topic thus was not worthy of further exploration. However, the team ultimately took a systems approach, noting that there is often a range of medications available to address a particular clinical need and that those medications may pose different risks for allergic reaction. The team created computerized alerts that recommended a safer alternative if a physician ordered a medication with a high allergy risk. In addition, the team implemented immediate review of a developing ADE by a pharmacist, under the theory that early intervention might abort the event before it progressed to more serious levels. When implemented, the team’s intervention reduced serious allergic and idiosyncratic drug reactions within the hospital by more than 50 percent (Evans et al., 1994; Pestotnik et al., 1996).

Another good example of a problem previously thought to be largely unpreventable (after standardizing sterile measures) is that of bloodstream infections with central venous lines. While they have important advantages (e.g., the ability to administer large volumes of fluid), short-term vascular catheters are associated with serious complications, particularly infections. Central venous catheters impregnated with rifampin and minocycline have been shown to reduce the incidence of catheter-related bloodstream infection (Darouiche et al., 1999).

It is also important to recognize that current beliefs concerning preventability may be quite limited. Many events presently judged not to be preventable may be so with careful investigation and creative thought. Finally, even if a class of injuries is not presently preventable, a broad focus can generate and prioritize a research agenda that can improve patient safety over time.

Patient safety data systems should cast a wide net, focusing on all types of adverse events, not just those that are preventable based on current understanding and current systems of care delivery. Achieving this broad focus will require careful use of the term “error,” with clear recognition of its linkage to system-level solutions and attention to its pejorative connotations for health professionals. Using the term “injuries” may even be preferable and might make it possible to avoid the type of negative behavior described by the cycle of fear.

Implications for Patient Safety Data Systems

Patient safety data systems must be able to support the full range of applications, from accountability to learning. If they are to do so, they must be carefully designed to capture all relevant data and comply with national data standards. It will also be important to establish an external auditing



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