Key Topic Guide Series - Patient Safety (& CPOE)
Consortium Activities | History | Legislation |
Articles | White Papers | Journals |
Government | Organizations | Web Sites
The Consortium participates on the eRx Collaborative Steering Committee
The eRx Collaborative is a joint effort of Blue Cross Blue Shield of Massachusetts (BCBSMA), Tufts Health
Plan (Tufts HP), Neighborhood Health Plan, and their technology partners DrFirst and ZixCorp®, to promote
ePrescribing adoption in Massachusetts. Learn about the eRx Collaborative's mission and projects in the
accompanying Fact Sheet. The Committee has also published a Fact Sheet on the Benefits of e-Prescribing
to emphasize the benefits to all health care stakeholders in embracing electronic prescribing.
The MedsInfo-ED project, supported by the Consortium's MA-SHARE initiative,
piloted a test project to make patients' prescription history data available to hospital emergency departments.
Massachusetts Senator Richard T. Moore (D - Worcester) was instrumental
in forming the Massachusetts Medication Error Reduction Task
Force. In the fall of 2001, Senator Moore approached the Consortium
about assisting the Technology Working Group of this Task Force
to investigate the current status of information technology initiatives
for CPOE in order to improve patient safety in Massachusetts. The
Consortium enthusiastically agreed to assist.
The Association of Health Care Journalists have published a timeline
of significant events in the growing awareness of the patient safety
problem in the AHCJ guide, "Covering the Quality of Health Care:
Resource Guide for Journalists." www.ahcj.umn.edu/qualityguide/timeline.html
See also the Legislative Tracking page on this web site
Commonwealth of Massachusetts
AN ACT FACILITATING ELECTRONIC TRANSACTIONS,
Chapter 133 of the Acts of 2003
(Senate Bill 2076)
This landmark bill became law in November 2003 and will permit prescriptions to be sent to pharmacies via secure e-mail.
Blue Cross Blue Shield of Massachusetts and Tuft Health Plan have organized pilot e-prescribing in conjunction with
PocketScript (Zix Corporation). Read
Tufts' press release about the new legislation and their experience with the e-prescribing pilot.
See also the
Patient Safety Resource Center on Medscape (free registration required)
Baldwin, Gary, Bringing
Order to CPOE: 10 Make or Break Steps (and 5 Myths) HealthLeaders,
November 2005, pp. 25-36. Insightful suggestions from CIOs
of seven hospitals who've inhabited CPOE trenches, have survived
the battle and are now experiencing results that made the effort
worth it. Note: it is not necessary to register with HealthLeaders.com
in order to view the article
Journal of the American Medical Informatics
Association, July /August 2005, Volume
12, Number 4. -- This issue focuses on e-prescribing with six articles on the topic.
Robert S. Galvin, Suzanne Delbanco, Arnold Milstein, and Greg Belden
Has the Leapfrog Group Had an Impact on the Health Care Market?
Health Affairs, January/February 2005; 24(1): 228-233.
Eric G. Poon, David Blumenthal, Tonushree Jaggi, Melissa M. Honour, David W. Bates, and Rainu Kaushal
Overcoming Barriers To Adopting And Implementing Computerized Physician Order Entry Systems In U.S. Hospitals
Health Affairs, July/August 2004; 23(4): 184-190.
Sengstack PP, Gugerty B.
CPOE Systems: Success Factors and Implementation Issues
J Healthc Inf Manag. 2004 Winter;18(1):36-45.
Douglas S. Bell, Richard S. Marken, Robin C. Meili, C. Jason Wang, Mayde Rosen, Robert H. Brook, and RAND Electronic
Prescribing Expert Advisory Panel
Recommendations For Comparing Electronic Prescribing Systems: Results Of An Expert Consensus Process
Health Affairs Web Exclusive, May 25, 2004
Kelly J. Devers, Hoangmai H. Pham, and Gigi Liu
What Is Driving Hospitals' Patient-Safety Efforts?
Health Affairs, March/April 2004; 23(2): 103-115.
Potts AL, Barr FE, Gregory DF, Wright L, Patel NR
Computerized physician order entry and medication errors in a pediatric critical care unit.
Pediatrics, 2004 Jan;113(1 Pt 1):59-63
Neil Versel, Cedars-Sinai Learns
from Its CPOE Mistakes to Improve Workflow
Health-IT World News, September 9, 2004
Tamblyn RM, McLeod PJ, Abrahamowicz M, Laprise R.
Do too many cooks spoil the broth? Multiple physician involvement in medical management of elderly patients and
potentially inappropriate drug combinations.
Canadian Medical Association Journal, 1996 Apr 15;154(8):1177-84
Treatment Plan: High Tech Transfusion -- Case Statement for Implementation of CPOE in all Massachusetts Hospitals
www.masstech.org/institute/health/health_final_4.0.pdf
Massachusetts Technology Collaborative, working in partnership with New England Healthcare Institute. Report
prepared by First Consulting Group, Fall 2004.
AHRQ WebM&M
http://webmm.ahrq.gov/
The Agency for Health Care Research and Quality (AHRQ) publishes
this online journal and forum on patient safety and health quality.
It features expert analysis of medical errors reported anonymously.
iHealthBeat
http://ihealthbeat.org/
iHealthBeat is a daily, free e-mail newsletter that reports on patient safety issues as well as other issues in the
context of "Reporting the Internet's Impact on Health Care."
Sentinal Event Alert
www.jcaho.org/about+us/news+letters/sentinel+event+alert/index.htm
Sentinel Event Alert identifies specific sentinel events,
describes their common underlying causes, and suggests steps to
prevent occurrences in the future. The newsletter is available
for free via e-mail.
Agency for Health Care Research and Quality
www.ahrq.gov
The AHRQ has developed the Q-Pack of
quality-related consumer information materials. These materials
which can be downloaded from the AHRQ's website include Quick Tips
sheets on the following topics: getting medical tests; getting
a prescription; planning for surgery; talking with your doctor.
There is also a patient fact sheet "20 Tips to Help Prevent Medical
Errors", "Now You Have a Diagnosis: What's Next?", and "Your Guide
to Choosing Quality Health Care."
A Caring Commonwealth
www.caringcommonwealth.com
Massachusetts Senator Richard T. Moore (D-Uxbridge) has launched
a website to spotlight his drive for a "consensus-based vision" for
health care in Massachusetts. The website presents his policy document, "A
Caring Commonwealth", section by section analysis of the proposed
policy, and a feedback mechanism. Sen. Moore outlines ten goals,
from "patient-centered care" to compassionate end-of-life, and
lays out a plan for the implementation of these goals.
U.S. DHHS Patient Safety Task Force
US Department of Health and Human Services, Patient Safety Task
Force is coordinating national efforts to improve patient safety.
The Patient Safety Task Force serves under the HHS Secretary's
Quality Improvement Initiative. The mission of the Task Force is
multifaceted (for more information, see Patient Safety Task Force
Fact Sheet. April 2001. Agency for Healthcare Research and Quality,
Rockville, MD. www.ahrq.gov/qual/taskforce/psfactst.htm)
including coordinating data collection from federal agencies and
other organizations, conducting patient safety research, creating
a coordinated reporting system, implementing patient safety demonstration
projects, and promoting national benchmarks. www.ahrq.gov/qual/errorsix.htm
U.S. Department of Health and Human Services. Office of the Inspector General
"Managed
Care Organization Nonreporting to the National Practitioner Data
Bank: A Signal for Broader Concern"
Released in May 2001, this report examines the level of reporting
by managed care organizations to the NPDB from 1990 through September
1999. Only 715 adverse events were reported during this period,
with 84% of organizations reporting no adverse events at all. Managed
care organizations responded that they relied upon other entities
to monitor safety of care.
U.S. Veterans Administration, National Center for Patient Safety
www.patientsafety.gov/
"Our program is unique in healthcare; we focus on prevention
not punishment, applying human factor analysis and the safety research
of high reliability organizations (aviation and nuclear power)
targeted at identifying and eliminating system vulnerabilities." Includes
a vision statement about the "culture of safety" that
the VA is espousing, safety alerts and advisories issued within
the VA medical network, and a module for how to perform root cause
analysis.
Health Grades
Health Grades is a for-profit healthcare quality ratings and
services company. In July 2004, it completed its first
Patient
Safety in American Hospitals Study in which researchers analyzed
37 million Medicare patient records, and then extrapolated that
about 195,000 patients die annually in the U.S. because of preventable
errors. Of the 16 categories of patient-safety incidents tracked,
just two -- failure to diagnose and treat a serious medical problem
in time, and unexpected death in a low-risk hospitalization --
accounted for nearly 75% of deaths in the Medicare study. The
195,000 deaths estimate is nearly twice the size of the widely-quoted
estimate of up to 98,000 deaths from To Err is Human,
published by the Institute of Medicine in 1999 (see below). Health
Grades published its
3rd Patient Safety Study in April 2006.
Institute for Healthcare Improvement
www.ihi.org
This organization conducts programs on safety issues, particularly
medication error prevention. Their "100K Lives" campaign
seeks to save that number of lives during an 18-month period through
a limited set of high impact changes in hospital care. In
June 2006, the IHI reported that, participating hospitals had surpassed
the 100,000 lives saved goal.
Institute of Medicine (IOM)
www.iom.edu
The Institute of Medicine has published several influential reports
in which the Institute has made a strong case for placing a high
priority on devising management systems and information technology
solutions to improve the safety of health care in the United States.
Beginning with "To Err is Human: Building a Safer Health System"
(www.nap.edu/catalog/9728.html),
published in September 1999, the Institute raised the alarm about
a shockingly high estminated rate of medical errors - between 44,000
and 98,000 deaths per year. The Institute has published several
more reports detailing patient safety issues relevent to different
health care segments and population groups.
Institute for Safe Medication Practices (ISMP)
www.ismp.org
Publishes an e-mail newsletter title "ISMP Medication Safety Alert!" that
calls attention to specific safety problems that have been documented. They
also provide a list of commonly misinterpreted abbreviations that
may pose potential harm to the safety of patients: www.ismp.org/MSAarticles/specialissuetable.html
Joint Commission for the Accreditation of Healthcare Organizations (JCAHO)
www.jcaho.org/accredited+organizations/patient+safety/npsg.htm
The Joint Commission has an initiative devoted to improving patient safety, particularly in the area of standards.
Leapfrog Group
www.leapfroggroup.org
The Leapfrog Group was organized by the Business Roundtable and
numerous large Fortune 500 companies to establish criteria for
improving patient safety in hospitals. In 2001, the Group issued
its first web-based, voluntary survey to hospitals in six regions.
The Survey serves as a means for hospitals to communicate to their
communities their efforts to reduce preventable medical errors.
The survey focuses on three recommended safety practices: computerized
drug orders, intensivist physicians in the ICU, and minimum procedure
volumes by specific procedure. The MEDSTAT Group conducts the survey
on behalf of the Leapfrog Group.
Massachusetts Hospital Association
www.mhalink.org
Patientsfirst Initiative
www.patientsfirstma.org
Massachusetts Hospital Association launched a new initiative
in 2005 to inform consumers on their progress in patient safety
and staffing levels. Massachusetts hospitals have come together
with nursing leaders across the state to introduce “Patients
First” – a sweeping quality-and-safety initiative.
Massachusetts Medical Society
www.massmed.org/pages/ptsafetycurriculum.asp
The Massachusetts Medical Society, in response to the Institute
of Medicine's well-publicized reports highlighting the prevalence
of medical error, has developed a curriculum which practitioners
may use to improve the safety of their clinical practices. The
curriculum is organized into three modules: Medical Error Scenarios
and Perspectives on Patient Safety; Medication Safety, Systems & Communication;
Case Studies and Root Cause Analysis of Adverse Events.
Massachusetts Technology Collaborative
www.masstech.org/ehealth/index.html
The Collaborative has set a goal of implementing computerized
physician order entry (CPOE) systems in all Massachusetts hospitals.
The Collaborative formed a partnership with the New
England Healthcare Institute (NEHI) to combine MTC's strengths
in analysis and grasp of the high-tech economy with NEHI's knowledge
of the Massachusetts healthcare system. Together, they are
working to speed adoption of advanced technologies in healthcare. In
December 2005, MTC organized testimony before Joint Committees
on Healthcare Financing and Economic Development and Emerging Technologies,
Commonwealth of Massachusetts. Read the testimony and view the tar
Case Statement for Implementation of CPOE in Massachusetts Hospitals.
New England Healthcare Institute
www.nehi.net/CMS/viewPage.cfm?pageId=1
New England Healthcare Institute, an independent, not-for-profit organization dedicated
to transforming health care for the benefit of patients and their
families. In partnership with members from all across the health
care system, NEHI conducts evidence-based research and stimulates
policy change to improve the quality and the value of health care.
In particular, areas of concentration include
chronic disease, disease prevention and healthy behaviors, moving
science forward and promoting a culture of innovation, saving lives
and money with health care information technology, identifying
and removing waste from the health care system.
Patient Safety Institute
www.ptsafety.org/
The Institute is a non-profit consortium of hospitals, medical
groups and consumer organizations that has raised $8 million from
information technology vendors to test a new platform for medical
record sharing. Specifically, the technology would keep track of
prescriptions, allergies, immunizations, lab test and diagnoses.
Partnership for Clear Health Communication
www.AskMe3.org
Communication problems have implications for patient safety. The
Partnership aims to improve physician - patient communication and
health literacy. The site includes information for both providers
and patients, including fact sheets, white papers, lists of "words
to watch", program implementation guides which include the three
recommended starting questions for patients to ask physicians,
and links to resources in cultural competency and health literacy.
Virginians Improving Patient Care & Safety (VIPC&S)
www.vipcs.org
Provides an extensive list of patient safety links, from government
agencies, national organizations, and state organizations. Hosts
conferences on Best Practices in Patient Safety.
AHRQ Patient Safety Indicators (PSIs)
http://www.qualityindicators.ahrq.gov/psi_download.html
The AHRQ Quality Indicators Windows Application is a tool to
assist quality improvement efforts in acute care hospital settings.
Using hospital discharge data from your organization, the application
facilitates the review of individual cases flagged by the AHRQ
Quality Indicators and calculates basic rates for comparison with
peers. The single application includes all of the AHRQ QI modules: Prevention
Quality Indicators, Patient
Safety Indicators, and Inpatient
Quality Indicators.
The Tools and Techniques of Improved Medication Use
www.aahp.org/content/navigationmenu/medcollab/medcollab.htm
The American Association of Health Plans - Health Insurance Association
of America (AAHP-HIAA), Harvard Pilgrim Health Care, Harvard Medical
School, the Agency for Healthcare Research and Quality (AHRQ) and
HMO Research Network Center have collaborated in the creation of
this website. The website features 50 studies (as of February
2004) that focus on improved medication use and patient compliance,
through varied intervention strategies - implementing disease management
approaches, educating patients and providers, and monitoring and
providing feedback about target populations.
This page last updated June 30, 2006
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