Healthcare Safety Quotes

Until our world decides that every human matters, that everyone has a right to food and safety and freedom and healthcare and equality, it is the obligation of those privileged to have food and safety and freedom and healthcare and equality to fight tirelessly for those who do not.

These are not ordinary times where we play politics and juggle with the safety of the society. These are the times that demand prompt decisions and utter responsibility towards not just the self but our kind – the humankind.

With a focus on creativity in schools and nurturing future job talent, many Danes are getting a leg-up right to the summit of the triangle. By contrast, some developed countries haven’t even got past the second rung of ‘safety’ – with no healthcare or job security (hello, USA).

Lean is about the total elimination of waste and showing respect for people.

open immigration can’t exist with a strong social safety net; if you’re going to assure healthcare and a decent income to everyone, you can’t make that offer global

There is no justifiable reason why any man, woman or child on this planet should ever have to endure a single day without access to nutritious food,clean water,adequate shelter,healthcare,education and safety.

Psychologists at the University of British Columbia in Vancouver, Canada, found that the better educated and wealthier a nation is, the less likely its population is to believe in a higher being. The Global Index of Religion and Atheism also assessed that poverty was a key indicator of a society’s tendency towards religion – so that poorer countries tend to be the most religious. The one exception to the rule? America. But in the strongly religious USA, despite the country’s wealth, there’s no universal healthcare, little job security, and a flimsy social welfare safety net. This means that the USA has a lot more in common with developing countries than she might like to think. Researchers from the University of British Columbia suggest that people are less likely to need the comfort of a god if they’re living somewhere stable, safe and prosperous.

I use “anticapitalist” because conservative defenders of capitalism regularly say their liberal and socialist opponents are against capitalism. They say efforts to provide a safety net for all people are “anticapitalist.” They say attempts to prevent monopolies are “anticapitalist.” They say efforts that strengthen weak unions and weaken exploitative owners are “anticapitalist.” They say plans to normalize worker ownership and regulations protecting consumers, workers, and environments from big business are “anticapitalist.” They say laws taxing the richest more than the middle class, redistributing pilfered wealth, and guaranteeing basic incomes are “anticapitalist.” They say wars to end poverty are “anticapitalist.” They say campaigns to remove the profit motive from essential life sectors like education, healthcare, utilities, mass media, and incarceration are “anticapitalist.” In doing so, these conservative defenders are defining capitalism. They define capitalism as the freedom to exploit people into economic ruin; the freedom to assassinate unions; the freedom to prey on unprotected consumers, workers, and environments; the freedom to value quarterly profits over climate change; the freedom to undermine small businesses and cushion corporations; the freedom from competition; the freedom not to pay taxes; the freedom to heave the tax burden onto the middle and lower classes; the freedom to commodify everything and everyone; the freedom to keep poor people poor and middle-income people struggling to stay middle income, and make rich people richer. The history of capitalism—of world warring, classing, slave trading, enslaving, colonizing, depressing wages, and dispossessing land and labor and resources and rights—bears out the conservative definition of capitalism.

Growing up, those of us who had to put a hyphen before "American" got scoffed at for sending money home to cousins in the old country or supporting aging parents here on green cards. But you used to shake your head and tell me how, back home, nobody put their parents into nursing homes or let their kin go hungry. The same thing lives on among Sami's queer and trans friends of color, he tells me, crowdfunding for medical care and housing online, or in the group chats he tells me about where friends help one another escape abusive relationship or housing crises with safety planning and couches to sleep on. We take care of one another because no one else will, eh says. But every time is a gamble.

Until I felt the tenuousness of my own safety net, I didn’t understand that most don’t have access to basic healthcare, savings or stable familial support. I’d been raised to believe that comfort was the result of hard work or innate intellect, but I was starting to understand that fulfillment of these basic human needs was tied to a person’s body, bloodline, and the origins of their birth. Papa’s wealth had made me feel entitled to a level of security that no one is owed or guaranteed. I had a simplistic understanding of the world and how it worked because it worked well enough for me, and it was only when it stopped working for me that I began to think about the ways in which it failed to work for others.

At the very least, to set our healthcare workers, patients, and patient caregivers up for success, we must modernize the systems that guide their work and enable their voices to be heard—especially when they see opportunities to prevent harm and improve care environments.

Poor health was not just the result of random acts, bad luck, bad behavior or unfortunate genetics. Deliberate public policy decision about housing, education, parks and streets were the key drivers of racial differences in mortality. Crime kept people off the streets and limited their ability to exercise. The lack of grocery stores limited dietary choices. The lack of primary care doctors and specialists in these communities made chronic disease care more difficult. The degradation and loss of hospital services in these communities affected hospital-based outcomes. … The chronic underfunding of critical health services at Cook County Hospital and other safety-net providers contributed to these poor outcomes as well. The deleterious impact of social structures such as urban poverty and racism on health has been called 'structural violence.

Gradually, however, the liberal story expanded its horizons, and at least in theory came to value the liberties and rights of all human beings without exception. As the circle of liberty expanded, the liberal story also came to recognize the importance of communist-style welfare programs. Liberty is not worth much unless it is coupled with some kind of social safety net. Social-democratic welfare states combined democracy and human rights with state-sponsored education and healthcare. Even the ultracapitalist United States has realized that the protection of liberty requires at least some government welfare services. Starving children have no liberties.

My loneliness humbled me. It sounds embarrassingly ignorant now, but until I felt the tenuousness of my own safety net, I didn’t understand that most don’t have access to basic healthcare, savings, or stable familial support. I’d been raised to believe that comfort was the result of hard work or innate intellect, but I was starting to understand that fulfillment of these basic human needs was tied to a person’s body, bloodline, and the origins of their birth. Papa’s wealth had made me feel entitled to a level of security that no one is owed or guaranteed. I had a simplistic understanding of the world and how it worked because it worked well enough for me, and it was only when it stopped working for me that I began to think about the ways in which it failed to work for others. —

This is not a story which denies trans identities; nor that argues trans people deserve to lead anything other than happy lives, free of harassment, with access to good healthcare. This is a story about the underlying safety of an NHS service, the adequacy of the care it provides and its use of poorly evidenced treatments on some of the most vulnerable young people in society. And how so many people sat back, watched, and did nothing.

Many of us in healthcare entered the profession because we wanted to help, heal, and serve. At our core, we have compassion, empathy, and a drive to help people live their best lives. Recognizing and implementing actions to prevent patient and employee harm has the greatest potential effect on the quality of care delivered in our health care system, just as preventative care and wellness efforts slow or stop the progression of disease.

Prostitution is not exactly a reputable business over there either, even though the girls actually have to pay taxes on their earnings, and submit to regular health check ups. Even the prostitutes have universal healthcare over there. The benefit of legal prostitution is obvious: tax income for the city, healthier girls, and safety. In Amsterdam, each girl has an alarm button next to her bed that she can press if one of her "customers" tries to rape or hurt her. The police will arrive within minutes and protect the girl from harm.

Psychologists at the University of British Columbia in Vancouver, Canada, found that the better educated and wealthier a nation is, the less likely its population is to believe in a higher being. The Global Index of Religion and Atheism also assessed that poverty was a key indicator of a society's tendency towards religion - so that poorer countries tend to be the most religious. The one exception to the rule? America. But in the strongly religious USA, despite the country's wealth, there's no universal healthcare, little job security, and a flimsy social welfare safety net. This means that the USA has a lot more in common with developing countries than she might like to think.

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Currently, the wealthy who have no pre-existing conditions can afford high-quality health care, while the poor and sick are relegated to hoping for and negotiating whatever health care safety net might exist in their area. This neoliberal form of capitalism structuring health care in the United States has led to those with the highest burden of sickness being simultaneously those with the least access to care.

A Supreme Court decision (Riegel v. Medtronic, Inc., 552 US 312, 2008) protected devices from most lawsuits. It exempts the companies from litigation if the FDA agreed on the device’s effectiveness and safety during the approval process. When the drugmakers have issues, they may have to defend lawsuits, but this Supreme Court decision protects the appliance manufacturers.

which found that nearly 4 percent of hospitalized patients suffered a serious injury, of which 14% were fatal and 69% were due to errors and were thus preventable.

These efforts were dramatically successful: they reduced the mortality of anesthesia 90%, from 1 in 20,000 to 1 in 200,000, within a decade

George realized that my paper would be a red flag for many doctors, who were very sensitive to anything that might make them look bad . Their institutional arm was the AMA , which saw its primary responsibility as the defense of physicians’ pride and privilege. Naively, I thought the paper offered so much in the way of opportunity to reduce harm to patients that it would be rapidly embraced by doctors. Here was the way they could reduce harm to their patients and decrease the risk of malpractice suits.

Most importantly, however, the paper influenced Ken Shine , president of the Institute of Medicine (IOM) and its Quality of Care Committee, to make safety a focus of its work in quality of care. (See Chap. 9.) The Committee’s later report To Err is Human [14] was in many ways a detailed explication of the information in Error in Medicine, amplified with patient examples and specific recommendations for policy changes. It brought to public attention what the paper brought to the profession

We established an investigative team at each hospital and selected 11 nursing units for the study at the 2 hospitals: 5 intensive care units and 6 general, non-obstetric care units. David Bates was the leader of the Brigham team and David Cullen led the MGH team.

This rate of ADEs , 6.5 for every 100 patients, was astounding! It was almost ten (10) times higher than had ever been reported. And this was at the two flagship teaching hospitals of Harvard, institutions that considered themselves the best in the country!

Based on this evidence, the NQF endorsed bar coding , and it has since been adopted as standard practice in hospitals nationwide.

The IOM urges Congress to pass legislation extending peer review protections to data related to patient safety and quality improvement that are collected and analyzed by healthcare organizations for purposes of improving safety and quality. (We all agreed this was essential if we were ever to get people to talk about error in the current litigious environment.)

It’s not bad people, it’s bad systems.

Suddenly PSIs were viewed not as tools for improvement, but as instruments of punishment—a complete inversion of what we were trying to do in patient safety.

AHRQ created a website, psnet.​ahrq.​gov, with the latest news, research, legislation, and tools for patient safety.

On the other hand, within days of the publication of Error in Medicine, I received letters from friends and others congratulating me and thanking me for the paper.

The Lehman case was a life-changing event for DFCI , which underwent a major reorganization under the leadership of Jim Conway to dramatically improve its safety and ultimately achieve the lowest medication error rate in the nation.

The paper also influenced the thinking of future leaders in patient safety. Within a year, Jerod Loeb , from the Joint Commission, and Mark Eppinger of the Annenberg Center decided to convene a conference on medical error . Despite the displeasure with Lundberg at the AMA , its legal counsel, Marty Hatlie , convinced the leadership to shift its efforts from tort reform to error prevention . That ultimately led the AMA to found the National Patient Safety Foundation .

The before-after study at BWH showed that CPOE reduced all medication errors by 83% and ADEs by 17% [4]. The estimated cost saving if the system were implemented hospital-wide was $480,000 per year. The controlled study of pharmacist participation on rounds at the MGH showed a 66% reduction of ADEs caused by errors in prescribing [5]. Finally, we had evidence that systems change worked in healthcare.

Ninety-six hospitals completed the collaborative . They reduced the mean rate of CLABSI /1000 catheter days from 7.7 to 1.4 in 18 months.

The other was Atul Gawande , a surgical resident who I had gotten to know during his year at the Harvard School of Public Health . Atul later developed the surgical checklist for WHO and created Ariadne Labs, an influential collaboration of innovators, implementers, and healthcare leaders focused on quality and safety.

Further analysis showed that disclosure of the AE to the patient by the medical team only occurred 40% of the time. Disclosure was more likely if additional treatment was needed and less likely if the AEs were preventable (an error ). Patients were twice as likely to rate the quality of care high when there was disclosure [4]. High patient participation in their care was associated with fewer AE (49%) and higher likelihood that patients would rate the quality of their care good or excellent [5

the NPSF rolled ahead. Patient safety was beginning to be talked about widely. In the report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry , led by Don Berwick , head of the Institute for Healthcare Improvement (IHI) , reduction of error was one of six recommended national aims, and NPSF was cited. JCAHO revised their sentinel event policy to make reporting voluntary, and the Agency for Healthcare Policy and Research (AHCPR) (later renamed the Agency for Healthcare Research and Quality (AHRQ) identified patient safety as a priority.

Dr. Ron Westrum described information flow as a “prime variable in creating safety, but also it is an indicator of organizational functioning.”19 This was based on studying human factors in system safety in complex and risky industries, including aviation and healthcare. Westrum asserted that “When information does not flow, it imperils the safe and proper functioning of the organization…and second, information flow is a powerful indicator of the organization’s overall functioning.”20

The most gifted healers are those who are continually and actively doing their own inner work behind the scenes.

In the words of David Kilcullen—former special adviser for counterinsurgency in George W. Bush’s administration and chief counterterrorism strategist for the U.S. State Department—the most important thing governments can do is to “remedy grievances and fix problems of governance that create the conditions that extremists exploit.” If America does not change its current course, dangers loom. In the case of the United States, the federal government should renew its commitment to providing for its most vulnerable citizens, white, Black, or brown. We need to undo fifty years of declining social services, invest in safety nets and human capital across racial and religious lines, and prioritize high-quality early education, universal healthcare, and a higher minimum wage. Right now many working-class and middle-class Americans live their lives “one small step from catastrophe,” and that makes them ready recruits for militants. Investing in real political reform and economic security would make it much harder for white nationalists to gain sympathizers and would prevent the rise of a new generation of far-right extremists.

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Employment drug testing is a critical practice that helps businesses maintain a safe and productive environment. It ensures that employees are not using substances that could impair their judgment, performance, or safety at work. In industries where precision and safety are key, such as construction, healthcare, and transportation, regular drug testing reduces the risk of accidents and enhances overall workplace efficiency. Employers can implement employment drug testing during the hiring process or conduct random tests for current employees. This not only helps in detecting potential substance abuse but also serves as a preventive measure, deterring employees from using drugs. Additionally, it helps companies comply with legal regulations, avoiding costly lawsuits or fines related to workplace safety violations.

Solution #4: DELAY HEP-B VACCINATION UNTIL A PRE-TEEN YEAR. This is not a vaccine for infants. Hepatitis B vaccine should not be administered to infants directly after birth, unless the mother is infected with this virus and could pass it along to the child. All pregnant women should be screened for hep B infection. Recommended age of hep B vaccination should be changed to a preteen year just before high school. Notify the parents/guardians and mandate that a warning label be placed on hep B vaccines indicating aluminum levels within the vaccine exceeds FDA safety levels for parenteral aluminum, which may result in aluminum toxicity.

W.A. supported fair wages, even opposing wage reductions when copper prices fell, and as a result he didn’t suffer from strikes. He also offered model healthcare for workers, and when Daly opposed a law requiring safety cages in the mines, Clark supported it—even if only for political advantage. He also supported voting rights for women.

Pennsylvania's Religious Freedom Protection Act of 2002 (RFPA), removed a number of categories from its reach, including criminal offenses; motor vehicles; licensing of health professionals; the health or safety of individuals in facilities operated under the public welfare code; the safe construction and operation of health-care facilities; health and safety in construction; and mandatory reporting of child abuse.30

India has tens of thousands of NGOs, including local arms of global charities and homegrown groups, working on causes including the status of women, urban safety, human rights, environmental protection, healthcare, agriculture and clean energy.

Clinical handovers are high-risk situations for patient safety. Errors lead to delays in diagnosis and treatment, unnecessary tests and treatments, incorrect patient treatment, increases in the length of hospital stay, patient complaints, and malpractice claims.

Travel Tips for the First Summer Vacation with a Baby Introduction Travelling with your child can be both exhilarating and distressing especially if it is your first summer vacation with your baby. The summers can especially be daunting for the health of your child. Hence, the best childcare expert in Chandigarh recommends you prepare beforehand and always keep yourself ready, and follow summer health tips for kids. If you are planning to take your first summer vacation with your baby, here is all that you need to know. The best paediatrics specialist doctors at sector 44 recommend the below travel tips to ensure your baby’s safety: Keep Your Expectations Minimum Of course, it is your first time out with your kids and you may be super excited to show them the world. Keep in mind, however, that there is more work involved in taking your baby out than traveling as a couple. With babies, you need to keep everything handy and ensure that they are fed on time. Moreover, plan your trip in a way that does not hamper your sleep routine. The Paediatricians at Motherhood Chaitanya, Chandigarh suggest adjusting your expectations in a way that does not hamper your fun and ensures that you take good care of your baby.

The Australian union movement called an 'illegal' general strike in 1976, when Prime Minister Malcolm Fraser's government was trying to destroy our embryonic universal healthcare system. That strike brought the country to a standstill. Fraser backed down, and what became Medicare remains. The same people who disagree [with strike action] may also want to reflect on this the next time they enjoy a leisurely weekend, or are saved from an accident by workplace safety standards, or knock off work after an eight-hour shift. Union members won all these conditions in campaigns that were deemed 'illegal' industrial actiona at the time. These union members built the living standards we all enjoy. They should be celebrated and thanked for their bravery and sacrifices, not condemned and renounced.

The moment he spoke in Telugu with them, something in the room changed. There was a new sense of comfort in the air, a sense of ease and safety. It was the feeling of assurance that came with being surrounded by their own people.

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The Jews did not “take Palestine.” There was no Palestine for the taking. There was no state, no united governance, not much industry, or a healthcare system, or agriculture, economic or education systems. There was certainly no democracy, equality, safety, or prosperity for the people living there.

The company's journey into the healthcare sector not only reflected a commitment to immediate pandemic needs but also signaled a long-term dedication to public health. QYK Brands invested in research and development to enhance the effectiveness of its healthcare products, ensuring they met the highest standards of safety and quality.

The world didn’t owe anyone anything—not a good life, not healthcare, not even safety.

But in the strongly religious USA, despite the country’s wealth, there’s no universal healthcare, little job security, and a flimsy social welfare safety net. This means that the USA has a lot more in common with developing countries than she might like to think. Researchers from the University of British Columbia suggest that people are less likely to need the comfort of a god if they’re living somewhere stable, safe and prosperous. This helps to explain why Denmark and her Scandi cousins Sweden and Norway regularly rate among the most irreligious in the world. Scandinavians don’t have to pray to a god that everything’s going to be OK – because the state has this sorted. In other words, Danes don’t have so much left to pray for. And because there isn’t a big culture

The most common source of injury caused by treatment in the hospital, of course, is a surgical operation,

In our sample of 30,121 records, we found that 1133 patients had suffered an adverse event , which computed to a serious injury rate of 3.7%, a bit lower than what the Mills study found. Twenty-seven percent of AEs were judged to be due to negligent care. From these data we estimated that in 1984 there were 98,689 adverse events in New York hospitals, of which 13,451 (13.6%) were fatal [3].

Adverse event rates were higher in large academic medical centers than in community hospitals, but the fraction due to negligence was much lower.

This meant that of the projected 180,000 deaths each year, more than 120,000 were potentially preventable.

Latent errors create “accidents waiting to happen.” Latent errors result from poor system design [1, 4].

From this distinction between active and latent errors came the fundamental principle that underlies essentially all safety efforts: errors are not fundamentally due to faulty people but to faulty systems. To prevent errors, you have to fix the systems.

No one knew how many people were hurt by negligent care—that is, substandard care.

How many people were harmed by medical treatment in hospitals? What percentage was caused by errors ? By negligence ? Of those harmed by negligent care, how many sued? What were the costs of medical injury —not just for those harmed by bad care, but for all patients, including those who suffered nonpreventable injuries? How were these costs paid for? All was unknown. All was potentially knowable.

several studies of overuse of healthcare services and was leading a study of underuse.

more than two-thirds of the injuries seemed to be potentially preventable.

then nationwide 1.3 million patients were injured by medical care in American acute care hospitals that year, and 180,000 died

The results of the study were published in two papers in the New England Journal of Medicine in February 1991 [3, 4].

Swiss cheese” model

Donald Norman, director of The Design Lab at the University of California, San Diego, is the author of the delightful book, The Design of Everyday Things,

On balance, we believed that our rates, shocking as they were, underestimated the true extent of harm . In fact, later studies would bear this out.

Although it was designed to address malpractice , its far greater significance came from the revelation of the horrendous extent of harm that resulted from routine medical care.

The Harvard Medical Practice Study confirmed what smaller studies had shown earlier—that nearly 4% of patients in acute care hospitals suffered a significant injury from their medical treatment.

The Harvard Medical Practice Study confirmed what smaller studies had shown earlier—that nearly 4% of patients in acute care hospitals suffered a significant injury from their medical treatment. What was shocking, and previously totally unrecognized, was that two-thirds of those injuries resulted from errors

James Reason, of the University of Manchester, UK, is without doubt the person who has contributed the most to the understanding of the causes and prevention of errors. His book, Human Error (1990), is the “Bible” of error theory.

It seemed inescapably clear that healthcare needed to take a systems approach to medical errors . We needed to stop punishing individuals for their errors since almost all of them were beyond their control, and we had to begin to change the faulty systems that “set them up” to make mistakes. We needed to design errors out of the system. I had no doubt we could do that.

documentation issues were more common in small private hospitals, where records were less standardized and notes were sparse because only the patient’s physician writes progress notes. In teaching hospitals, by contrast, there are multiple notes by residents, medical students, and nurses as well.

I wanted to work on quality improvement; injury and costs were clearly quality issues. At the time, I had not thought much about medical errors

States required hospitals to report deaths but rarely investigated their causes. The Joint Commission asked hospitals to report “sentinel events” (serious injuries), but few hospitals did. Surgical departments had M&M meetings, but neither other departments nor the hospitals kept tabulations or continuing records of iatrogenic injuries. Medical injury was largely invisible, and hospitals and doctors liked it that way.

We finally settled on “adverse event .” We spent many hours debating its exact definition and ultimately agreed on “an unintended injury that was caused by medical management rather than the patient’s underlying disease.” The important point was to distinguish harm caused by treatment from harm caused by disease, independent of whether there was an error or negligence . We knew that making this judgment would be difficult for doctors, as it indeed proved to be.

we estimated that the total lifetime cost of adverse events in New York State in 1984 was $3.8 billion

Charles Perrow , professor of sociology at Yale, studied risks and accidents in large organizations. His book, Normal Accidents: Living with High-Risk Technologies,

We would focus on adverse events that could potentially trigger a malpractice suit. These were injuries that resulted in some degree of disability, temporary or permanent, including death, or were sufficiently severe to prolong the hospital stay.

But more was needed if patient safety was to be recognized as a true discipline. Accordingly, in 2011, NPSF established the Certification Board for Professionals in Patient Safety . The Board set appropriate educational and training requirements and developed a qualifying examination for its credential, Certified Professional in Patient Safety (CPPS). In recognition that patient safety must be a team effort with broad responsibility, certification is open to interested parties across multiple disciplines. Within 4 years 1100 individuals were certified. To meet the educational needs of students and professionals, NPSF created a comprehensive online Patient Safety Curriculum. By 2018, over 5000 had taken this online course, and 3000 individuals held the CPPS credential. In

The Advisory Commission’s 1998 report, “Quality First: Better Healthcare for All Americans,” brought together the evidence for quality problems and the broad consensus for reform [1]. It concluded that quality problems were pervasive and by no means confined to managed care systems. The report was aimed at Congress and policy-makers in Washington and made clear recommendations, including a call for a “Patient Bill of Rights,” which the Clinton administration enacted. Otherwise, even though it got a lot of attention, the report resulted in little action.

A focus on safety might also enlist the support of the medical profession, which had become defensive about efforts to improve quality. When challenged, doctors would typically counter with “My patients are different.

Safe: the reporter must not be at risk of losing their job or being disciplined for reporting a mistake they have made.

Simple: people will not report if the process is too complicated (a long form) or takes too much time.

Productive: reporting must lead to a response by the organization to address the issue reported.

that care should be safe, effective, patient-centered, timely, efficient, and equitable. The aims resonated with all and were quickly embraced. They became the centerpiece of the recommendations in the final report, Crossing the Quality Chasm

The report on quality ( Crossing the Quality Chasm) would be targeted to healthcare professionals and would spell out the theoretical concepts and details of what was needed to improve quality of care overall, based on the six aims .

The report was titled To Err Is Human [4]. It “made the case” for patient safety, explaining the science of error-making and the theoretical and practical evidence for human-factors -based systems changes.

To Err Is Human explained the concept of using a systems approach based on human factors principles and proclaimed that application of this methodology could have a profound effect. It boldly called for a 50% reduction in medical harm in 5 years.

What got attention was the estimate that there were up to 98,000 preventable deaths a year due to medical errors . That number also headlined the newspaper stories the next day.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) This survey initiative began in 1995, before the Agency became involved in patient safety, in response to the recognition that quality of care issues that are important to consumers, such as communication skills of providers and ease of access to healthcare, were often overlooked. The obvious way to find out about them was to ask patients. The Agency began to fund, oversee, and work closely with a consortium of research organizations to conduct research on patient experience and develop the survey. The survey has since been expanded to ask patients to evaluate their experiences with health plans, providers, and healthcare facilities regarding care coordination , shared decision-making, and patient engagement . The survey is now widely used by healthcare organizations, health plans, purchasers, consumer groups, and accreditation organizations to evaluate providers and improve quality and safety of care. It has been a major factor in teaching clinicians and hospitals to be more aware of patient’s concerns and to engage them more meaningfully in their care. It has magnified their voice

In the end PSIs may have done more harm than good over the years. Meyer agrees. He considers them “the worst thing I ever did” at AHRQ .

WebM&MTo engage and inform physicians, AHRQ initiated WebM&M, using the familiar format of mortality and morbidity rounds to make available analysis of real-world medical error cases by experts, monthly.

But the need for support of health IT was clear. Hospitals and doctors were being required to implement electronic health records (EHRs) and were having serious problems.