Patient Safety: Achieving a New Standard for Care

551 Pages·2004·8.29 MB·English

by  Committee on Data Standards for Patient Safety

http://www.nap.edu/catalog/10863.html
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Patient Safety:� Achieving a New Standard for Care

Philip Aspden, Janet M. Corrigan, Julie Wolcott, Shari

M. Erickson, Editors, Committee on Data Standards for
Patient Safety

ISBN: 0-309-52932-8, 550 pages, 6 x 9, (2004)

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Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
PATIENT SAFETY
ACHIEVING A NEW STANDARD FOR CARE
Committee on Data Standards for Patient Safety
Board on Health Care Services
Philip Aspden, Janet M. Corrigan, Julie Wolcott, and
Shari M. Erickson, Editors
Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board
of the National Research Council, whose members are drawn from the councils of the Na-
tional Academy of Sciences, the National Academy of Engineering, and the Institute of Medi-
cine. The members of the committee responsible for the report were chosen for their special
competences and with regard for appropriate balance.
Support for this project was provided by the Agency for Healthcare Research and Quality
(AHRQ). The views presented in this report are those of the Institute of Medicine Committee
on Data Standards for Patient Safety and are not necessarily those of the funding agencies.
Library of Congress Cataloging-in-Publication Data
Patient safety : achieving a new standard for care / Committee on Data Standards for Patient
Safety, Board on Health Care Services ; Philip Aspden ... [et al.], editors.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-09077-6 (hardcover)
1. Medical records—Standards—United States. 2. Medical informatics. 3. Medical errors—
Data processing—Standards—United States.
[DNLM: 1. Medical Errors—prevention & control—United States. 2. Health Policy—
United States. 3. Information Services—standards—United States. 4. Patient Care—stan-
dards—United States. 5. Policy Making—United States. 6. Risk Management—United States.
7. Safety Management—United States. WB 100 P2975 2004] I. Aspden, Philip. II. Institute
of Medicine (U.S.). Committee on Data Standards for Patient Safety.
R864.P38 2004
651.5′04261—dc22
2004001869
Additional copies of this report are available from the National Academies Press, 500 Fifth
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Copyright 2004 by the National Academy of Sciences. All rights reserved.
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Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Adviser to the Nation to Improve Health
Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distin-
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advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is
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National Research Council.
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Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
COMMITTEE ON DATA STANDARDS FOR PATIENT SAFETY
PAUL C. TANG (Chair), Chief Medical Information Officer, Palo Alto
Medical Foundation, and Associate Clinical Professor, University of
California, San Francisco
MOLLY JOEL COYE (Vice-Chair), CEO, Health Technology Center
SUZANNE BAKKEN, Alumni Professor of Nursing and Professor of
Biomedical Informatics, Columbia University
E. ANDREW BALAS, Dean, School of Public Health, Saint Louis
University
DAVID W. BATES, Chief, Division of General Medicine, Brigham &
Women’s Hospital; Medical Director of Clinical and Quality Analysis,
Partners Healthcare System; and Associate Professor of Medicine,
Harvard Medical School
JOHN R. CLARKE, Professor of Surgery, Drexel University, and Adjunct
Professor of Computer and Information Science, University of
Pennsylvania
DAVID C. CLASSEN, Vice President, First Consulting Group, and
Associate Professor of Medicine, University of Utah
SIMON P. COHN, National Director of Health Information Policy, Kaiser
Permanente
CAROL CRONIN, Consumer Health Information Consultant
JONATHAN S. EINBINDER, Assistant Professor, Harvard Medical School,
and Corporate Manager, Partners Health Care Information Systems
LARRY D. GRANDIA, Executive Vice President and Chief Technology
Officer, Premier, Inc.
W. ED HAMMOND, Professor, Division of Medical Informatics, Duke
University
BRENT C. JAMES, Executive Director, Intermountain Health Care Institute
for Health Care Delivery Research, and Vice President for Medical
Research, Intermountain Health Care
KEVIN B. JOHNSON, Associate Professor and Vice Chair, Department of
Biomedical Informatics, and Associate Professor, Department of
Pediatrics, Vanderbilt University
JILL ROSENTHAL, Project Manager, National Academy for State Health
Policy
TJERK W. van der SCHAAF, Associate Professor of Human Factors in Risk
Control, Eindhoven University of Technology, Eindhoven Safety
Management Group, Department of Technology Management
v
Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
Study Staff
PHILIP ASPDEN, Study Director
JULIE WOLCOTT, Program Officer
SHARI ERICKSON, Research Associate
DANITZA VALDIVIA, Senior Project Assistant
REBECCA BENSON, Senior Project Assistant
Health Care Services Board
JANET M. CORRIGAN, Director
ANTHONY BURTON, Administrative Assistant
Editorial Consultants
RONA BRIERE, Briere Associates, Inc.
ALISA DECATUR, Briere Associates, Inc.
vi
Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with proce-
dures approved by the National Research Council’s Report Review Commit-
tee. The purpose of this independent review is to provide candid and critical
comments that will assist the institution in making its published report as
sound as possible and to ensure that the report meets institutional standards
for objectivity, evidence, and responsiveness to the study charge. The review
comments and draft manuscript remain confidential to protect the integrity
of the deliberative process. We wish to thank the following individuals for
their review of this report:
ENRIQUETA C. BOND, Burroughs Wellcome Fund
WILLIAM A. BORNSTEIN, Emory Healthcare
RICHARD BOTNEY, Oregon Health & Science University
CAROL C. DIAMOND, Markle Foundation
HAROLD S. KAPLAN, Columbia University
CLEMENT J. MCDONALD, Regenstrief Institute for Health Care,
Indiana University
ROBERT L. PHILLIPS, American Academy of Family Physicians
NANCY RIDLEY, Massachusetts Department of Public Health
WILLIAM B. RUNCIMAN, Australian Patient Safety Foundation,
Royal Adelaide Hospital, Australia
PAUL M. SCHYVE, Joint Commission on Accreditation of Healthcare
Organizations
vii
Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
viii REVIEWERS
Although the reviewers listed above have provided many constructive com-
ments and suggestions, they were not asked to endorse the conclusions or
recommendations, nor did they see the final draft of the report before its
release. The review of this report was overseen by Don E. Detmer, Univer-
sity of Cambridge and University of Virginia, and John Bailar, University of
Chicago, Professor Emeritus. Appointed by the National Research Council
and the Institute of Medicine, they were responsible for making certain that
an independent examination of this report was carried out in accordance
with institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of this report rests entirely
with the authoring committee and the institution.
Copyright © National Academy of Sciences. All rights reserved.
Patient Safety:�� Achieving a New Standard for Care
http://www.nap.edu/catalog/10863.html
Preface
Just as the health care system has started to come to grips with the threat
of patient safety concerns, new data are expanding the scope of the threat.
Unintended harm arising from medical management is not limited to the
hospital setting; nor is it limited to acts of commission. The Committee on
Data Standards for Patient Safety believes that patient safety should be a
new standard for quality care—care that is free of unintended injury from
acts of commission or omission, in any setting in which it is delivered. Con-
sequently, data standards needed to support patient safety go well beyond
the needs of adverse event and near-miss reporting. In this report, we de-
scribe a vision of patient safety systems integrated with clinical information
systems and recommend strategies to create data standards that support that
vision.
The past 2 years have seen three very positive developments with regard
to clinical data standards. In October 2001, the Department of Health and
Human Services (DHHS) established the Consolidated Health Informatics
(CHI) initiative to articulate and execute a strategy for the adoption of health
care interoperability standards by federally operated and funded health care
providers. Given the purchasing power of the federal government, repre-
senting more than 40 percent of health care expenditures in the United
States, the incorporation of the standards into government programs will be
a powerful and effective means of establishing these standards on a national
basis. On March 20, 2003, HHS Secretary Thompson announced that the
federal government, including DHHS, the Department of Defense, and the
ix
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