In 1999, the Institute of Medicine (IOM) released the landmark report, To Err is Human: Building a Safer Health System. The report revealed that one million people in the United States suffer from preventable medical injuries and 100,000 die from them every year. Since that time, the IOM panel called on health care organizations, doctors' groups, regulators, government agencies and Congress to make patient safety a priority. Medical errors most often result from a complex interplay of multiple factors. The chief culprit is often inadequate dissemination and implementation of ideas and practices that are known to be effective. The Academy's patient safety study previously revealed that 86% of the reported errors in the family physician's office setting were process errors.
The 2001 IOM report, "Crossing the Quality Chasm," addressed the importance of aligning payment policies with quality improvement (which has already begun) using information technology, and having clinicians working cooperatively. The report identified six aims which included providing care that was timely, efficient, safe, effective, equitable, and patient-centered. In 2002, the AAFP recognized a need to develop a more coordinated and efficient approach to address patient safety and decided to convene a patient safety strategic planning meeting.
The AAFP Strategic Planning Meeting for Patient Safety in the Primary Care Ambulatory Setting was held in March 2003 and generated a wealth of knowledge from a variety of experts, both internal and external. These priorities were based on the findings from that meeting. These priorities are not in rank order. Although the AAFP has already begun to take steps to address several of these priorities, much work remains to build a safer healthcare system.
AAFP's Strategic Priorities for Patient Safety
- AAFP will pursue payment reforms to support patient safety and quality improvement efforts.
- AAFP should explore becoming a Patient Safety Organization (PSO). A Patient Safety Organization (PSO) means a private or public organization, or component thereof, that: collects and analyzes voluntarily reported data on medical errors; develops and disseminates information information on improving patient safety to reporters; protects confidentiality of reported data; and has been granted a federal certification to operate as a PSO.
- AAFP will take a leadership role in forming a coalition of organizations that have an interest in primary care and patient safety. This coalition will:
- build and strengthen relationships among the organizations involved and create a united front when addressing legislative and advocacy issues
- provide a link between organizations further expanding the possibility in the standardization improvement efforts in systems and process designs
- share multi-perspective views and create programs and/or materials which are applicable to all primary health care providers regarding patient safety
- AAFP will conduct an aggressive research agenda on patient safety in the primary care ambulatory setting. Research will include:
- studying the epidemiology of ambulatory patient safety
- evaluating the best methodology for assessing quality and safety in practice
- translating research findings into clinical practice to produce measurable improvements in quality and patient safety
- AAFP will build an awareness of systems thinking and assist physicians to apply this to patient care.
- AAFP will frame patient safety as an essential component of quality improvement for patient care.
- AAFP will facilitate the development of patient safety/quality improvement knowledge, skills and attitude through all levels of medical education.
- AAFP will support and facilitate the movement from CME to life-long learning, self-assessment and physician performance improvement and recognize "learning practices".
- AAFP will pursue the availability of a comprehensive, integrated, low-cost, standardized and secure electronic health record with embedded evidence-based diagnostic, therapeutic and preventive clinical guidelines.
Background Note
