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 care.
"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. Fried said.
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 Twitter and Facebook.