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Internet resources for patient safety
Patient Safety First
AUGUST 2005, VOL 82, NO 2
P A T I E N T
SAFETY
FIRST
Internet resources for patient safety
S
ince the release of the Institute of Medicine's report, To Err is Human, Buildiiig a Safer Health System,' a number of organizations have developed Internetbased resources to provide-clinicians, researchers, and educators with a variety of helpful materials to guide their patient safety efforts. Using the Internet to obtain information about patient safety can be effective for busy clinicians. This column reviews a number of patient safety web sites. The intent is not to be all inclusive but to provide information about some web sites that have not been featured in earlier columns2or that may be recent additions to the vast number of Internet resources.
THEAGENCYFOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) The AHRQ has added some important safety-related web sites to support its agenda of improving the quality, safety, efficiency, and effectiveness of health care for all American~.~ The AHRQ Patient Safety Network (PSNet) at http://psnet.akrq.gov provides up-todate information on patient safety, and users of PSNet can subscribe to the PSNet Weekly electronic newsletter to receive updates about the latest literature, news, and conferences on patient safety. Morbidity and Mortality Rounds on the Web (WebM&M) at http://webmnr .ahrq.gov features case studies related to risk management, surgery/anesthesia, medicine, radiology, nursing, and a host of other medical specialties and case commentaries developed by safety experts. The case studies are submitted by clinicians and typically concern medical errors or other patient safety and quality issues. Individuals who submit a case study receive an honorar-
ium if the case is posted, and they can chose to submit the case anonymously. This web site also contains a patient safety glossary, a topic index, a variety of forums and discussion groups, and opportunities to obtain continuing education units. The AHRQ also offers the National Guidelines Clearinghouse at http://www .guideZine.gov. This resource has more than 1,500 evidencebased practice guidelines to help clinicians provide Busy the highest quality care based-on reskarch. The the availability of these guidelines provides clinicians with another strategy to provide evidenceto obtain based, safe care.
cl nicians can use Internet
THEJOINT COMMISSION
CJ
variety of
The joint Commission information on Accreditation of Healthcare Organizations (JCAHO)recently launched the Joint Commission Intemationa1 Center for Patient Safety to identi@, gather, analyze, and disseminate information about patient safety solutions worldwide. The overall goal of the center is to continuously improve the safety of patient care by providing solutions, procedures, and processes that help reduce medical errors and adverse events in all health care settings." Resources available at http://u~.su7u.jci patienfsafety.org include information for patients and their family members, health care professionals and providers, and government and business leaders. The web site contains updates about JCAHOs National Patient Safety Goals, Sentinel Event Alerts, news and updates about patient safety topics, networking
about patient safety.
AORN JOURNAL
291
Patient Safety First
AUGUST 2005, VOL 82, NO 2
description of the techruque, a based patient safety resources. reference list, a worksheet, and In fact, typing ”patient safety” guidelines related to the topic. into an Internet search engine Other patient safety topics that results in millions of entries can be researched here include on this topic. The web sites safety measures, improvement described here represent some stories, tools, medication sysof the latest to be developed and made available to the THEINSTITUTE FOR HEALTHCARE tems, and surgical site infecpublic and health care profestions. The web site also proIMPROVEMENT (IHI) vides a variety of links to topsionals. Searching these sites The IHI web site at ics such as leading system provides a first step to learnlit f,u://www.ilzi.oprovides rg improvement, office practice, users with a vast number of ing more about patient safety medical-surgical care, health and finding h k s to additionresources focused on advancprofessions education, and al resources. *3 ing the quality, safety, and critical care. value of health care. For SUZANNE C. BEYEA example, the IHI recently RN, PHD, FAAN VETERANS HEALTH launched the 100K Lives camDIRECTOR OF NURSING RESEARCH paign to encourage thousands ADMINISTRATION (VHA) DARTMOUTH-HITCHCOCK MEDICAL CENTER NATIONAL CENTERFOR PATE I NT of US hospitals to commit to LEBANON, NH SAFETY(NCPS) implementing six interventions that have been demonAnother patient safety NOTES strated to prevent avoidable resource is provided by the 1. Institute of Medicine, To Err is deaths. These interventions NCPS at http://www.patient Human, Building a Safer Health include rapid response teams, sufety.gov.The NCPS describes Sysfenz (Washington, DC: Nationreliable evidence-based care al Academy Press, 2000). their program as a “unified 2. S C Beyea, “Safety resources for acute myocardial mfarcand cohesive patient safety for perioperative clinicians,” tions, and the prevention of program with active particiAORN Journal 79 (April 2005) adverse drug events, central pation by all the VA hospitals 853-855. supported by dedicated line infections, surgical site 3. “Mission and budget,“ Agency for Healthcare Research patient safety manager^."^ infections, and ventilatorand Quality, htfp://www.ahrq.gov associated pneumonias? Thls web site includes a vast /about/budgtix.htrn (accessed 21 number of resources, includAudiovisual materials about June 2005). the campaign are available, as ing VHA Patient Safety Alerts 4.“About the center,” Joint are discussion groups and a and Advisories, information Commission International, hfkp:// www.jcipa tientsafety.org/show.asp?d link to Canadian efforts on the on how to conduct a root same topic. cause analysis or a health care urki=9270 (accessed23 June 2005). 5. ”100K Lives campaign,” The IHI web site also has facility’s failure mode and Institute for Healthcare Improvevaluable information about a effect analysis, a description ment, http://www.ihi.org/i€i@’ro grarns/Carnpaign/Carnpaign.ht t n ? wide variety of quality and of the VHA’s patient safety Tabld=Z (accessed 23 June 2005). safety initiatives, a monthly curriculum, a number of 6. “SBAR technique for commuelectronic newsletter, and vari- patient safety resources, and nication: A situational briefing ous products and services.For answers to frequently asked model,” Institute for Healthcare example, the web site provides questions. Improvement, http://~u~u~i~.ihi.org /ihi/search/searchresults.aspx?search a variety of links and resources terni=sbar&searchtype=basic related to the SBAR (ie, situaTHETIP OF THE ICEBERG (accessed 23 June 2005). tion, background, assessment, The web sites featured in 7.VA National Center for Patient recommendation)communica- this column are just a few of Safety, http://www.pafienfsafify.gov the vast number of Internettion technique: including a (accessed 23 June 2005). communities, complimentary safety resources, patient safety products and services, information about upcoming events, and answers to frequently asked questions.
AORN JOURNAL
293
AUGUST 2005, VOL 82, NO 2
P A T I E N T
SAFETY
FIRST
Internet resources for patient safety
S
ince the release of the Institute of Medicine's report, To Err is Human, Buildiiig a Safer Health System,' a number of organizations have developed Internetbased resources to provide-clinicians, researchers, and educators with a variety of helpful materials to guide their patient safety efforts. Using the Internet to obtain information about patient safety can be effective for busy clinicians. This column reviews a number of patient safety web sites. The intent is not to be all inclusive but to provide information about some web sites that have not been featured in earlier columns2or that may be recent additions to the vast number of Internet resources.
THEAGENCYFOR HEALTHCARE RESEARCH AND QUALITY (AHRQ) The AHRQ has added some important safety-related web sites to support its agenda of improving the quality, safety, efficiency, and effectiveness of health care for all American~.~ The AHRQ Patient Safety Network (PSNet) at http://psnet.akrq.gov provides up-todate information on patient safety, and users of PSNet can subscribe to the PSNet Weekly electronic newsletter to receive updates about the latest literature, news, and conferences on patient safety. Morbidity and Mortality Rounds on the Web (WebM&M) at http://webmnr .ahrq.gov features case studies related to risk management, surgery/anesthesia, medicine, radiology, nursing, and a host of other medical specialties and case commentaries developed by safety experts. The case studies are submitted by clinicians and typically concern medical errors or other patient safety and quality issues. Individuals who submit a case study receive an honorar-
ium if the case is posted, and they can chose to submit the case anonymously. This web site also contains a patient safety glossary, a topic index, a variety of forums and discussion groups, and opportunities to obtain continuing education units. The AHRQ also offers the National Guidelines Clearinghouse at http://www .guideZine.gov. This resource has more than 1,500 evidencebased practice guidelines to help clinicians provide Busy the highest quality care based-on reskarch. The the availability of these guidelines provides clinicians with another strategy to provide evidenceto obtain based, safe care.
cl nicians can use Internet
THEJOINT COMMISSION
CJ
variety of
The joint Commission information on Accreditation of Healthcare Organizations (JCAHO)recently launched the Joint Commission Intemationa1 Center for Patient Safety to identi@, gather, analyze, and disseminate information about patient safety solutions worldwide. The overall goal of the center is to continuously improve the safety of patient care by providing solutions, procedures, and processes that help reduce medical errors and adverse events in all health care settings." Resources available at http://u~.su7u.jci patienfsafety.org include information for patients and their family members, health care professionals and providers, and government and business leaders. The web site contains updates about JCAHOs National Patient Safety Goals, Sentinel Event Alerts, news and updates about patient safety topics, networking
about patient safety.
AORN JOURNAL
291
Patient Safety First
AUGUST 2005, VOL 82, NO 2
description of the techruque, a based patient safety resources. reference list, a worksheet, and In fact, typing ”patient safety” guidelines related to the topic. into an Internet search engine Other patient safety topics that results in millions of entries can be researched here include on this topic. The web sites safety measures, improvement described here represent some stories, tools, medication sysof the latest to be developed and made available to the THEINSTITUTE FOR HEALTHCARE tems, and surgical site infecpublic and health care profestions. The web site also proIMPROVEMENT (IHI) vides a variety of links to topsionals. Searching these sites The IHI web site at ics such as leading system provides a first step to learnlit f,u://www.ilzi.oprovides rg improvement, office practice, users with a vast number of ing more about patient safety medical-surgical care, health and finding h k s to additionresources focused on advancprofessions education, and al resources. *3 ing the quality, safety, and critical care. value of health care. For SUZANNE C. BEYEA example, the IHI recently RN, PHD, FAAN VETERANS HEALTH launched the 100K Lives camDIRECTOR OF NURSING RESEARCH paign to encourage thousands ADMINISTRATION (VHA) DARTMOUTH-HITCHCOCK MEDICAL CENTER NATIONAL CENTERFOR PATE I NT of US hospitals to commit to LEBANON, NH SAFETY(NCPS) implementing six interventions that have been demonAnother patient safety NOTES strated to prevent avoidable resource is provided by the 1. Institute of Medicine, To Err is deaths. These interventions NCPS at http://www.patient Human, Building a Safer Health include rapid response teams, sufety.gov.The NCPS describes Sysfenz (Washington, DC: Nationreliable evidence-based care al Academy Press, 2000). their program as a “unified 2. S C Beyea, “Safety resources for acute myocardial mfarcand cohesive patient safety for perioperative clinicians,” tions, and the prevention of program with active particiAORN Journal 79 (April 2005) adverse drug events, central pation by all the VA hospitals 853-855. supported by dedicated line infections, surgical site 3. “Mission and budget,“ Agency for Healthcare Research patient safety manager^."^ infections, and ventilatorand Quality, htfp://www.ahrq.gov associated pneumonias? Thls web site includes a vast /about/budgtix.htrn (accessed 21 number of resources, includAudiovisual materials about June 2005). the campaign are available, as ing VHA Patient Safety Alerts 4.“About the center,” Joint are discussion groups and a and Advisories, information Commission International, hfkp:// www.jcipa tientsafety.org/show.asp?d link to Canadian efforts on the on how to conduct a root same topic. cause analysis or a health care urki=9270 (accessed23 June 2005). 5. ”100K Lives campaign,” The IHI web site also has facility’s failure mode and Institute for Healthcare Improvevaluable information about a effect analysis, a description ment, http://www.ihi.org/i€i@’ro grarns/Carnpaign/Carnpaign.ht t n ? wide variety of quality and of the VHA’s patient safety Tabld=Z (accessed 23 June 2005). safety initiatives, a monthly curriculum, a number of 6. “SBAR technique for commuelectronic newsletter, and vari- patient safety resources, and nication: A situational briefing ous products and services.For answers to frequently asked model,” Institute for Healthcare example, the web site provides questions. Improvement, http://~u~u~i~.ihi.org /ihi/search/searchresults.aspx?search a variety of links and resources terni=sbar&searchtype=basic related to the SBAR (ie, situaTHETIP OF THE ICEBERG (accessed 23 June 2005). tion, background, assessment, The web sites featured in 7.VA National Center for Patient recommendation)communica- this column are just a few of Safety, http://www.pafienfsafify.gov the vast number of Internettion technique: including a (accessed 23 June 2005). communities, complimentary safety resources, patient safety products and services, information about upcoming events, and answers to frequently asked questions.
AORN JOURNAL
293