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A New Federal Agency to Oversee Patient Safety?

flying cadeuciiPatient safety should be a major priority for the United States, and that requires designating a centralized entity or coordinating body to oversee efforts to ensure it. Such centralized oversight is one of the key recommendations of “Free from Harm,” a report published in December by the National Patient Safety Foundation. The report highlights the need to create a safety culture, since preventable medical errors in hospitals are estimated to result in as many as 440,000 deaths annually. That would make it the third leading cause of death – after heart disease and cancer.

A new report by the U.S. Government Accounting Office illuminates the challenges that hospitals face in implementing evidence-based safety practices. One of those challenges – determining which patient safety practices should be implemented – underscores the need for a coordinating entity and resource. The report states: “(Hospital) Officials noted that they face challenges identifying which evidence-based patient safety practices should be implemented in their own hospitals, such as when only limited evidence exists on which practices are effective. For example, officials from one hospital told GAO that the hospital tried several different practices in an effort to reduce patient falls without knowing which, if any, would prove effective.”

What’s more, preventing medical errors in hospitals is only part of the national challenge, as most health care is provided outside of hospital settings: in physicians’ offices and clinics; in outpatient surgical, medical, and imaging centers; and, in long-term, hospice, and home-care settings, among others. There are about 1 billion ambulatory visits each year in the United States, compared to 35 million hospital admissions. Those ambulatory settings are subject to medical errors as well. According to studies cited in “Free from Harm,” more than half of annual, paid, medical malpractice claims were for events in the outpatient setting.

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