Patient safety is a critical component of quality. We can not improve patient safety simply by punishing health care workers for human errors.
The problem is seldom the fault of the individual, it is the fault of the system. To truly improve patient safety, we must focus on creating systems that minimize the opportunities for human error and mistakes. Systems that forcus on prevention, not punishment. Establishing a culture of safety where people are able to report adverse events and close calls without fear of punishment is the key to making patient safety a reality.
The legislation affects hospitals, ambulatory surgical centers and private mental hospitals. Many of the requirements in the legislation are consistent with JCAHO sentinel event standards.
Key components of the legislation include:
- Facilities must establish a patient safety program that includes risk reduction strategies. A root cause analysis must be conducted and a corrective action plan developed when specific adverse events are identified. Department representatives may review this information during an onsite review, but the facility will not be required to submit copies of this information to the department. Facilities should have started this process on June 20, 2003.
- Facilities must submit to the department an annual report that lists the number of occurrences of the specific adverse events listed in the legislation. Annual reporting begins in July 1, 2004.
- Facilities are required to submit to the department at least one best practice and safety measure related to a reported event. Best practice reporting will begin July 1, 2004.
- Requires that the department develop a patient safety program to serve as a clearinghouse for information about best practices and quality improvement strategies.
- The department will be responsible for compiling the data pertaining to reported events and best practices and making a summary of the information available to the public. The information made available to the public may not directly or indirectly identify a particular hospital or individual, or the specific events, circumstances or individuals surrounding a reported event. To view the latest report, press the back button and select the link to the DSHS Annual Occurrence and Best Practice Report.
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Texas Department of State Health Services, Health Facillity Licensing Program
1100 West 49th Street - Austin, Texas 78756 - (512) 834-6646