Virginians Improving Patient Care and Safety (VIPC&S): Advancing
Patient Safety and Reducing Medical Errors in Virginia.
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Virginians Improving Patient Care and Safety (VIPC&S) Core Principles for Addressing the Institute of Medicine’s Report on Medical Errors
Adopted June 13, 2000
VIPC&S supports systematic efforts to continuously improve quality of care and patient safety through:
- collaborative efforts between consumers and other purchasers, providers, health plans, regulators, accrediting bodies, and others;
- the dissemination and implementation of best practices;
- and education and training guided by appropriate data collection and analysis.
VIPC&S concurs with the basic message of the IOM report: we can and must do more to improve patient safety by encouraging learning from mistakes.
VIPC&S recognizes that "To Err is Human." Competent professionals can make mistakes. Most adverse events have multiple underlying causes and more attention needs to be paid to those underlying causes.
VIPC&S believes that sharing knowledge about errors in a non-punitive way is essential for improving patient safety. We support confidential, non-punitive safety reporting systems because this approach has been proven to be effective in healthcare and other industries and we believe that the interest of the public can best be served by adopting the most effective methods available to improve patient safety.
VIPC&S believes that any reporting system to improve patient safety should have the following attributes:
- Strict confidentiality of individual reports is maintained and protections are in place to insure that reporting does not lead to liability exposure.
- Reports are used for learning and improvement rather than punishment.
- Reports are made to a non-regulatory, independent organization or organizations with access to expertise in patient safety and systems improvement.
- Adequate resources are provided and feedback mechanisms are implemented to facilitate the exchange of knowledge, encourage learning from
reported errors, and lead to the implementation of safe delivery systems that minimize the risk of human and technical error.
- Periodic reassessment is conducted to insure that the reporting system is meeting its intent and not having undesired consequences.
- Reporting is neither duplicative nor burdensome.
- Any aggregate analysis reported to the public should be based on reportable events that are clearly defined, concentrate on long-term or irreversible patient harm, and be coordinated with national efforts to promote consistency with standardized methods of reporting, analysis, and follow-up that emphasize process improvement.
VIPC&S believes the public has a right to expect healthcare organizations and practitioners to have effective patient safety programs.
VIPC&S believes that policy makers and regulators should allow healthcare providers the flexibility to determine the specifics of error reduction programs to best suit local conditions, evolving science, and a focus on systems improvement.
VIPC&S embraces the role of purchasers in evaluating and rewarding those payers and providers who demonstrate a clear commitment to systems, policies and practices that improve healthcare quality and patient safety. Incentives should be developed to encourage collaborative, multidisciplinary approaches among all interested parties.
VIPC&S recognizes that leadership, commitment and the dedication of resources are imperative to reduce medical errors and promote patient safety.
VIPC&S recognizes the critical need for new research into causes and means to prevent medical errors.
1200 E. Clay Street • Richmond, VA 23219 • e-mail