Historical timelines are provided for each of the four types of initiatives started by 37 States since the mid-1970s through mid-2006. Conversely, these same timelines demonstrate that 13 States and the District of Columbia have not developed any broad-based patient safety initiatives, as defined in this website. The temporal relationship of the initiatives to publication of the IOM's report To Err is Human: Building a Safer Health System, is also demonstrated across each timeline.
Links to discussions regarding the history and development of each category of events are available for each state in the map. The categories include Adverse Events reporting programs (including Physician reporting programs coupled with adverse event reporting), Patient Safety Coalitions/Commissions, Outcomes and Other categories of reporting programs (cardiac, non-cardiac, and IQI outcomes reporting, medication error reporting, and JCAHO National Patient Safety Goal compliance reporting), Patient Safety Centers, and the Cumulative Totals of these four categories. General trends confirm an initial development of reporting programs in States through the mid-1990s, usually in association with medical malpractice crises in most States.
The publication of the Harvard Medical Practice Study in 19911 and the work and publications of the IOM National Roundtable on Health Care Quality (NRHCQ) and the Committee on Quality of Health Care in America (QHCA) beginning in 1996 through 2000 undoubtedly influenced some of the crescendo in activity that began immediately prior to release of the sentinel IOM report, To Err is Human in late 1999.
Subsequent activity through 2006 suggests some decreasing enthusiasm and activity in existing Patient Safety Coalitions. Mississippi's Patient Safety Coalition that developed in April 2005 is the only new Patient Safety Coalitions since 2003, and in at least three States (AR, MO, WI), there is no apparent staffing or visible activity since 2004. There is some leveling off of new reporting initiatives in 2005 with no apparent declared plans for new reporting programs in any of the 18 States without reporting programs in 2006.
The effect on States' policy due to the July 29, 2005 passage of the federal Patient Safety and Quality improvement Act of 2005, [P.L. 109-41], which calls for voluntary adverse event reporting via Patient Safety Organizations, has yet to be appreciated.
1 Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH, "Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I." N Engl J Med 1991; 324:370-6. (Reprint available from Qual Saf Health Care 2004;13:145-151)