current standards-setting activities in three key areas—health data interchange, terminologies, and medical knowledge representation. For each of these areas, the committee reviewed the future work needed and recommended a work plan.

To achieve an acceptable standard of patient safety, the committee recommends that all health care settings establish comprehensive patient safety programs operated by trained personnel within a culture of safety and involving adverse event and near-miss detection and analysis. In addition, the federal government should pursue a robust applied research agenda on patient safety, focused on enhancing knowledge, developing tools, and disseminating results to maximize the impact of patient safety systems. Finally, the committee recommends that a standardized format and terminology be developed for the capture and reporting of data related to medical errors.

Since the release of the Institute of Medicine (IOM) report To Err Is Human: Building a Safer Health System (Institute of Medicine, 2000), national attention has been focused on the need to reduce medical errors. The health care community and the public at large have come to realize that the nation’s health care system is not as safe as it should be.

Every day, tens if not hundreds of thousands of errors occur in the U.S. health care system. 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), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation (e.g., a lethal drug overdose was administered but discovered early and countered with an antidote). Sadly, however, a small proportion of errors do result in adverse events—that is, they cause harm to patients—exacting a sizable toll in terms of injury, disability, and death.

To Err Is Human focuses primarily on errors that occur in hospitals and is based on the evidence available at the time that report was written. Newly released research indicates the existence of serious safety issues in other settings as well, including ambulatory settings and nursing homes (Gurwitz et al., 2000, 2003). In fact, because the number of outpatient encounters far exceeds the number of inpatient admissions, the consequences of medical errors in the former settings—and the opportunities to improve—may dwarf those in hospitals.



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