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

Index

A

AAMI. See Association for the Advancement of Medical Instrumentation

Academic institutions, terminologies of, 104–106

Accountability versus learning

case study, 262–263

concept of preventability, 268–269

implications for patient safety data systems, 269–273

Scherkenbach’s cycle of fear, 265–268

selection of measures, 263–265

understanding the continuum, 252–254, 262–273

Accredited Standards Committee (ASC), 335

ASC X12N, 99, 115

ACP Journal Club, 110

Acronyms, 24–25, 335–339

Acute myocardial infarction (AMI), 335

ADA. See American Dental Association

ADEs. See Adverse drug events

Administrative processes, 446–447, 458–459

Adverse drug events (ADEs), 73–75, 335

frequency by cause, 183

major causes of, 187

preventing, 185–187

scenario for interoperability demonstration project, 74–75

triggers for, 205

Adverse Event Reporting System (AERS), 215–221, 335

functional requirements, 215–216

implications for data standards, 217–221

Adverse events (AEs), 30, 327, 335

addressing errors of omission, 216

analysis, 171, 200–225

detection of, 185–187, 202–215

future detection approaches, 221–224

hazard analysis and systems approach to, 490–491

implications for data standards, 217–221

prevention, 185–187

sources of data, 202–203

triggers for, 205, 208, 221–222, 327

understanding, 215–216

verifying, 196

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

AERS. See Adverse Event Reporting System

AEs. See Adverse events

Agency for Healthcare Research and Quality (AHRQ), 9, 11, 19, 23, 25, 32, 48, 109, 335

overarching coordination, 121–123

AHRQ. See Agency for Healthcare Research and Quality

AIMS. See Australian Incident Monitoring System

AIMS Risk Assessment Index (RAI), 294

Alert message, 327

Alertness, 230

Alternative Summary Reporting-Medical Devices (ASR), 335

AMA. See American Medical Association

American Dental Association (ADA), 99

American Hospital Association, 117–118

American Medical Association (AMA), 106

American National Standards Institute (ANSI), 97, 137, 335

American Society for Testing and Materials (ASTM), 100, 335

AMI. See Acute myocardial infarction

Ancillary information, 219

ANSI. See American National Standards Institute

Applications, continuum of, 252–254

Applied research agenda, 192–197

dissemination, 196–197

knowledge generation, 192–195

tool development, 195–197

Applied Strategies for Improving Patient Safety, 157

ASC. See Accredited Standards Committee

ASR. See Alternative Summary Reporting-Medical Devices

Assertional knowledge, 327

Association for the Advancement of Medical Instrumentation (AAMI), 137

ASTM. See American Society for Testing and Materials

Audit procedures, 196–197

Australian Incident Monitoring System (AIMS), 335

Risk Assessment Index, 294

taxonomy from, 509–510

Authentication, 327

Automated surveillance, rules for detecting possible adverse drug events using, 207

Automated triggers

for adverse events, 327

for chart review, 205

increasing importance of, 221–222

for outpatient adverse events, 208

B

Blood Product Deviation Reporting System (BPD), 335

BPD. See Blood Product Deviation Reporting System

C

Case-based reasoning, 327

Case studies, 184–192, 262–263, 492–507

continuous quality improvement (CQI), 492–493

detected ADE rates, 187

detecting and preventing adverse drug events, 185–187

failure mode and effect analysis (FMEA), 496–497

hazard analyis and critical control points (HACCP), 493–494

hazard and operability studies (HAZOP), 494–495

healthcare failure mode and effect analysis (HFMEA), 498–499

major causes of adverse drug events, 187

postoperative infections, 188–190

probabilistic risk assessment (PRA), 499–501

root-cause analysis (RCA), 501–503

Six Sigma, 503–505

Toyota Production System (TPS), 505–507

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

Causal analysis, 293, 295–301, 333

Eindhoven classification model, medical version, 297, 300–301

generic reference model diagram, 297

Causal continuum assumption, 230–231, 327

Cause-and-effect diagram of preventable adverse drug events, 182

CDA. See Clinical Document Architecture

CDC. See Centers for Disease Control and Prevention

CDSS. See Clinical Decision Support System

CEN. See Comité Européean Normalisation

Center for Quality Improvement and Patient Safety (CQuIPS), 32, 335

Centers for Disease Control and Prevention (CDC), 73, 103, 335

example of federal patient safety/ health care reporting and surveillance systems, 346–357

Centers for Education and Research on Therapeutics (CERTs), 110

Centers for Medicare and Medicaid Service (CMS), 69, 111, 335

CERTs. See Centers for Education and Research on Therapeutics

CHAI. See Child Health Accountability Initiative

Chart review, 328

to detect adverse drug events, 205–206

CHF. See Congestive heart failure

CHI. See Consolidated Health Informatics

Child Health Accountability Initiative (CHAI), overview of, 312–313

Children’s Health Insurance Program (CHIP), 335

CHIP. See Children’s Health Insurance Program

Chronic obstructive pulmonary disease (COPD), 335

Clinical data

interchange standards, 16, 49

repository, 328

Clinical Decision Support System (CDSS), 58, 70, 78

Clinical Document Architecture (CDA), 66, 136, 328, 335

Clinical domains, 328

for patient safety, 427–429

Clinical event monitors, 328

and data repositories, 64–65

Clinical guideline representation model, 158–160

Clinical information systems, 72, 328, 335

Clinical performance data, 252–254

Clinical templates, 136–137

Clinical terminologies, 16–17, 50

Close calls, 328

CMS. See Centers for Medicare and Medicaid Services

Cochrane Collaboration, 110, 161

Coding, 328

Comité Européean Normalisation (CEN), 335

Communication technologies, 69–71

Internet and private networks, 71

Comprehensive patient safety programs, 169–245

adverse event analysis, 171, 200–225

applied research agenda, 169–170, 192–197

case studies, 184–192

culture of safety, 174–177

establishment of, 169–171

in health care settings, 173–199

model for introducing safer care, 178–184

near-miss analysis, 171–172, 226–245

patient safety reporting systems and applications, 250–278

recommendations, 169–170

standardized reporting, 279–316

streamlining patient safety reporting, 247–249

Computer-based patient record system (CPRS), 35–36

Computerized patient records (CPRs), 79

Computerized physician order entry (CPOE), 328–329, 335

validation modules for prescribing medication, 214

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

Conceptual model of standards-based systems to support patient safety, 56–61, 329

integrated systems and large institutions, 58–59

integrated systems and office practice, 59–61

Congestive heart failure (CHF), 335

Connecting for Health initiative, 39

Consequence-driven investigations, a problem with data collection, 237

Consolidated Health Informatics (CHI) Initiative, 11, 17, 25, 38, 48, 108, 116, 119–121, 122–123, 335

domain areas, 146–147

Context variables, 233

Continuous quality improvement (CQI), 335

case studies, 492–493

COPD. See Chronic obstructive pulmonary disease

CORAS. See Risk Assessment of Security Critical Systems

Core functionalities for an electronic health record system, 442, 447–449

See Electronic health record

Core terminology group, 148–158

drug terminologies, 152–153

Logical Observation Identifiers, Names and Codes (LOINC), 149, 152

mapping to supplemental terminologies, 154–155

medical device terminologies, 153–154

overview of core and supplemental terminologies, 150–151

Systemized Nomenclature for Human and Veterinary Medicine, Clinical Terms (SNOMED CT), 149

terminologies for further investigation and research, 155–158

Cost/benefit analysis of patient safety programs, 194

CPOE. See Computerized physician order entry

CPRS. See Computer-based patient record system

CPRs. See Computerized patient records

CPT. See Current Procedural Terminology

CQI. See Continuous quality improvement

CQuIPS. See Center for Quality Improvement and Patient Safety

Crossing the Quality Chasm: A New Health System for the 21st Century, 29, 36–37

Culture of safety, 174–177

a “just” culture, 177

open communication, 177

organizational commitment, 175–176

recruitment and training with patient safety in mind, 175

shared beliefs and values, 175

Current dental terminology, 151

Current Procedural Terminology (CPT), 106, 151, 335

Current standards-setting processing, 97–114

Consolidated Health Informatics (CHI) initiative, 116

data interchange standards, 97–102

federal and private sectors, 114–118

Integrating the Healthcare Enterprise initiative, 118

knowledge representation standards, 108–111

National Alliance for Health Information Technology, 117–118

National Committee on Vital and Health Statistics (NCVHS), 115

Public Health Data Standards Consortium, 116–117

reporting standards, 111–114

terminologies, 102–108

D

DailyMed database, 162

Data acquisition, 329

methods and user interfaces, 61–62

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

Data elements, 329

Data filtering and cycle of fear, 267–268

Data interchange standards, 12–14, 48–49, 97–102, 128–129, 132–142, 329

clinical templates, 136–137

message format standards, 132–135

patient data linkage, 141–142

user interface, 137–141

Data management procedures, 85

clinical resource consumption quality assurance, 85

data validation, 85

data verification, 85

de-identification methods, 85

final reconciliation, 85

initial reconciliation, 85

manual data audit, 85

warehouse audit, 85

Data mining, 329

techniques for, 65–67

techniques for large patient safety databases, 196

Data repositories and clinical event monitors, 64–65

Data requirements for diabetes quality improvement project measures, 209, 210–213

Data requirements for adverse event detection, 204–206

automated surveillance, 206

chart review, 205–206

voluntary and mandatory reporting, 204

Data set, 329

Data standards, 63–64, 127–168, 214–215, 217, 221, 242–245

comprehensive list of data sources and reporting requirements, 130–131

data interchange formats, 12–14, 48–49, 128–129, 158–162

defining terms, 128–132, 217–218

definitions and models, 128–132, 242–243

design and operation of system components, 243–244

implementation, 163–164

knowledge representation, 13, 15, 49, 129

minimum datasets, 218–220

overview of, 127–132

recommendations, 163–164

relevance to patient safety systems, 63

setting standards, 98–99

sources, 130–131

standards development organizations, 102

technical review of health care data standards, 132–164

terminologies, 13–15, 49–50, 129, 142–158, 331, 442–443, 450–453

work plan, 15–17

Data system design, 270

Data types, 329

Data validation, 85

Data verification, 85

Data warehouse, 329

Davies award, winners of, 79

De-identification and data protection, 307–308

methods for, 85

Decision support systems, 330, 444–445, 454–455

Decision trees, 330

Default reasoning, 330

Definitions and models, data standards, 242–243

Dental terminology, current, 151

Department of Defense (DoD), 121, 335

Department of Health and Human Services (DHHS), 7, 11, 16, 25, 46–47, 89, 108, 123, 335

leadership strengthened for the NHII, 123

Detection of adverse events, 185–187

comparison of various approaches for, 203–204

data requirements for, 204–206

design and operation of system components, 243

general framework for processing near-miss reports, 240

implications for data standards, 214–215

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

monitoring the progress of patients, 206–214

multiple approaches, 202–215

sources of adverse event data, 202–203

using claims data, 222–223

DHHS. See Department of Health and Human Services

Diabetes Quality Improvement Project (DQIP), 69, 207–218, 336

Diagnostic and Statistical Manual (DSM), 336

Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), 151

Dialysis Surveillance Network (DSN), 336

DICOM. See Digital Imaging and Communications in Medicine

Digital Imaging and Communications in Medicine (DICOM), 25, 99–100, 132, 335

Digital sources of evidence or knowledge, 67–69

Dissemination, 196–197

audit procedures, 196–197

knowledge dissemination, 196

R6, 20, 171

Document Ontology Task Force, 66

DoD. See Department of Defense

Domains

basic, 286–287

for a common patient safety reporting format, 303

completeness of, 330

DQIP. See Diabetes Quality Improvement Project

Drug terminologies, 152–153

DSM. See Diagnostic and Statistical Manual

DSM-IV. See Diagnostic and Statistical Manual for Mental Disorders

DSN. See Dialysis Surveillance Network

Dual pathways to system improvement, 231

E

E-Codes. See External Causes and Injury Codes

Early detection, 195

EHR. See Electronic health record

Eindhoven classification model, medical version, 22, 297, 300–301

Electronic communication and connectivity, 445–446, 454–457

Electronic health record (EHR), 4, 7, 25, 46, 330, 442

administrative processes, 446–447, 458–459

background, 435–438

core functionalities, 442, 447–449

decision support, 444–445, 454–455

defining constructs for, 222

electronic communication and connectivity, 445–446, 454–457

framework for identifying core functionalities, 439–441

health information and data, 442–443, 450–453

implementation of, 78

letter report, 430–470

order entry/order management, 443–444, 452–453

patient support, 446, 456–457

project overview, 438–439

reporting and population health management, 447, 458–459

results management, 443, 452–453

system capabilities by time frame and site of care, 450–459

Encryption, 330

End-stage renal disease (ESRD), 336

EPC. See Evidence-based Practice Center

Errors, 330

of commission, 31

of omission, 31, 216

ESRD. See End-stage renal disease

Event-type taxonomy, 287–292

Evidence, levels of, 331–332

Evidence-based guidelines, 330

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

Evidence-based Practice Center (EPC), 336

Explicit data collection processes, 221

Explicit relationships, 330

Extensible markup language (XML), 111, 113, 330–331, 339

External Causes and Injury Codes (E-Codes), 22, 336

F

FACCT. See Foundation for Accountability

Failure mode and effect analysis (FMEA), 180, 336

case studies, 496–497

proactive hazard analysis, 481–482

Failure root causes, 233

FDA. See Food and Drug Administration

Federal leadership

need for leadership, 119–123

public-private partnerships, 96–126

standards activities, 114–118

standards-setting processing, 97–114

Federal reporting systems, 342–381

analysis of serious events, 344–345

examples, 346–357

format for reporting, 344

method of reporting, 344

reportable events, 343

surveillance or reporting systems, 342–343

tabular information, 345

terminologies for, 103–106

Financial incentives, 88–90

Florida state

annual report, 400

Code 15 report, 401

reportable events, 399

FMEA. See Failure mode and effect analysis

Food and Drug Administration (FDA), 73, 104, 336

example of federal patient safety/ health care reporting and surveillance systems, 358–373

Format for reporting, 382–383

in federal reporting systems, 344

in private-sector reporting systems, 404

Fostering Rapid Advances in Health Care: Learning from System Demonstrations, 39

Foundation for Accountability (FACCT), 113–114, 336

Free text uses, 233

Frequency of adverse drug events by cause, 183

G

GELLO. See Guideline Expression Language, Object-Oriented

Generic Reference Model (GRM), 336

diagram of, 297

GLIF. See Guideline Interchange Format

Global Patient Index, 55

Glossary, 327–335

GRM. See Generic Reference Model

Guideline Expression Language, Object-Oriented (GELLO), 160, 336

Guideline Interchange Format (GLIF), 159, 336

H

HACCP. See Hazard analysis and critical control points

Hazard analysis and critical control points (HACCP), 180, 336

case studies, 493–494

proactive hazard analysis, 482–483

Hazard and operability studies (HAZOP), 339

case studies, 494–495

proactive hazard analysis, 484

HAZOP. See Hazard and operability studies

HCFA. See Health Care Financing Administration

HCPCS. See Health Care Financing Administration Common Procedure Coding System

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

Health care data standards. See Data standards

Health Care Financing Administration (HCFA), 336

Health Care Financing Administration Common Procedure Coding System (HCPCS), 151, 339

Health Insurance Portability and Accountability Act of 1996 (HIPAA), 16, 25, 38, 60, 90, 336

Health Level Seven (HL7), 25, 72, 99–100, 135–136, 336

Clinical Document Architecture (CDA) of, 74

context manager, 140

demonstration project, 76–77

reference information model, 135

Health Plan Employer Data and Information (HEDIS), 112

Health Resources and Services Administration, 89

Healthcare failure mode and effect analysis (HFMEA), 336

case studies, 498–499

proactive hazard analysis, 481–482

Healthcare Informatics Standards Board (HISB), 101–102

Healthcare Information Management Systems Society (HIMSS), 72, 336

HEDIS. See Health Plan Employer Data and Information

HFMEA. See Healthcare failure mode and effect analysis

HHCC. See Home Health Care Classification

High-risk issues, 176

High-risk patients, 192

HIMSS. See Healthcare Information Management Systems Society

HIPAA. See Health Insurance Portability and Accountability Act of 1996

HIPAA Security Rule, 70

HISB. See Healthcare Informatics Standards Board

HL7. See Health Level Seven

Home Health Care Classification (HHCC), 336

Human factors engineering, HE74 standard, 138

I

Iatrogenic injury, 331

ICD. See International Classification of Diseases

ICD-9 CM. See International Classification of Diseases, Ninth Edition, Clinical Modification

ICD-10. See International Classification of Diseases, Tenth Edition

ICD-O. See International Classification of Diseases, Oncology

ICF. See International Classification of Functioning, Disability and Health

ICNP. See International Classification of Nursing Practice

ICPC. See International Classification of Primary Care

IEEE. See Institute of Electrical and Electronics Engineers

IHE. See Integrating the Healthcare Enterprise

Implementation

of adverse event systems, 183–184

of the common report format, 304–307

of data standards, 163–164

of near miss systems, 237–240

of NHII, 78–91

Incident causation model, 228

Information infrastructure, components of

clinical information systems, 72

communication technologies, 69–71

data acquisition methods and user interfaces, 61–62

data mining techniques, 65–67

data repositories and clinical event monitors, 64–65

digital sources of evidence or knowledge, 67–69

health care data standards, 63–64

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

Information management in an electronic health record system, 81

Information technology (IT), 337

role in designing a safer health care system, 34–36

Injury detection, 178–180

deployment and implementation, 183–184

epidemiologic analyses, hypotheses for change generation, and prioritization, 180–181

holding the gains, 184

rapid-cycle testing, 181–183

use of standardized data for, 179

Institute for Safe Medication Practice (ISMP), 337

Institute of Electrical and Electronics Engineers (IEEE), 25, 99, 336

Integrating the Healthcare Enterprise (IHE) initiative, 118, 336

Integration

with adverse event systems, 239–240

of individual human error/recovery models with team-based error/ recovery models, 193

with other systems, 234

of retrospective and prospective techniques, 193–194

International Classification of Diseases (ICD), 25

Ninth Edition, Clinical Modification (ICD-9 CM), 22, 336

Oncology (ICD-O), 336

Tenth Edition (ICD-10), 336

International Classification of Functioning, Disability and Health (ICF), 103, 151, 339

International Classification of Nursing Practice (ICNP), 336

International Classification of Primary Care (ICPC), 103, 151, 336

International Organization for Standardization (ISO), 97–98, 133, 337

IOM-Health Level Seven demonstration project, 72–78

final ADE scenario for interoperability demonstration project, 74–75

patient scenario data standards, 76–77

ISMP. See Institute for Safe Medication Practice

ISO. See International Organization for Standardization

IT. See Information technology

J

JAMIA. See Journal of American Informatics Association

JCAHO. See Joint Commission on Accreditation of Healthcare Organizations

Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 5, 25, 337

Sentinel Event Policy, 418–423

Journal of American Informatics Association (JAMIA), 337

“Just” culture, 177

K

Kaiser Permanente of Ohio, 80–82

Key Capabilities of an Electronic Health Record System, 7, 46

Knowledge representation, 13, 15, 17, 49, 50, 129, 158–162, 331

formalism in, 331

language of, 331

standards for, 64, 108–111

L

Learning approaches

need to invest more resources in, 273

Logical Observation Identifiers, Names and Codes (LOINC), 149–150, 152, 337

LOINC. See Logical Observation Identifiers, Names and Codes

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

M

Magnetic resonance imaging (MRI), 337

Magnitude of the problem, 30–32

health care errors in the U.S., 31

Mandatory reporting, 204, 332

Manual data audit, 85

Manufacture and User Data Experience-Medical Devices (MAUDE), 337

Mapping terminologies, 154–155

Markle Foundation, Connecting for Health initiative, 39, 73

MAUDE. See Manufacture and User Data Experience-Medical Devices

Mayo Clinic, 156

MDS. See Minimum Data Set for Nursing Home Care

MEDCIN. See Medicomp Systems Incorporated

MedDRA. See Medical Dictionary for Drug Regulatory Affairs

Medical device terminologies, 153–154

Medical Dictionary for Drug Regulatory Affairs (MedDRA), 150, 337

Medical Event Reporting System for Transfusion Medicine (MERS TM), 337, 406–417

risk assessment index, 294

Medical literature

representation of, 161–162

Medical Product Surveillance Network (MedSun), 337

Medical Subject Headings (MeSH), 337

Medicare Patient Safety Monitoring System (MPSMS), 337

Medication Errors Reporting (MER), 337

Medicomp Systems Incorporated (MEDCIN), 150

MedSun. See Medical Product Surveillance Network

MER. See Medication Errors Reporting

MERS TM. See Medical Event Reporting System for Transfusion Medicine

MeSH. See Medical Subject Headings

Message format standards, 132–135

HL7 reference information model, 135

MHS PSP. See Military Health System Patient Safety Program

Military Health System Patient Safety Program (MHS PSP), 80, 337

Mindfulness, 230

Minimum Data Set for Nursing Home Care (MDS), 337

Minimum datasets, 218–220

ancillary information, 219

detailed analysis, 219

the discovery, 219

the event itself, 219

results, 220

Model for safer care, 178–184

Monitoring for adverse effects, 206–214

computerized physician order entry and medication prescribing, 214

rules for detecting possible adverse drug events using automated surveillance, 207

triggers for outpatient adverse drug events, 208

MPSMS. See Medicare Patient Safety Monitoring System

MRI. See Magnetic resonance imaging

N

NANDA. See North American Nursing Diagnosis Association

NASA. See National Aeronautics and Space Administration

NaSH. See National Surveillance System for Health Care Workers

NASHP. See National Academy for State Health Policy

National Academy for State Health Policy (NASHP), 337

National Aeronautics and Space Administration (NASA), 337

National Alliance for Health Information Technology, 117–118

National Center for Health Statistics (NCHS), 116, 337

National Center for Patient Safety (NCPS), 337

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

National Committee for Quality Assurance (NCQA), 108, 113, 272, 337

National Committee on Vital and Health Statistics (NCVHS), 6, 10, 25, 46, 78, 107, 115, 119–121, 143, 145–146, 337

terminologies, 17

National Council for Prescription Drug Programs (NCPDP), 25, 99, 132, 337

National Drug Codes (NDCs), 104, 151, 337

National Drug File Clinical Drug Reference Terminology (NDF RT), 337

National Electronic Disease Surveillance System (NEDSS), 337

National Equipment Manufacturers Association (NEMA), 337

National Guideline Clearinghouse, 158

National Health Information Infrastructure (NHII), 37, 53, 88–90, 123, 332, 337

agenda for data standards, 48

building, 45–168

challenges to implementation, 86–91

components of, 46–47, 52–95

conceptual model of standards-based, integrated data systems to support patient safety, 56–61

dimensions of, 54

elements of, 6–8

enforcement of privacy and security, 90

federal leadership and public-private partnerships, 96–126

financial incentives, 88–90

health care data standards, 127–168

implementing the systems, 72–78, 86–91

informatics components, 61–72

organizational leadership, 86–88

practical approaches to moving forward, 78–86

recommendations, 6–8, 45, 47

technical assistance, 90

National Healthcare Safety Network (NHSN), 337

National Institute of Standards and Technology (NIST), 101

National Library of Medicine (NLM), 16–17, 107, 119–121, 337

National Nosocomial Infections Surveillance (NNIS), 338

National Patient Safety Foundation (NPSF), 338

National Quality Forum (NQF), 338

National Research Council (NRC), 338

National Surveillance System for Health Care Workers (NaSH), 337

National Uniform Billing Committee, 99

Natural language processing (NLP), 196, 332, 337

NCHS. See National Center for Health Statistics

NCPDP. See National Council for Prescription Drug Programs

NCPS. See National Center for Patient Safety

NCQA. See National Committee for Quality Assurance

NCVHS. See National Committee on Vital and Health Statistics

NDCs. See National Drug Codes

NDF RT. See National Drug File Clinical Drug Reference Terminology

Near-miss analysis, 30, 171–172, 226–245, 332, 338

causal continuum assumption, 230–231

data collection, 237–238

design and operation of system components, 244

framework for processing near-miss reports, 240–242

functional aspects, 215–216

functional requirements of near-miss systems, 234–236

fundamental aspects of near-miss systems, 232–233

gaps between ideal and current systems, 242

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

general framework for processing reports, 241–242

goals for near-miss systems, 229–230

implementation and operational considerations, 236–240

implications for data standards, 242–245

incident causation model, 228

integration with adverse events systems, 239–240

mindfulness/alertness, 230

modeling for qualitative insight, 229

reporting and analysis, 229–232

role of the patient, 231–232

testing assumptions of, 192–193

trending for quantitative insight, 229–230

NEDSS. See National Electronic Disease Surveillance System

Negative predictive value (NPV), 338

NEHEN. See New England Healthcare Electronic Data Interchange Network

NEMA. See National Equipment Manufacturers Association

Neural networks, 332

New England Healthcare Electronic Data Interchange Network (NEHEN), 55

New York Patient Occurrence Reporting and Tracking System (NYPORTS), 33, 248, 338

medication supplement, 398

reportable events, 394–396

root-cause analysis form, 397

short form, 397

NHII. See National Health Information Infrastructure

NHSN. See National Healthcare Safety Network

NIC. See Nursing Intervention Classification

Nicholas E. Davies award winners, 79

NIST. See National Institute of Standards and Technology

NLM. See National Library of Medicine

NLP. See Natural language processing

NMHS. See North Mississippi Health Services

NNIS. See National Nosocomial Infections Surveillance

NOC. See Nursing Outcomes Classifications

Normalized notations for clinical drugs (RxNORM), 150, 338

North American Nursing Diagnosis Association (NANDA), 337

North Mississippi Health Services (NMHS), 83

NPSF. See National Patient Safety Foundation

NPV. See Negative predictive value

NQF. See National Quality Forum

NRC. See National Research Council

Nursing Intervention Classification (NIC), 337

Nursing Outcomes Classifications (NOC), 338

NYPORTS. See New York Patient Occurrence Reporting and Tracking System

O

OASIS. See Outcome and Assessment Information Set for Home Care

Omission, addressing errors of, 216

Open communication, 177

Order entry/order management, 443–444, 452–453

Organizational commitment

to detect patient injuries and near misses, 175–176

high-risk areas that deserve special attention, 176

Organizational leadership, 86–88

Organizational learning, as a system focus, 234–235

ORYX initiative, 113

Outcome and Assessment Information Set for Home Care (OASIS), 338

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

P

Parameters of a medical event reporting system

desirable, 285

Partnerships among CHI initiative, NCVHS, and NLM, 119–122

PATH. See Program for Appropriate Technology in Health

Patient Care Data Set (PCDS), 338

Patient data linkage, 141–142

Patient medical record information (PMRI), 115, 338

Patient roles, 194

engaging patients and their families more in patient safety, 190–192

Patient safety data

applications of, 247

audits of, 271–273

possible uses and mechanisms of action for, 253

Patient safety data standards (PSDS), 40, 338

Patient Safety Institute (PSI), 141

Patient safety reporting standards, 40–41

Patient safety reporting system (PSRS), 250–278, 338

and accountability, 252–254

versus learning, understanding the continuum, 262–273

need to invest more resources in learning approaches, 273

Patient safety systems, 269–273

acceptability of the scheme to all personnel, 237

cost/benefit analysis of programs for, 194

data system design, 270

design and operation of system components, 244

in health care settings, 17–20

IOM-Health Level Seven demonstration project, 72–78

level of help provided for collecting and analyzing the data, 236

nature of the information collected, 236

nature of the organization of the reporting scheme, 236–237

patient safety data audits, 271–273

recommendations, 19, 20–23

reporting, 20–23

selection of measures for, 263–265

design and operation of system components, 243

general framework for processing near-miss reports, 240

sources of variation in measured outcomes, 264

standardized data, 270–271

PBRNs. See Practice-based research networks

PCDS. See Patient Care Data Set

Perioperative Nursing Data Set (PNDS), 338

PHA. See Proactive hazard analysis

Pharmacy knowledge bases, 151

PMRI. See Patient medical record information

PNDS. See Perioperative Nursing Data Set

Positive predictive value (PPV), 338

Postoperative infections, 188–190

PPV. See Positive predictive value

PQI. See Prevention quality indicator

PRA. See Probabilistic risk assessment

Practical approaches to data systems, 78–86

data management procedures, 85

information management, 81

Kaiser Permanente of Ohio, 82

Nicholas E. Davies award winners, 79

North Mississippi Health Services (NMHS), 83

Perspective Online, 85

Practice-based research networks (PBRNs), 109

President’s Information Technology Advisory Committee, 6

Preventability

concept of, 268–269

Preventing adverse drug events, 185–187

Prevention quality indicator (PQI), 338

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

Primary and secondary uses of report data, 308–310

Primary standards development organizations in the U.S., 99

American Dental Association, 99

American Society for Testing and Materials, 335

ASC X12N, 99

Digital Imaging and Communications in Medicine, 99

Health Level Seven, 99

Institute of Electrical and Electronics Engineers, 99

National Council for Prescription Drug Programs, 99

Priority Areas for National Action: Transforming Health Care Quality, 9, 38, 147

Privacy, enforcement of, 90

Private networks, representative applications conducted over, 71

Proactive hazard analysis (PHA), 338, 481–485

features common to all approaches, 486

features unique to specific tools, 487

FMEA/HFMEA, 481–482

HACCP, 482–483

HAZOP, 484

PHA, 484–485

quality improvement tools, 476–477

RCA, 485

Probabilistic risk assessment (PRA), 338

case studies, 499–501

Professional associations

terminologies of, 104–106

Program for Appropriate Technology in Health (PATH), 338

Proof theory, 333

PS. See Patient safety

PSDS. See Patient safety data standards

PSI. See Patient Safety Institute

PSRS. See Patient safety reporting system

Public and private partnership to set standards, 8–12, 47–48, 120

recommendations, 8–12, 47–48

Public Health Data Standards Consortium, 116–117

Q

QIPS. See Quality indicators for patient safety

Quality improvement and proactive hazard analysis models, 471–508

applicability to adverse event prevention, 490–491

case studies, 492–507

common features to all QI tools, 486

conceptual and methodological considerations, 488–489

data requirements and measurement tools, 491–492

essential features of health care quality, 473

features unique to specific QI tools, 487

key common principles and attributes of methodologies, 486–489

overview of existing models, 473–485

proactive hazard analysis, 481–485

of QI/PHA methodologies, 486–489

quality improvement tools, 473–481

unique features to specific PHA tools, 487

Quality improvement tools, 473–481

proactive hazard analysis approaches, 476–477

quality improvement approaches, 474–475

Six Sigma, 480–481

TPS, 479–480

TQM/CQI, 478–479

Quality in Australian Health Care Study, 30

Quality indicators for patient safety (QIPS), 338

Quality Interagency Coordination Task Force (QuIC), 10, 32, 112–113, 338

QuIC. See Quality Interagency Coordination Task Force

R

R-Demo. See Reporting demonstration

Radiological Society of North America (RSNA), 338

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

RAI. See AIMS risk assessment index

RCA. See Root-cause analysis

Recommendations, 6–8, 15–17, 45, 47–48, 49–50

clinical data interchange standards, 16, 49

clinical terminologies, 16–17, 50

elements of a health information infrastructure, 6–8

establishment of comprehensive patient safety programs, 169–170

knowledge representation, 17, 50

patient safety reporting, 22–23

patient safety systems in health care settings, 19

standardized reporting, 248–249

Recovery root causes, 233

Recovery taxonomy

testing a suitable, 193

Reference Information Model (RIM), 338

Reference terminology, 333

Regulated Clinical Research Information Management, 305

Reportable events, 382

in federal reporting systems, 343

in private-sector reporting systems, 403

Reporting and population health management, 447, 458–459

Reporting demonstration (R-Demo), 338

Reporting formats, 333

Reporting methods, 383

in federal reporting systems, 344

in private-sector reporting systems, 404

Reporting standards, 111–114

Research agenda, 192–197

developing a recovery taxonomy, 195

dissemination, 196–197

knowledge generation, 192–195

tool development, 195–197

RIM. See Reference Information Model

Risk assessment index, 292–295

AIMS risk assessment index (RAI), 294

MERS TM risk assessment index, 294

Risk Assessment of Security Critical Systems (CORAS), 335

Root-cause analysis (RCA), 333, 338

case studies, 501–503

proactive hazard analysis, 485

Root-cause taxonomies

context variables, 233

failure root causes, 233

free text, 233

need for, 233

recovery root causes, 233

RSNA. See Radiological Society of North America

RxNORM. See Normalized notations for clinical drugs

S

SAC. See Safety Assessment Code

Safe care, 334

Safety Assessment Code (SAC), 292–293, 338

Safety data

using for accountability, licensing, or legal action, 255

using for selection, 256

Scherkenbach’s cycle of fear, 265–268

SDO. See Standards development organizations

Securities and Exchange Act of 1934, 114

Security, enforcement of, 90

Semantics, 334

Serious events

analysis of, 384

in federal reporting systems, 344–345

in private-sector reporting systems, 404–405

Setting standards for the exchange of health care data in the U.S., 98

Seven-module framework for processing, general framework for processing near-miss reports, 241

Shared beliefs and values, 175

Six Sigma, 503–505

case studies, 503–505

quality improvement tools, 480–481

Six Sigma anticoagulation improvements at Virtua Health, 504–505

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

SNAEMS. See Special Nutritionals Adverse Event Monitoring System

SNOMED CT. See Systemized Nomenclature for Human and Veterinary Medicine, Clinical Terms

SPARCS. See Statewide Planning and Research Cooperative System

Special Nutritionals Adverse Event Monitoring System (SNAEMS), 338

Standardized mappings of terminologies, 105, 107–108

Standardized report format

basic domains, 286–287

causal analysis, 293, 295–301

desirable parameters of a medical event reporting system, 285

essential elements of, 283–304

event-type taxonomy, 287–292

lessons learned, 302

need for, 280–283

risk assessment index, 292–295

summary of domain areas for a common report format, 302–304

Standardized reporting, 247–249, 279–316

de-identification and data protection, 307–308

essential elements of, 283–304

implementation of, 304–307

need for, 280–283

overview of CHAI, 312–313

primary and secondary uses of, 308–310

recommendations, 248–249

Standards activities in the federal and private sectors, 114–118

CHI initiative, 116

Integrating the Healthcare Enterprise initiative, 118

National Alliance for Health Information Technology, 117–118

National Committee on Vital and Health Statistics (NCVHS), 115

Public Health Data Standards Consortium, 116–117

Standards development organizations (SDO)

overlap of work by major, 97

terminologies, 105–107

Standards-setting processing, 97–114

data interchange standards, 97–102

knowledge representation standards, 108–111

reporting standards, 111–114

terminologies, 102–108

State reporting systems, 382–401

analysis of serious events, 384

examples from the New York and Florida reporting system, 386–393

Florida state annual report, 400

Florida state Code 15 report, 401

Florida state reportable events, 399

format for reporting, 382–383

method of reporting, 383

New York Patient Occurrence Reporting and Tracking System (NYPORTS) medication supplement, 398

NYPORTS reportable events, 394–396

NYPORTS root-cause analysis form, 397

NYPORTS short form, 397

reportable events, 382

tabular information, 385

Statewide Planning and Research Cooperative System (SPARCS), 338

Streamlining patient safety reporting, 247–249

patient safety data applications, 247

standardized reporting, 247–249

Supplemental terminologies, overview of, 150–151

Surveillance. See Automated surveillance

Surveillance of clinical data, 334

automated, 206

in federal reporting systems, 342–343

Syntactic aspect of knowledge representation language, 334

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

Systemized Nomenclature for Human and Veterinary Medicine, Clinical Terms (SNOMED CT), 25, 33, 106, 149–150, 338

T

Taxonomies

data standards for, 243

Terminology, 13–15, 49–50, 102–108, 129, 142–158, 334

academic institutions, 104–106

clinical domain areas of the CHI initiative, 146–147

defining, 217–218

evolution and development of new, 147–148

federal government, 103–106

for further investigation and research, 155–158

international organizations, 103–104

knowledge representation standards, 108–111

professional associations, 104–106

representation of clinical domains, 143–146

selection of the core terminology group, 145, 148–158

standardized mappings of, 105, 107–108

standards development organizations, 105–107

technical criteria and representation of clinical domains, 143–146

To Err Is Human, 2, 30–31, 33

response to, 32–34

Tool development, 195–197

data mining of patient safety databases, 196

early detection, 195

natural language processing, 196

prevention capabilities, 195

R6, 20, 170

verifying adverse events, 196

Total quality management (TQM), 339

and quality improvement tools, 478–479

Toyota Production System (TPS), 339

case studies, 505–507

quality improvement tools, 479–480

TPS. See Toyota Production System

TQM. See Total quality management

U

UCSF. See University of California, San Francisco

UHI. See Universal health identifier

UMDNS. See Universal Medical Device Nomenclature System

UMLS. See Unified Medical Language System

Unified Medical Language System (UMLS), 108, 121, 339

Unique Ingredient Identifier (UNII), 150

United States Pharmacopeial Convention, Inc. (USP), 339

Universal health identifier (UHI), 14, 25, 339

Universal Medical Device Nomenclature System (UMDNS), 150, 291, 339

University of California, San Francisco (UCSF), 339

User interfaces, 137–141, 334

HL7 context manager, 140

human factors engineering process governing the HE74 standard, 138

USP. See United States Pharmacopeial Convention, Inc.

V

Vaccine Adverse Event Reporting System (VAERS), 339

Vaccine Safety Datalink (VSD), 339

VAERS. See Vaccine Adverse Event Reporting System

Veterans Health Administration (VHA), 80, 85, 339

example of federal patient safety/ health care reporting and surveillance systems, 374–381

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

Veterans Health Integration System and Technology Architecture (VISTA), 89

VHA. See Veterans Health Administration

VISTA. See Veterans Health Integration System and Technology Architecture

Voluntary reporting, 204, 335

VSD. See Vaccine Safety Datalink

W

WEDI. See Workgroup on Electronic Data Interchange

WHO. See World Health Organization

Willingness to report patient safety events, 237–238

WONCA. See World Organization of National Colleges, Academies, and Academic Associations of General Practitioners and Family Physicians

Workgroup on Electronic Data Interchange (WEDI), 163

World Health Organization (WHO), 103

World Organization of National Colleges, Academies, and Academic Associations of General Practitioners and Family Physicians (WONCA), 103, 156, 339

X

XML. See Extensible markup language

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Patient Safety: Achieving a New Standard for Care Get This Book
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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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