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.
In December 2005, MOCPS became operational with the hiring of Becky Miller as Executive Director.
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.
MOCPS has successfully implemented statewide projects – the Missouri Just Culture Collaborative to improve the culture for safety and the Banding Together – for patient safety project to improve processes of care by decreasing the potential to confuse the use of colored wristbands, led collaboratives to reduce healthcare acquired infections, and utilized the Comprehensive Unit-based Safety Program developed by Johns Hopkins to develop a unique program among hospital units focused on teamwork and communication to proactively identify unsafe conditions to prevent errors.
In addition, the Center has established two traditions– MOCPS’ annual conference and sponsoring of Missouri Patient Safety Awareness Month.
As a federally listed Patient Safety Organization (PSO) MOCPS 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, MOCPS can offer protection and confidentiality to health care providers that work with us.
As a PSO, we work with providers on a voluntary and confidential basis to gather the necessary data and information about medical errors to learn why they occur, and most importantly, to share the learning about how to prevent errors.
As a PSO, MOCPS will continue to provide education and training, serve as a resource center, and facilitate statewide projects by working with stakeholders across Missouri to make measurable improvements in the safety of health care provided to Missourians.
Having completed our fifth year, MOCPS has reached significant mile markers. We have:
• Achieved organizational goals as a result of successful funding efforts, obtaining more than $1.5 million in grants and additional funding to support special projects.
• Gained recognition as a state and national leader in patient safety.
• Led successful statewide initiatives to improve safety culture, teamwork, communication and decrease blood stream infections.
• Provided education and training for health care providers, professionals, students, regulators, and consumers.
• Served as a statewide resource on patient safety through our website, interviews, articles, and other public outreach.
• Became a leader in PSO services – working with more than 180 providers to report medical mistakes, learn from mistakes and take actions aimed at prevention.
• Aimed toward future growth through short and long term communications and development strategies.
Completing five years of our vital work is more than an anniversary or an achievement – it’s an indicator. Our work in the first five years has been meaningful and will undoubtedly continue to be even more necessary into the future.
