The Agency for Healthcare Research and Quality is one of twelve agencies within the United States Department of Health and Human Services (HHS). The agency is headquartered in North Bethesda, Maryland, a suburb of Washington, D.C.. It was established as the Agency for Health Care Policy and Research (AHCPR) in 1989 as a constituent unit of the Public Health Service (PHS) to enhance the quality, appropriateness, and effectiveness of health care services and access to care by conducting and supporting research, demonstration projects, and evaluations; developing guidelines; and disseminating information on health care services and delivery systems.
Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients under his or her care.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.
A Patient Safety Organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery
A health professional, healthcare professional, or healthcare worker is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician, physician assistant, registered dietitian, veterinarian, veterinary technician, optometrist, pharmacist, pharmacy technician, medical assistant, physical therapist, occupational therapist, dentist, midwife, psychologist, audiologist, healthcare scientist, or who perform services in allied health professions. Experts in public health and community health are also health professionals.
Health services research (HSR) became a burgeoning field in North America in the 1960s, when scientific information and policy deliberation began to coalesce. Sometimes also referred to as health systems research or health policy and systems research (HPSR), HSR is a multidisciplinary scientific field that examines how people get access to health care practitioners and health care services, how much care costs, and what happens to patients as a result of this care. HSR utilizes all qualitative and quantitative methods across the board to ask questions of the healthcare system. It focuses on performance, quality, effectiveness and efficiency of health care services as they relate to health problems of individuals and populations, as well as health care systems and addresses wide-ranging topics of structure, processes, and organization of health care services; their use and people's access to services; efficiency and effectiveness of health care services; the quality of healthcare services and its relationship to health status, and; the uses of medical knowledge.
Clinical Nurse Leader (CNL) is a relatively new nursing role that was developed in the United States to prepare highly skilled nurses focused on the improvement of quality and safety outcomes for patients or patient populations. The CNL is a registered nurse, with a Master of Science in Nursing who has completed advanced nursing coursework, including classes in pathophysiology, clinical assessment, finance management, epidemiology, healthcare systems leadership, clinical informatics, and pharmacology. CNLs are healthcare systems specialists that oversee patient care coordination, assess health risks, develop quality improvement strategies, facilitate team communication, and implement evidence-based solutions at the unit (microsystem) level. CNLs often work with clinical nurse specialists to help plan and coordinate complex patient care.
Donald M. Berwick is a former Administrator of the Centers for Medicare and Medicaid Services (CMS). Prior to his work in the administration, he was President and Chief Executive Officer of the Institute for Healthcare Improvement a not-for-profit organization.
Fatal Care: Survive in the U.S. Health System is a book about preventable medical errors written by Sanjaya Kumar, president and chief medical officer of Quantros, Milpitas, California. Fatal Care was published in April 2008 by IGI Publishing, Minneapolis, Minnesota.
The healthcare error proliferation model is an adaptation of James Reason’s Swiss Cheese Model designed to illustrate the complexity inherent in the contemporary healthcare delivery system and the attribution of human error within these systems. The healthcare error proliferation model explains the etiology of error and the sequence of events typically leading to adverse outcomes. This model emphasizes the role organizational and external cultures contribute to error identification, prevention, mitigation, and defense construction.
ECRI is an independent nonprofit organization tasked with "improving the safety, quality, and cost-effectiveness of care across all healthcare settings worldwide."
The Patient Safety and Quality Improvement Act of 2005 (PSQIA): Pub. L.Tooltip Public Law 109–41 (text)(PDF), 42 U.S.C. ch. 6A subch. VII part C, established a system of patient safety organizations and a national patient safety database. To encourage reporting and broad discussion of adverse events, near misses, and dangerous conditions, it also established privilege and confidentiality protections for Patient Safety Work Product. The PSQIA was introduced by Sen. Jim Jeffords [I-VT]. It passed in the Senate July 21, 2005 by unanimous consent, and passed the House of Representatives on July 27, 2005, with 428 Ayes, 3 Nays, and 2 Present/Not Voting.
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. A discipline-specific process may be referenced accordingly.
The Improvement Science Research Network (ISRN) is a research network for academics and physicians who are conducting studies in the new medical field of improvement science.
In United States healthcare, service excellence is the ability of the provider to consistently meet and manage patient expectations. Clinical excellence must be the priority for any health care system. However, the best healthcare systems combine professional (clinical) service excellence with outstanding personal service. Although health care in the United States is touted as the “world’s largest service industry,” the quality of the service is infrequently discussed in medical literature. Thus, many questions regarding service excellence in healthcare largely remain unanswered.
Health care quality is a level of value provided by any health care resource, as determined by some measurement. As with quality in other fields, it is an assessment of whether something is good enough and whether it is suitable for its purpose. The goal of health care is to provide medical resources of high quality to all who need them; that is, to ensure good quality of life, cure illnesses when possible, to extend life expectancy, and so on. Researchers use a variety of quality measures to attempt to determine health care quality, including counts of a therapy's reduction or lessening of diseases identified by medical diagnosis, a decrease in the number of risk factors which people have following preventive care, or a survey of health indicators in a population who are accessing certain kinds of care.
David Bates is an American-born physician, biomedical informatician, and professor, who is internationally renowned for his work regarding the use of health information technology (HIT) to improve the safety and quality of healthcare, in particular by using clinical decision support. Bates has done work in the area of medication safety. He began by describing the epidemiology of harm caused by medications, first in hospitalized patients and then in other settings such as the home and nursing homes. Subsequently, he demonstrated that by implementing computerized physician order entry (CPOE), medication safety could be dramatically improved in hospitals. This work led the Leapfrog Group to call CPOE one of the four changes that would most improve the safety of U.S. healthcare. It also helped hospitals to justify investing in electronic health records and in particular, CPOE. Throughout his career, Bates has published over 600 peer reviewed articles and is the most cited researcher in the fields of both patient safety and biomedical informatics, with an h-index of 115. In a 2013 analysis published by the European Journal of Clinical Investigation, he ranked among the top 400 living biomedical researchers of any type. He is currently editor of the Journal of Patient Safety.
Surfing the Healthcare Tsunami: Bring Your Best Board is a made for television documentary that explores medical errors and waste in healthcare. It was broadcast globally on the Discovery Channel in 2012. It references federally-funded studies in the United States and news footage to support the claim that healthcare workers are afraid to speak up when medical errors occur in hospitals. The documentary covers solutions to preventable system failures causing harm. It aired four times on the Discovery Channel commercial-free in North America, Germany, the U.K., France, and other Western European countries including Sweden. It premiered at the National Press Club on April 27, 2012, after a short speech by Captain Sully Sullenberger who was featured in the film. The film was screened at the Texas Health Care Quality Improvement Awards on May 3, 2012.
Sorrel King is an author, patient safety advocate, and president/co-founder of the Josie King Foundation. Her 18-month old daughter, Josie, died at Johns Hopkins Bayview Hospital of dehydration due to medical error after being hospitalized for second-degree burns. Following a financial settlement from Johns Hopkins, Sorrel King started the Josie King Foundation and wrote a novel about her experience entitled Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe.
Kathryn McDonald is an American scientist who is Bloomberg Distinguished Professor at the Johns Hopkins University. She serves as co-director of the Johns Hopkins Center for Diagnostic Excellence. McDonald previously led the Centre for Health Policy at Freeman Spogli Institute for International Studies. Her research considers what makes for high-quality and safe healthcare delivery systems.
