Patient Safety: Achieving a New Standard for Care

TABLE 5-1 Frequency of Adverse Drug Events by Cause

Class	Percent	Description	Preventable
Allergic reaction with no prior history	28.0	Allergic or idiosyncratic reactions in patients with no prior history of allergy	Unclear
Renal dysfunction	23.0	Failure to adjust dosage in the face of declining renal function, among drugs excreted through the kidneys	Yes
Patient age	14.2	Failure to adjust dosage for patient age	Yes
Patient weight	5.7	Failure to adjust dosage for patient body mass	Yes
Dosage error	5.0	Simple error in dosage ordered (excluding other sources on this list)	Yes
Hematologic factors	4.6	Failure to appropriately adjust for other known hematological factors	Yes
Patient compliance	3.8	Failure of patient to comply with medical instructions	Unclear
Drug administration rate	2.7	Error on rate of administration of medication	Yes
Liver dysfunction	2.3	Failure to appropriately adjust for reduced liver function, for hepatically excreted drugs	Yes
Known allergies	1.5	Failure to recognize and respond to known allergies	Yes
Electrolyte imbalances	1.5	Failure to appropriately adjust dosage for known electrolyte imbalances	Yes
Dosage schedule error	1.5	Error on medication order regarding dosing schedule	Unclear
NOTE: The first cause accounted for 28 percent of all events recorded; the second an additional 23 percent. Among almost 40 causes originally hypothesized in the cause-and-effect diagram, the first 6 shown here accounted for 80 percent of all ADEs detected.

Deployment and Implementation

“Pilot and deploy” is an approach to implementing improvements that has been successful in a number of care delivery organizations. The idea is simple: choose an important systemwide safety problem; then determine methods for achieving demonstrated performance within a small group using rapid-cycle improvement tools. A small group often avoids larger organizational change issues and thus can discover effective process steps more rapidly. Once the necessary process steps are known, they can be implemented in other parts of the organization. Demonstrated success in the pilot

Table of Contents

Front Matter R1-R22

Executive Summary 1-28

1 Introduction 29-44

PART I: BUILDING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE 45-51

2 Components of a National Health Information Infrastructure 52-95

3 Federal Leadership and Public-Private Partnerships 96-126

4 Health Care Data Standards 127-168

PART II: ESTABLISHING COMPREHENSIVE PATIENT SAFETY PROGRAMS 169-172

5 Comprehensive Patient Safety Programs in Health Care Settings 173-199

6 Adverse Event Analysis 200-225

7 Near-Miss Analysis 226-246

PART III: STREAMLINING PATIENT SAFETY REPORTING 247-249

8 Patient Safety Reporting Systems and Applications 250-278

9 Standardized Reporting 279-316

Appendix A: Biographies of Committee Members 317-326

Appendix B: Glossary and Acronym List 327-340

Appendix C: Examples of Federal, State, and Private Sector Reporting Systems 341-426

Appendix D: Clinical Domains for Patient Safety 427-429

Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report 430-470

Appendix F: Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel 471-508

Appendix G: Australian Incident Monitoring System Taxonomy 509-510

Index 511-528

Deployment and Implementation