National Academies Press: OpenBook

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

Chapter:Appendix G: Australian Incident Monitoring System Taxonomy

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Suggested Citation:"Appendix G: Australian Incident Monitoring System Taxonomy." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
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G
Australian Incident Monitoring System Taxonomy

Health Incident Type

Component Factors

Therapeutic agents

  • Medication

  • Intravenous fluids

  • Oxygen and gases

  • Blood and blood products

  • Nutrition

Therapeutic devices and equipment services and infrastructure

  • Equipment or therapeutic device

  • Infrastructure and services

  • Buildings, fittings, fixtures, and surroundings

Injuries and pressure ulcers

  • Falls

  • Injuries unrelated to falls

  • Pressure ulcers

Clinical processes or procedures

Nosocomial infections

  • Factors: Environmental

  • Factors: Organizational

  • Factors: Human

  • Factors: Subject of incident

  • Factors: Agents

  • Agent

  • Incident type

  • Incident problem class

  • Person involved

  • Timing of incident

  • Timing of detection

  • Method of detection

  • Preventability

  • Factors that minimized or aggravated severity of incident

  • Outcome for subject of incident

  • Severity of outcome for subject of incident

  • Consequences for organization

  • Short-term response or action taken

  • Subsequent response or action taken

  • Resource impact

  • Risk level

Suggested Citation:"Appendix G: Australian Incident Monitoring System Taxonomy." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
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Health Incident Type

Component Factors

Behavior, human performance, violence, aggression, security, and safety

  • Behavior and human performance

  • Violence and aggression

  • Safety and security

Logistics, organization, documentation, and infrastructure technology

  • Logistics and organization

  • Documentation

  • Information technology

Specialist domains (completed)

  • Anesthesia

  • Intensive care

  • Obstetrics

  • Hyperbaric medicine, etc.

  • Hospital pharmacy

  • Retrieval medicine

  • Retail pharmacy

Other sources of data

  • Complaint cases

  • Coronial cases

  • Medico-legal cases

  • Literature and media reports

  • Consumer reports

  • Occupational health and safety reports

  • Narrative(s)

  • Time, date, location

  • Persons reporting incident

Specialist domains to be developed

  • Hemovigilance

  • Ambulance services

  • Surgical specialties

  • Internal medicine specialties

  • Neonatal intensive care unit

  • Ophthalmology

  • Orthopedic surgery

  • Gynecology

  • Radiotherapy

  • Domiciliary care

  • Other areas as required

Suggested Citation:"Appendix G: Australian Incident Monitoring System Taxonomy." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
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Page509
Suggested Citation:"Appendix G: Australian Incident Monitoring System Taxonomy." Institute of Medicine. 2004. Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press. doi: 10.17226/10863.
×
Page510
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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.

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