Tag Archive for: Medical errors

According to the Institute of Medicine (IOM), preventable medical errors are a leading cause of death in the United States. Yet, state officials who focus on patient safety have few venues to meet, share innovative strategies, and problem solve with each other because patient safety initiatives originate in a variety of state agencies.
This report summarizes the Pennsylvania Learning Exchange, an event that brought state officials to Pennsylvania in September 2007 to learn about the state’s successes, challenges, and key elements of its patient safety initiatives. The event was supported by the Commonwealth Fund.
Pennsylvania’s initiative is a model for developing a comprehensive, interagency approach to address patient safety within a broader context of state health policy and as a critical component of health reform. The Prescription for Pennsylvania coordinates patient safety efforts under an umbrella entity (the Governor’s Office of Health Care Reform) and involves multiple agencies. The learning exchange event focused on Pennsylvania’s innovative strategies, including its successful efforts to call statewide attention to the issue of patient safety; build a case for change; translate data into practice and policy; and create a state infrastructure to address the issue. It also provided an opportunity for visiting state officials to share their own innovations.
The purpose of the learning exchange was to enable state officials to explore policy and operational issues, identify emerging issues, develop policy solutions, and improve state health policy and practice.
Ten Pennsylvania patient safety officials from key state agencies were host officials. Participants included 24 state officials representing eleven states. All visiting officials provided short written summaries of what they gained from the learning exchange and how they planned to apply this new knowledge to their state’s work to improve patient safety.