefits. The coalition was formed to address patient safety and quality issues in the US health care system. The group, founded by the Business Roundtable, focuses on basic patient safety and encourages employers to follow purchasing principles designed to improve patient safety and quality.

The Joint Commission on Accreditation of Healthcare Organizations' web site includes a web page titled "Facts about patient safety." This resource focuses on standards that help facilities develop processes to identify, report, analyze, and prevent sentinel events. Visitors to the page can access Sentinel Event Alert, a monthly newsletter, and obtain information related to sentinel events, such as fatal falls, postoperative complications, wrong site surgery, and blood transfusion errors. Users also can sign up to receive an e-mail version of the newsletter. A listing of sentinel events and related frequency reports of these events is located on the page as well.

The Institute for Safe Medication Practices site provides an independent review of medication errors submitted to the Medical Errors Reporting Program developed by United States Pharmacopoeia. It focuses on improving medication distribution, naming, packaging, labeling, and delivery system design. Visitors to this site can review medication safety alerts, patient alerts, a message board, and a conceptual framework for a national medical error reporting system.

The Institute of Medicine web site provides objective information and advice about health to government officials, businesses, and the public. The Institute's Special Initiative on Health Care Quality aims to improve the quality of health care in the United States. The goals of this initiative are to evaluate quality assessment and improvement tools and their use and to inform consumers, policy makers, providers, and others of key opportunities and obstacles to achieving better health outcomes for individuals and populations. This web site also provides access to recent Institute of Medicine reports and publications.

The goal of the National Patient Safety Foundation is to measurably improve patient safety in the delivery of health care. Its site offers literature, programs, and a variety of other resources regarding patient safety. Visitors to the site will find a bibliography and book reviews. Additional resources include full-text news stories and full-text reports on patient safety, such as A Tale of Two Stories: Contrasting Views of Patient Safety. The foundation's goal is for the health care industry to transition from a culture of blame to a culture of safety.

The National Quality Forum for Health Care Quality Measurement and Reporting is a nonprofit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. Numerous resources are available to Internet users, including the latest news and press releases. This group also posts reports of safety-related projects and newsletters.

As an independent nonprofit health services research agency, ECRI's mission is to improve the safety, quality, and cost-effectiveness of health care. This group focuses on health care technology, health care risk and quality management, and health care environmental management. Recent postings on ECRI's web site include information about misconnected flow meters leading to two deaths and an update about a recent defibrillator/monitor/pacemaker evaluation. By becoming an ECRI member, users also can access additional web resources.

ADDITIONAL RESOURCES

Other web sites provide helpful safety resources, information, and links.

* The American Hospital Association's Improving Medication Safety site offers resources, references, and links to other medication safety sites.

* The American Society for Healthcare Risk Management site offers news, products, and educational opportunities.

* The web site for the Institute for Healthcare Improvement, a group created to help health care professionals improve the quality and decrease the costs of health care, provides valuable resources on patient safety and quality improvement, as well as links and bibliographies.

* Mederrors.com offers resources for reducing medication errors and continuous quality improvement, including tips, information on new legislation, and continuing education material.

* The Medical Misadventures Resource Center, part of the American Society of Health-System Pharmacists' web site, offers announcements, resources, error-reporting programs, links to web sites, message boards, chat rooms, and articles related to preventing medication errors.

* The National Coordinating Council for Medication Error Reporting and Prevention site features information on medication errors, council recommendations, and a vehicle for reporting medication errors.

* The Partnership for Patient Safety is a network of organizations focused on reducing adverse outcomes related to health care errors. Its site includes information on upcoming safety events and safety-related products.

* The Risk Management Foundation was developed by Harvard Medical Institutions. Its web site provides news, articles, and alerts related to risk management and includes services, resources, articles, research, and products.

CONCLUSION

Obviously, there are many web resources that can provide users with helpful and timely information. Visit the Internet and learn more about these resources, and save your favorites as bookmarks for future visits. Also, visit http://www.patientsafetyfirst.org, a web site containing resources specific to establishing safe practices in perioperative settings. Initiated by AORN, it is the hope that this web site will become a collaborative site, with other members of the surgical team developing and contributing resources. The Patient Safety First web site still is under construction, and you can contribute to its development by offering suggestions or ideas. Please visit this new web resource and let us know what will help you in your efforts to provide safe care to patients undergoing a surgical or other invasive procedures. This site is intended to be a one-stop resource for clinicians interested in patient safety in perioperative settings. Help us make this dream a reality.

Table 1
SAFETY-RELATED WEB SITES

Organization            Web site

Agency for              http://www.ahcpr.gov/qual/errorsix.htm
Healthcare
Research and
Quality

American                http://www.aha.org/medicationsafety
Hospital
Association:
Improving
Medication Safety

American Society        http://www.ashrm.org
for Healthcare
Risk Management

American Society        http://www.ashp.com/public/proad/mederror/
of Health-System        index.html
Pharmacists: Medical
Misadventures
Resource Center

ECRI                    http://www.ecri.org

Institute for           http://wvwv.ihi.org
Healthcare
Improvement

The Institute           http://www.ismp.org
for Safe
Medication
Practices

Institute of            http://www.iom.edu
Medicine

Joint Commission on     http://www.jcaho.org/ptsafety_frm.html
Accreditation  of
Healthcare
Organizations: Facts
About Patient Safety

The Leapfrog Group      http://www.leapfroggroup.org
for Patient Safely

Mederrors.com           http://vwwv.mederrors.com

National Center for     http://www.patientsafety.gov/index.html
Patient Safety

National Coordinating   http://www.nccmerp.org
Council for
Medication Error
Reporting and
Prevention

National Patient        http://www.npsf.org
Safety Foundation

The National Quality    http://www.qualityforum.org
Forum for Health
Care Quality
Measurement and
Reporting

Partnership for         http://vwwv.p4ps.org
Patient Safely

Patient Safety First    http://www.patientsafetyfirst.org
(AORN)

Quality Interagency     http://www.quic.gov
Coordination
Task Force

Risk Management         http://www.rmf.org
Foundation

Veterans Health         http://www.va.gov/med/osp/cgi-bin/patient.asp
Administration's
Virtual Learning
Center
SUZANNE C. BEYEA
RN, PHD
AORN DIRECTOR OF RESEARCH

COPYRIGHT 2002 Association of Operating Room Nurses, Inc.
COPYRIGHT 2002 Gale Group