National Academies Press: OpenBook

Patient Safety: Achieving a New Standard for Care (2004)

Chapter:Appendix D: Clinical Domains for Patient Safety

« Previous: Appendix C: Examples of Federal, State, and Private Sector Reporting Systems
Suggested Citation:"Appendix D: Clinical Domains for Patient Safety." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×

D
Clinical Domains for Patient Safety

Consolidated Health Informatics Initiative Clinical Domain Areas

Additional Domains for Patient Safety

Demographics

 

Diagnosis/problem lists for:

Signs

Symptoms

Diseases

Social problems

Patient risk factors/precursors (e.g., designation of comorbid diagnosis)

Interventions/procedures including:

Laboratory orders

Laboratory results contents

Complications associated with specific procedures

Encounters

Episodes

 

Process-specific risk factors (e.g., managing coronary health failure)

 

Departmental risk factors (e.g., delays in the emergency room)

 

Clinical data measures for health conditions

Medications including:

Clinical drugs

Warnings

Alternative medicines

Nutritional supplements

Vitamins

Suggested Citation:"Appendix D: Clinical Domains for Patient Safety." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×

Consolidated Health Informatics Initiative Clinical Domain Areas

Additional Domains for Patient Safety

Allergic reactions

Adverse drug events (ADE)

Over-the-counter medications

Previous known adverse drug reactions

Triggers

Medication orders

Drug interactions

Patient-specific drug dosing

Diagnosis-specific drug indications

Diagnosis-specific drug contraindications

Text-based reports including:

Clinical document architecture

Clinical document naming

Clinical template

History and physical including:

History

Vital signs

Anatomy

Exam findings

Functional status

Nutritional status

Discharge or treatment plan

Determinants for genetic testing/screening of family-related diseases

Immunizations

 

 

Provider information

Training level, cultural factors, speaking language, health

Population health including:

Nosocomial infections reporting

Reportable infections reporting

Other reportable conditions

Hospital errors other than ADE

Emergency room trauma reporting

Other national health statistics

Near misses

Patient complaints

Readmission indicators

Performance measurement

Causal factors

Malpractice claims

Risk management reports

Potential adverse events assessment through electronic surveillance

Genes and proteins

Pharmacogenomic markers for drug response or drug complication

Multimedia including but not limited to:

Image

Audio

Waveforms

 

Suggested Citation:"Appendix D: Clinical Domains for Patient Safety." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×

Consolidated Health Informatics Initiative Clinical Domain Areas

Additional Domains for Patient Safety

Nursing including:

Diagnoses

Interventions

Goals and outcomes

Process-specific nursing factors

Acuity levels for nurse staffing

Physiology

 

 

Knowledge bases (systematic reviews of):

Clinical guidelines

Medical literature

Health outcomes data

Disease registries

 

Patient self-management

Data set and guidelines for self-care

Rx interaction program access

Functioning and disability

Rehabilitation therapies

Respiratory

Occupational

Speech, etc.

Supplies including:

Ontology for the ordering physician

Medical devices

Medical device simulations and testing

 

Organizational process factors

Organizational risk factors

Hazard analysis

Chemicals (Unified Medical Language System—UMLS)

 

Billing (Health Insurance Portability and Accountability Act, Administrative Simplification, Transactions and Code Sets)

Data from claims attachment

Scientific/fundamental (UMLS)

 

Units (UMLS)

Suggested Citation:"Appendix D: Clinical Domains for Patient Safety." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×
Page427
Suggested Citation:"Appendix D: Clinical Domains for Patient Safety." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×
Page428
Suggested Citation:"Appendix D: Clinical Domains for Patient Safety." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×
Page429
Next: Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report »
Patient Safety: Achieving a New Standard for Care Get This Book
×
Buy Hardback | $54.95
MyNAP members save 10% online.
Login or Register to save!
Download Free PDF

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.

  1. ×

    Welcome to OpenBook!

    You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

    Do you want to take a quick tour of the OpenBook's features?

    No Thanks Take a Tour »
  2. ×

    Show this book's table of contents, where you can jump to any chapter by name.

    « Back Next »
  3. ×

    ...or use these buttons to go back to the previous chapter or skip to the next one.

    « Back Next »
  4. ×

    Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

    « Back Next »
  5. ×

    Switch between the Original Pages, where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

    « Back Next »
  6. ×

    To search the entire text of this book, type in your search term here and press Enter.

    « Back Next »
  7. ×

    Share a link to this book page on your preferred social network or via email.

    « Back Next »
  8. ×

    View our suggested citation for this chapter.

    « Back Next »
  9. ×

    Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

    « Back Next »
Stay Connected!