48 The limited number of CPOE systems means that most patient safety reports

48 the limited number of cpoe systems means that most

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48 The limited number of CPOE systems means that most patient safety reports cannot be generated automatically, making data collection mechanisms cumbersome, expensive and sporadic.The lack of standardization also makes it difficult to aggregate data or identify trends. 49 Only a fraction of hospi- tals have implemented electronic health record sys- tems. However, many hospitals have made progress implementing computerized laboratory results. 50 Patient Responsibility JCAHO and the Centers for Medicare and Medicaid Services (CMS) launched a national pro- gram, Speak Up, to urge patients to take a role in preventing health care errors.The program distrib- utes brochures, posters, and buttons on patient safety topics. For example, one brochure, Help Prevent Errors in Your Care: For Surgical Patients , offers tips to help patients prepare for surgery and to ensure that they have the correct procedure performed at the correct site on their body. Another, Preparing to Be a Living Organ Donor , gives basic facts about organ donations. 51 Recent Patient Safety Activity Veterans Administration Activity Prior to the IOM report, the Veterans Administration identified patient safety as a high priority issue and began a Patient Safety Improvement Initiative.The VA launched a National Center for Patient Safety to lead its patient safety effort.The VA has also supported its patient safety and quality improvement activities with a computerized patient record system and other clinical information systems.The VA requires all of its hospitals to implement a bar code med- ication administration system to prevent errors in drug dispensing and blood transfusion. Pilot tests indicated that the technology reduced the medica- tion error rate by 70 percent over a five-year period. 52,53 The VA also partnered with the National Aeronautics and Space Administration to apply the aviation error and near-miss reporting process to its health care delivery system.Together, the VA and NASA developed the Patient Safety Reporting System (PSRS), a voluntary, confiden- tial, and nonpunitive program for the reporting of events and concerns related to patient safety. PSRS, designed to identify broad system vulnera- bilities, serves as a complement to the VA’s manda- tory internal reporting system. 54 Recently, the Agency for Healthcare Quality and Research part- nered with the VA’s National Center for Patient Safety (NCPS) to create the Patient Safety Improvement Corps, a training program for state health officials and their hospital partners.The Corps offers training based on NCPS patient safety programs. In the first year, 50 organizations from 14 states participated. 55 NCPS also has served as an example for patient safety activities interna- tionally, training patient safety representatives from around the world to apply the NCPS program structure and principles to efforts in their respec- tive countries. 56 6 The Commonwealth Fund
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Medical Errors: Five Years After the IOM Report 7 Military Health Care System Activity
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