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First step in extension of medical Near Miss Registry for
application in all healthcare settings across the country
June 7, 2012
Washington - The American College of Physicians (ACP) today
announced collaboration with the New York ACP (NYACP) chapter to
extend its medical Near Miss Registry into a national patient
safety reporting and professional educational program. Today's
announcement was made possible with ACP's Center for Quality's
listing as an official Patient Safety Organization (PSO) by the
Agency for Healthcare Research and Quality (AHRQ) on behalf of the
U.S. Department of Health and Human Services.
According to Terence Brady, MD, FACP, NYACP's president, "This
joint venture between the New York Chapter of the ACP and the
American College of Physicians demonstrates the ongoing commitment
of these organizations and their members to provide our patients
with the highest quality and safest medical care in our rapidly
changing healthcare environment."
PSOs are designed to help clinicians, hospitals and health care
organizations improve the care they deliver to patients by
encouraging them to conduct quality and safety analyses. Through
federal protections of legal privilege and confidentiality, which
are authorized by the Patient Safety and Quality Improvement Act of
2005, PSOs foster a culture of safety and create a secure
environment where providers can collect and analyze data to
identify and reduce the risks and hazards associated with patient
"Near misses" are close calls or errors that are detected and
corrected before resulting in patient harm. As learned from the
airline industry, analysis of near misses presents an opportunity
for better understanding causes as well as methods for preventing
harm. Over the last five years, NY's ACP, under the leadership of
Ethan Fried, MD, MACP, of St. Luke's Roosevelt Hospital, and a
statewide advisory committee with the support of the New York State
Department of Health's Patient Safety Center, pioneered the first
statewide near miss registry. In the initial phase, the near miss
investigators trained more than 3,000 residents in internal
medicine throughout the state. In later phases of the registry and
education program, it was extended to all physicians and allied
health professionals. An educational program for health care
professionals outlining patient safety, system barriers and steps
to identify near miss events was presented at more than 50
hospitals and professional societies across New York State. "Our
goal is to change the culture of healthcare into one that learns
from mistakes and shares best practices in patient safety," Dr.
Building on this effort, ACP has joined forces with NYACP to
expand the Near Miss Registry nationwide, including expansion to
outpatient healthcare practices. It will link registry reports of
near misses to educational resources that will help clinical teams
strengthen patient safety through data-driven system improvements
shown to be effective.
"NYACP's Near Miss Registry shows that doctors and other
clinicians can both identify risks to patient safety and, learn how
to better protect patients in the healthcare system," noted ACP
Senior Vice President Dr. Michael Barr.
"National expansion of the program will give physicians and
their clinical teams tools to better understand and redress safety
challenges," said NYACP Executive Director Linda Lambert. "Patient
safety and the prevention of medical errors is a top priority for
NYACP. Through several phases of modeling and testing, the Near
Miss Registry has proven that clinicians are willing and able to
act on meaningful data that is evidence based."
"We know that clinicians and health care organizations want to
participate in efforts to improve patient care, but they often are
inhibited by fears of liability and sanctions," said AHRQ Director
Carolyn M. Clancy, MD. "PSOs facilitate a shared-learning approach
that supports effective interventions to reduce risk of harm to
patients and improve quality."
The American College of Physicians is the
largest medical specialty organization and the second-largest
physician group in the United States. ACP members include 132,000
internal medicine physicians (internists), related subspecialists,
and medical students. Internists specialize in the prevention,
detection, and treatment of illness in adults. Follow ACP on
David Kinsman, (202) 261-4554, firstname.lastname@example.org
Jacquelyn Blaser, (202) 261-4572, email@example.com