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2 nd Annual Betsy Lehman Patient Safety Symposium Accountability Panel Regulators Perspective

2 nd Annual Betsy Lehman Patient Safety Symposium Accountability Panel Regulators Perspective. Jean Pontikas Director, Division of Health Professions Licensure December 5, 2005. How did we get here?. Before DFCI IOM Report “To Err is Human” After DFCI – the media

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2 nd Annual Betsy Lehman Patient Safety Symposium Accountability Panel Regulators Perspective

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  1. 2nd Annual Betsy Lehman Patient Safety SymposiumAccountability PanelRegulators Perspective Jean Pontikas Director, Division of Health Professions Licensure December 5, 2005

  2. How did we get here? • Before DFCI • IOM Report “To Err is Human” • After DFCI – the media • Re-examining roles and responsibilities in assuring competency/safety/accountability • Desire for greater coordination among agencies • Consensus that promoting safe practice is important and external review is necessary

  3. Current System • Duplicate reporting to multiple agencies • Multiple investigations at different times • Availability of Information – it depends on which group you belong to • Different methods/focus of investigations • Lack of knowledge about boards, what they do and who their members are • Resources and subject matter experts

  4. Current System • Expertise of the Boards – peers • Struggle with achieving best outcome for licensee and the public • Remediation/education vs. discipline • Board’s ability to address issue –statewide • Individuals moving from one employer to next • Transparency • Deliberations, decisions are available to public • Due Process of Law • Opportunity to present documentation, witnesses and testimony

  5. Current System • Mission is to protect public not punish licensees • Boards strive for remediation and education not discipline • Will and desire to address misconceptions about boards, improve and streamline processes and procedures and adopt procedures that promote safer care and systems

  6. Possibilities • Streamline reporting – centralized? • Improve information exchange earlier in the process • Who is notified • When and how • What information is provided • Feedback aggregate data and learning • Pharmacy report on dispensing errors • Nursing report on errors • Newsletters • Betsy Lehman Center (studies, research, Best Practices)

  7. Possibilities • More involvement by employers and institutions • Sharing the corrective actions • Individual training and remediation • Assuring continued competence • There are no legal impediments to improving this information exchange now

  8. Possibilities • More disclosure to patients about what happened AND how it was addressed by the institution/employer • Big vs. incremental change • Greater transparency – can’t go back now. • Public confidence in the system of evaluating, responding to and addressing medical errors

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