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therapeutic accident; · Sentinel event; · Iatrogenic complication; iatrogenic injury; · Hospital acquired complication. Patient Safety Organizations The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the creation of Patient Safety Organizations (PSOs) to improve the quality and safety of U.S. health care delivery. The Patient Safety Act encourages clinicians and health care organizations to voluntarily report and share quality and patient safety information without fear of legal discovery. Despite the many terms used to describe medical errors, patient safety is the focus of multiple patient safety organizations. Their task is to collect data, assess it for trends, and make recommendations to hospitals and others about ways to prevent future mistakes. The US Department of Health and Human Services collates the data and is charged with disseminating best practices. Some patient safety organizations are: · Agency for Healthcare Research and Quality The Agency for Healthcare Research and Quality (AHRQ) is a federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. 11 · National Quality Forum The National Quality Forum (NQF) is a private, not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. It is a unique public-private partnership with broad participation from more than 260 organizations that represent all sectors of the healthcare industry, including healthcare providers, consumers, employers, insurers, and other stakeholders. Among its members are the AARP, AFL-CIO, the American Hospital Association, the American Medical Association, the American Nurses Association, the American Society of Health-System Pharmacists, the Ford Motor Company, and General Motors. · Institute of Safe Medication Practices The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. · Institute of Medicine The Institute of Medicine (IOM) is a nonprofit organization of the National Academies for sciencebased advice on matters of biomedical science, medicine, and health. · Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS) is a government agency that administers the Medicare program and is responsible for the administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and quality standards in healthcare facilities through its survey and certification activity. · Joint Commission The Joint Commission, previously known as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), evaluates and accredits more than 15,000 healthcare organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation's predominant standards-setting and accrediting body in healthcare. · Institute of Healthcare Improvement The Institute for Healthcare Improvement (IHI) is a not-for-profit organization driving the improvement of health by advancing the quality and value of healthcare. Interventions Many of the Patient Safety Organizations above have released goals for patient safety and have promoted particular interventions for the improvement of patient safety. This course provides an overview of some of the recommendations of a sampling of safety organizations. In particular interventions from the Agency for Healthcare Research and Quality (AHRQ) and a compilation of safety interventions focusing on the development of a healthcare partnership between provider and patient as a means of promoting patient safety and reducing medical errors. 12 Interventions from The Agency for Healthcare Research and Quality (AHRQ) Medical errors may occur in different health care settings, and those that happen in