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Patient Safety: Achieving a New Standard for Care (2004)
Board on Health Care Services (HCS)
Institute of Medicine (IOM)

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. "PART III: STREAMLINING PATIENT SAFETY REPORTING." Patient Safety: Achieving a New Standard for Care. Washington, DC: The National Academies Press, 2004.

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Patient Safety: Achieving a New Standard for Care

more than one factor precipitated the adverse event, and be incorporated into SNOMED CT.

  • The standardized report format should include the following:

  • A standardized minimum set of data elements.

  • Data necessary to calculate a risk assessment index for determining prospectively the probability of an event and its severity.

  • A free-text narrative of the event.

  • Data necessary to support use of the Eindhoven Classification Model—Medical Version for classifying root causes, including expansions for (1) recovery factors associated with near-miss events, (2) corrective actions taken to recover from adverse events, and (3) patient outcome/functional status as a result of those corrective actions.

  • 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, 2002).

REFERENCES

Department of Health and Human Services. 2002. HHS Moves Forward to Establish New System for Collecting Patient Safety Data. Online. Available: http://www.hhs.gov/news/press/2002pres/20021125.html [accessed August 18, 2003].


National Quality Forum. 2002. Serious Reportable Events in Patient Safety: A National Quality Forum Consensus Report. Washington, DC: National Quality Forum.

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