Stanley Edinger, Ph D, Center for Quality Improvement and Patient Safety, Agency for Healthcare Policy and Research, 5901 Montrose Road, 1400 South, Rockville, MD 20852, 301-427-1334, sedinger@ahrq.gov

According to a 2000 Institute of Medicine ( IOM) report, errors in health care have been estimated to be responsible for injury in as many as 1 out of every 25 hospital patients; an estimated 48,000-98,000 patients die from medical errors each year. Errors in health care have been estimated to cost more than $5 million dollars per year in a large teaching hospital, and preventable health care-related injuries cost the economy from $17 to $29 billion each year. Even the lower estimate is higher than the annual mortality from motor vehicle accidents, breast cancer or AIDS making medical errors the eight leading cause of death in the United States. A 2003 IOM report recommended that data standards be developed to support their vision of patient safety being integrated with clinical information systems. This, in turn, would lead to improved quality of care and improved safety. Medical errors were most frequently the result of system errors related to the organization of health care delivery and how resources are provided in the delivery system. Some of the common patient safety problems and mechanism to address them include the use of the electronic health record and data standards for data entry and analysis. Some of the common patient safety errors and potential remedies and their impact on quality, as well as, various alternatives for monitoring patient safety will be discussed.

Learning Objectives: At the conclusion of this session, the participant will be able to

• Recognize several of the causes of medical errors or patient safety problems and their relationship to quality of care problems. At least five.
• Articulate the mechanisms for addressing some of the major patient safety and quality of care issues and recognize the policy, cost and patient centered issues related to atlernative action plans.
• Develop possible action plans to address patient safety and quality of care issues.

Keywords: Health Care Quality, Health Care

Related Web page: www.ahrq.gov

Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: Agency for Healthcare Research and Quality
I have a significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.
Relationship: Employee of the Agency for Healthcare Research and Quality