• A free-text section for lessons learned as a result of the event.

  • Clinical documentation of the patient context.

  • The taxonomy and report format should be used by the federal reporting system integration project in the areas for basic domain, event type, risk assessment, and causal analysis but should provide for more extensive support for patient safety research and analysis (Department of Health and Human Services, 2002c).

The event taxonomy and standardized report format are intended to serve as a framework for federal, state, and private-sector reporting systems. AHRQ should also develop tools and guidelines to assist public- and private-sector reporting programs in implementing the common report format and data standards. Furthermore, the development of external data auditing criteria would provide assurance to all stakeholders that data used for reporting are valid and reliable.


The committee has laid out an ambitious agenda that has the potential to produce dramatic improvements in patient safety. This agenda is likely to yield considerable benefits in many other areas as well, including public health, homeland security, clinical and health services research, and health professions education.

At the heart of the agenda is the development of a national health information infrastructure, including EHR systems that adhere to national standards for data supporting patient safety in all health care settings. Although the committee recognizes that carrying out this agenda will require a sizable up-front capital investment, we believe its creation is essential not only to patient safety but also to the health of the American people more generally. The committee believes that establishing this information technology infrastructure should be the highest priority for all health care stakeholders.

This is a journey that will take a decade to accomplish and in which the federal government, working in partnership with the private sector, has a critical role to play. The federal government should act immediately to establish the national data standards called for in this report. Although modest financial resources will be required, the committee believes the return on this investment will be very high. Many if not most providers are investing in EHRs. National data standards are needed now to ensure that these systems possess the necessary capabilities to improve patient safety and are capable of exchanging information reliably.

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