Patient safety : achieving a new standard for care

Americans should be able to count on receiving health care that is safe. To achieve this, a new health care delivery system is needed ? a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure. Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data. Table of Contents Front Matter Executive Summary 1 Introduction PART I: BUILDING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE 2 Components of a National Health Information Infrastructure 3 Federal Leadership and Public-Private Partnerships 4 Health Care Data Standards PART II: ESTABLISHING COMPREHENSIVE PATIENT SAFETY PROGRAMS 5 Comprehensive Patient Safety Programs in Health Care Settings 6 Adverse Event Analysis 7 Near-Miss Analysis PART III: STREAMLINING PATIENT SAFETY REPORTING 8 Patient Safety Reporting Systems and Applications 9 Standardized Reporting Appendix A: Biographies of Committee Members Appendix B: Glossary and Acronym List Appendix C: Examples of Federal, State, and Private Sector Reporting Systems Appendix D: Clinical Domains for Patient Safety Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report Appendix F: Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel Appendix G: Australian Incident Monitoring System Taxonomy Index

• 1 Front Matter
• 2 Executive Summary
• 3 1 Introduction
• 4 PART I: BUILDING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE
• 5 2 Components of a National Health Information Infrastructure
• 6 3 Federal Leadership and Public-Private Partnerships
• 7 4 Health Care Data Standards
• 8 PART II: ESTABLISHING COMPREHENSIVE PATIENT SAFETY PROGRAMS
• 9 5 Comprehensive Patient Safety Programs in Health Care Settings
• 10 6 Adverse Event Analysis
• 11 7 Near-Miss Analysis
• 12 PART III: STREAMLINING PATIENT SAFETY REPORTING
• 13 8 Patient Safety Reporting Systems and Applications
• 14 9 Standardized Reporting
• 15 Appendix A: Biographies of Committee Members
• 16 Appendix B: Glossary and Acronym List
• 17 Appendix C: Examples of Federal, State, and Private Sector Reporting Systems
• 18 Appendix D: Clinical Domains for Patient Safety
• 19 Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report
• 20 Appendix F: Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel
• 21 Appendix G: Australian Incident Monitoring System Taxonomy
• 22 Index