The Institute of Medicine’s 1999 landmark report, To Err Is Human, reported as many as 98,000 deaths occur annually due to errors in hospitals with potentially many more deaths due to errors occurring in other health care settings.
The IOM’s report resulted in an international focus on quality improvement and patient safety further encouraged by the IOM’s March, 2001 report, “Crossing the Quality Chasm.”
In 2003, responding to these reports and to growing concerns about medical malpractice rates in Missouri, Governor Bob Holden formed a 16-member Missouri Commission on Patient Safety.
In July 2004, this Commission called for the creation of a “new private Missouri Center for Patient Safety…to act as a leadership vehicle for patient safety improvements and be a resource for health care organizations, professionals and consumers.” This center was to advocate for error reduction, assist in sharing information, identify best practices, develop curricula for professionals and disseminate consumer education materials. It also recommended that such a center serve as a Patient Safety Organization (PSO) should federal legislation be passed defining requirements for such organizations.
Responding to the Commission’s recommendation, the Missouri Hospital Association (MHA), Missouri State Medical Association (MSMA) and Primaris agreed to establish such an organization.
In January 2005, the Missouri Center for Patient Safety (MOCPS) was officially established as a new not-for-profit organization in the state of Missouri.
In July 2005, federal legislation followed in the form of the federal Patient Safety and Quality Improvement Act of 2005. Providing a structure for state-based PSOs, the legislation provides protection for physicians and health care providers that voluntarily and confidentially report adverse event data and information to designated PSOs.
During our first full three years of operation, MOCPS continued to gain recognition and participation in our work to improve the safety of health care provided in Missouri, bringing together health care providers, state agencies, insurers and others with a vested interest in improving patient safety to share, learn, and facilitate improvement. The year 2008 culminated with the Center certifying with the federal Agency for Healthcare Research and Quality as a Patient Safety Organization (PSO) to operate within the provisions of the Patient Safety and Quality Improvement act of 2005. As a PSO, the Center began to further support a culture that encourages the reporting, analysis, sharing, learning and prevention of medical errors.
MOCPS has successfully implemented regional projects – Early Center projects that continue to have an impact today are the Missouri Just Culture Collaborative, and Banding Together – for patient safety, projects that were each one of the first in the nation to take culture training statewide and to decrease the potential for error related to the use of colored wristbands across the state. Additionally, the Center has and continues to lead healthcare acquired infection prevention collaboratives and expand upon our own unique enhancement to the Comprehensive Unit-based Safety Program (CUSP), developed by Johns Hopkins, to improve bedside teamwork and communication. Again, our CUSP work has expanded statewide and nationally as a component of the On the CUSP/Stop HAI initiatives and continues today.
Beginning in 2012, the MOCPS reframed itself as the Center for Patient Safety (CPS) broadening its vision and mission nationally. As the CPS, the Center is enhancing its PSO, culture, education and other resources and services.
As the CPS, our three focus areas are General PSO services, EMS PSO services and improvement resources with a focus on safety culture assessment and reporting, in addition to valuable education and training.
As a federally listed Patient Safety Organization (PSO), CPS collects adverse event data and information, analyzes the data for the purpose of learning, and shares the learning to further improve care. Under federal legislation, CPS can offer protection and confidentiality to healthcare providers that work with us allowing for open reporting and sharing that leads to prevention. Additionally, CPS is the first PSO in the nation to develop data formats and PSO services specifically for EMS providers.
Improving healthcare safety to the extent possible can only occur when a culture for safety exists. As such, the CPS continues to provide and enhance our safety culture services by administering a user-friendly automated AHRQ Survey on Patient Safety for hospitals, long-term care and medical offices; and provide training in Just Culture and other elements of safety culture.
Education and training opportunities are also encompassed in our PSO and culture work, in addition to clinical collaboratives, annual support for patient safety awareness month, annual conferences and annual PSO day.
We at the CPS are excited about continuing to lend our voice and offer our services and resources to healthcare providers and consumers, continuing our successful efforts to improve healthcare quality and safety and reduce patient harm.