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Model."/>FIGURE 4.8 PDSA Quality Improvement Model.

      Source: Institute for Healthcare Improvement, 2018.

      Institute of Safe Medication Practices

      The ISMP is a nonprofit organization devoted to medication error prevention and safe medication use. It provides impartial, timely, and accurate medication safety information. ISMP's initiatives are built on non‐punitive approaches and system‐based solutions. It focuses on knowledge, analysis, education, cooperation, and communication. ISMP reviews all medication error reports submitted by health care facilities and health care professionals. In addition, it works directly and confidentially with the pharmaceutical industry to prevent errors that stem from confusing or misleading naming, labeling, packaging, and device design (Institute for Safe Medication Practices, 2018).

ISMP publishes monthly newsletters to educate the health care community about safe medication practices (Figures 4.4 and 4.5). They suggest that nursing students have a key role to play in a culture of safety. ISMP analyzed nursing student‐associated medication incidents and created the following practice tips to enhance the culture of safety: (a) students bring a new perspective to the medication‐use system and should be encouraged to question, identify, and report errors or gaps; (b) be sure that the preceptor's workload accounts for the level of supervision each student needs to optimize her of his learning in a safe environment; and (c) review organizational challenges impacting students to identify opportunities to improve the culture of safety (Institute for Safe Medication Practices, September 2018).

      National Patient Safety Foundation

      The National Patient Safety Foundation (NPSF) partners with patients and families, the health care community, and key stakeholders to create a world where patients and those who care for them are free from harm. They work collaboratively to advance patient safety, promote health care workforce safety, and disseminate strategies to prevent harm. NPSF offers a portfolio of programs targeted to diverse stakeholders across the health care industry. The American Society of Professionals in Patient Safety (ASPPS) is part of NPSF. It provides education and oversees professional certification in patient safety and quality. The Institute for Healthcare Improvement and the National Patient Safety Foundation began working together as one organization in May 2017. The merged entity uses its combined knowledge and resources to focus and energize the patient safety agenda in order to build systems of safety across the continuum of care (National Patient Safety Foundation, 2018).

      National Quality Forum

      The National Quality (NQF) focuses on improving the quality of health care, with patient safety central to achieving the goal. About 100 of the 600 NQF endorsed quality measures are patient‐safety focused. NQF has endorsed 34 Safe Practices for Better Health Care and 28 Serious Reportable Events. There are still significant gaps in the measurement of patient safety. By convening panels and other educational forums, NQF works with quality measure developers and others in health care to help understand measurement gaps and encourage strategies to fill them. A list of 28 adverse events, also called Never Events because they should never occur in health care, are grouped into six categories; surgical, product or device related, patient protection, care management, environmental, radiologic, and potential criminal events (National Quality Forum, 2018).

      Patient Safety Organization

      A Patient Safety Organization (PSO) is a group, institution, or association that improves patient care by reducing errors. PSOs exist to allow organizations to learn from their own safety events and the safety events of others. The Patient Safety and Quality Improvement Act of 2005 was enacted in response to the publication To Err is Human (Institute of Medicine, 1999) and growing patient safety concerns in the United States. The law provides confidentiality and privilege protections, which means the information cannot be included in a law suit. A complete list of federally‐approved PSOs may be found on the AHRQ website (AHRQ, n.d.).

      Government Agencies

      Government agencies also focus on safety and provide resources for organizations on a journey toward high reliability. Key agencies include the Agency for Healthcare Research and Quality; Centers for Disease Control and Prevention; and the Centers for Medicare and Medicaid.

      Agency for Healthcare Research and Quality

      The Agency for Healthcare Research and Quality (AHRQ)'s mission is to produce evidence to make health care safer; of higher quality; more accessible, equitable, and affordable; and to work with the U.S. Department of Health and Human Services and with other partners to make sure that research findings are understood and used. AHRQ funds a variety of research and demonstration initiatives and creates materials to teach and train health care providers and health care system professionals to put the results of research into practice. In addition to the AHRQ initiatives already discussed in this chapter, AHRQ safety innovations include:

       The Comprehensive Unit‐based Safety Program (CUSP) – this strategy for preventing health care‐associated infections (HAIs) combines improvement in safety culture, teamwork, and communication.

       EvidenceNOW – this initiative aligned with Million Hearts® provides clinical practice support to over 5,000 primary care physicians with the goal of improving the heart health of millions of patients and improving the capacity of the practices to incorporate new research findings and information into practice.

       Healthcare Cost and Utilization Project – this initiative highlighted the opioid overdose epidemic and contributed to Health and Human Services' launch of a major multipronged initiative to reduce opioid abuse.

       Re‐Engineered Discharge (RED) – this structured protocol and assortment of implementation tools help hospitals rework their discharge processes to reduce readmissions by determining patients' needs and designing and communicating discharge plans.

      Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) provides tools and data to assist organizations on their journey toward high reliability. Their website includes information on diseases and conditions; healthy living; travelers' health; emergency preparedness; injury, violence and safety; environmental health; and workplace safety and health (CDC, 2019). CDC provides educational material for both consumers and health care workers. For example, the website includes a variety of tools and promotional materials available at no cost to enhance the performance of hand hygiene (Figure 4.9) (Centers for Disease Control and Prevention, 2019).

FIGURE 4.9 This Clean Hands Flyer Count Flyer from the CDC increases patients' and visitors' involvement in safe care.

      Source: Clean Hands Campaign, Centers for Disease and Control (2019). Retrieved August 29, 2019. Retrieved from: from www.cdc.gov/handhygiene/campaign/index.html

      Centers for Medicare and Medicaid

      As a major financial reimbursor for health care services in the United States, the Centers for Medicare and Medicaid (CMS), recognizes the escalation of health care costs, poor patient outcomes, health care errors,

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