Patient Safety Achieving a New Standard for Care (2004) / Chapter Skim
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1 Introduction
1 Introduction
Pages 29-44
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From page 29... ...
This introductory chapter provides a brief description of the magnitude of the safety problem, with emphasis on recently released literature; an overview of the response to To Err Is Human; a discussion of the vital role of information technology in designing a safer health care system; an overview of the IOM Quality Chasm Series, intended to place this report within a broader context of health system change initiatives; a brief review of the charge to this IOM committee; and an overview of the report, including a discussion of essential concepts. The chapter also introduces definitions for key terms used throughout the report, which are summarized in Appendix B
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From page 30... ...
Fortunately, most of these errors result not in serious harm but in near misses. A near miss is defined as an act of commission or omission that could have harmed the patient but did not do so as a result of chance (e.g., the patient received a contraindicated drug but did not experience an adverse drug reaction)
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In addition, those interviewed gave written consent for researchers to review their medical records and use the information to evaluate performance on 439 detailed clinical indicators of care for 30 acute and chronic conditions, as well as preventive care. The study focused on identifying instances in which proven, noncontroversial, poten TABLE 1-1 Health Care Errors in the United States Type of Error Inpatient Care Other Care Settings Commission An estimated 44,000 to In outpatient care, 50 adverse drug 98,000 hospitalized patients events per 1,000 person-years were die annually in the United found (Gurwitz et al., 2003)
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Quality Interagency Coordination Task Force (Quality Interagency Coordination Task Force, 2000) , a major federal initiative was launched to reduce medical errors and improve patient safety.
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In addition, many health care institutions operate patient safety reporting systems for internal quality improvement purposes, and a few private-sector organizations operate such systems on a national basis. Of the patient safety reporting systems currently operational in the United States, most focus on adverse events; only a small proportion collect and analyze information on near misses (see Appendix C)
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From page 34... ...
In recent years, it has become increasingly apparent that major improvements in safety will be achieved only if a stronger information infrastructure is built. For example, the reporting and analysis of adverse drug events in hospitals have led to the identification of the following common factors associated with errors: a decline in renal or hepatic function requiring alteration of drug therapy (13.9 percent)
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From page 35... ...
longitudinal collection of electronic health information, defined as information pertaining to the health of an individual or health care provided to an individual; (2) immediate electronic access to person- and population-level information by authorized, and only authorized, users;
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The revised report also outlines the continuing challenges to the development and implementation of computer-based patient records, including resistance to change by the organizational culture, the lack of interoperability and data standards, security and privacy concerns, and financing and policy issues. In March 2001, the IOM released Crossing the Quality Chasm: A New Health System for the 21st Century, which calls for fundamental change in the health care system to achieve improvement in six national quality aims: safety, effectiveness, patient centeredness, timeliness, efficiency, and equity
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. Components of an NHII include national data standards for the collection, coding, and exchange of patient and other information; computerbased patient records with decision support; and a secure platform for the exchange of patient health information.
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. The CHI initiative played an important role in the recent decision by the federal government that programs of DHHS, the Veterans Administration, and the Department of Defense would incorporate certain data standards and terminologies (Department of Health and Human Services, 2003b)
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. Although data standards are set at the national level, the report recommends demonstration projects to establish state-of-the-art health care information technology infrastructure in a limited number of states, communities, or multistate regions by 2005.
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From page 40... ...
Its focus is on data standards for patient safety, i.e., standardized representations of clinical data important to systems that promote patient safety. In general, these standards fall into two categories: • Patient safety data standards -- formally accepted or endorsed definitions and rules regarding the format (e.g., structure)
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From page 41... ...
OVERVIEW OF THE REPORT The remainder of this report is divided into three main parts: • Part I: Building the National Health Information Infrastructure • Part II: Establishing Comprehensive Patient Safety Programs • Part III: Streamlining Patient Safety Reporting Part I focuses on the NHII that is needed to make patient safety a standard of care. Chapter 2 provides an overview of the components of an NHII.
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From page 42... ...
Appendix A contains biographical sketches of the committee members; Appendix B is a list of terms and acronyms used in the report; Appendix C presents examples of federal, state, and private-sector patient safety reporting systems; Appendix D provides a listing of those clinical domains important for patient safety and for which appropriate terminology should be developed; Appendix E is the committee's letter report on the key capabilities of an EHR system; Appendix F is a paper commissioned for this study on quality improvement and proactive hazard analysis models; and Appendix G outlines the Health Incident Type event taxonomy of the Australian Incident Monitoring System. REFERENCES Australian Council for Safety and Quality in Health Care.
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From page 43... ...
1991. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study II.
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From page 44... ...
Improving Patient Safety in Chronic Diseases Using Electronic Medical Records. PowerPoint presentation to the Institute of Medicine Committee on Data Standards for Patient Safety.
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