Patient Safety: Achieving a New Standard for Care

Voluntary reporting.

Those reporting systems for which the reporting of patient safety events is voluntary (not mandatory). Generally, reports on all types of events are accepted.

Working memory.

A component of production rule system containing information that the system has gained about the problem thus far.

ACRONYM LIST

ADE

adverse drug event

adverse event

AERS

Adverse Event Reporting System

AHRQ

Agency for Healthcare Research and Quality

AIMS

Australian Incident Monitoring System

AMI

acute myocardial infarction

ANSI

American National Standards Institute

ASC

Accredited Standards Committee

ASR

Alternative Summary Reporting—Medical Devices

ASTM

American Society for Testing and Materials

BPD

Blood Product Deviation Reporting System

CDA

Clinical Document Architecture

CDC

Centers for Disease Control and Prevention

CEN

Comité Européean Normalisation

CHF

congestive heart failure

CHI

Consolidated Health Informatics

CHIP

Children’s Health Insurance Program

CIS

clinical information systems

CMS

Centers for Medicare and Medicaid Services

COPD

chronic obstructive pulmonary disease

CORAS

Risk Assessment of Security Critical Systems

CPOE

computerized physician order entry

CPT

Current Procedural Terminology

CQI

continuous quality improvement

CQuIPS

Center for Quality Improvement and Patient Safety

DHHS

Department of Health and Human Services

DICOM

Digital Imaging and Communications in Medicine

DoD

Department of Defense

Table of Contents

Front Matter R1-R22

Executive Summary 1-28

1 Introduction 29-44

PART I: BUILDING THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE 45-51

2 Components of a National Health Information Infrastructure 52-95

3 Federal Leadership and Public-Private Partnerships 96-126

4 Health Care Data Standards 127-168

PART II: ESTABLISHING COMPREHENSIVE PATIENT SAFETY PROGRAMS 169-172

5 Comprehensive Patient Safety Programs in Health Care Settings 173-199

6 Adverse Event Analysis 200-225

7 Near-Miss Analysis 226-246

PART III: STREAMLINING PATIENT SAFETY REPORTING 247-249

8 Patient Safety Reporting Systems and Applications 250-278

9 Standardized Reporting 279-316

Appendix A: Biographies of Committee Members 317-326

Appendix B: Glossary and Acronym List 327-340

Appendix C: Examples of Federal, State, and Private Sector Reporting Systems 341-426

Appendix D: Clinical Domains for Patient Safety 427-429

Appendix E: Key Capabilities of an Electronic Health Record System: Letter Report 430-470

Appendix F: Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel 471-508

Appendix G: Australian Incident Monitoring System Taxonomy 509-510

Index 511-528

ACRONYM LIST