efficient if front-line providers became more involved in the detection and reporting of events and the dissemination of preventive measures. Such involvement cannot, of course, be allowed to substantially delay providers in delivering care, but it nonetheless could have a major impact. Early trials of this sort of approach (Bates et al., 1998) have already demonstrated that it can be efficacious, though it has rarely been used to date.

REFERENCES

Agency for Healthcare Research and Quality. 2001. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Washington, DC: Agency for Healthcare Research and Quality.

American Medical Association, Joint Commission on Accreditation of Healthcare Organizations, National Committee for Quality Assurance. 2001. Coordinated Performance Measurement for the Management of Adult Diabetes. Online. Available: http://diabetes-mellitus.org/diabetes.pdf [accessed January 27, 2004].


Bates, D. W. 2002. Diuretics: Adverse Reactions and Their Synonyms. Personal communication to Institute of Medicine’s Committee on Data Standards for Patient Safety.

Bates, D. W., R. S. Evans, H. Murff, P. D. Stetson, L. Pizziferri, and G. Hripcsak. 2003. Detecting adverse events using information technology. J Am Med Inform Assoc 10 (2):115–128.

Bates, D. W., M. A. Makary, J. M. Teich, L. Pedraza, N. M. Ma’luf, H. Burstin, and T. A. Brennan. 1998. Asking residents about adverse events in a computer dialogue: How accurate are they? Jt Comm J Qual Improv 24 (4):197–202.


Classen, D. C. 2003. Medication safety: Moving from illusion to reality. JAMA 289:1154–1156.

Classen, D. C., S. L. Pestotnik, R. S. Evans, and J. P. Burke. 1991. Computerized surveillance of adverse drug events in hospital patients. JAMA 266 (20):2847–2851.

Cullen, D. J., D. W. Bates, S. D. Small, J. B. Cooper, A. R. Nemeskal, and L. L. Leape. 1995. The incident reporting system does not detect adverse drug events: A problem for quality improvement. Jt Comm J Qual Improv 21 (10):541–548.


Evans, R. S., R. A. Larsen, J. P. Burke, R. M. Gardner, F. A. Meier, J. A. Jacobson, M. T. Conti, J. T. Jacobson, and R. K. Hulse. 1986. Computer surveillance of hospital-acquired infections and antibiotic use. JAMA 256 (8):1007–1011.


Honigman, B., P. Light, R. M. Pulling, and D. W. Bates. 2001. A computerized method for identifying incidents associated with adverse drug events in outpatients. Int J Med Inf 61 (1):21–32.


Iezzoni, L. I., J. Daley, T. Heeren, S. M. Foley, E. S. Fisher, C. Duncan, J. S. Hughes, and G. A. Coffman. 1994. Identifying complications of care using administrative data. Med Care 32 (7):700–715.

Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press.


Jha, A. K., G. J. Kuperman, J. M. Teich, L. Leape, B. Shea, E. Rittenberg, E. Burdick, D. L. Seger, M. Vander Vliet, and D. W. Bates. 1998. Identifying adverse drug events:



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