and medication safety in particular, such as introducing a culture of safety, implementing computerized error detection and prevention systems, standardizing procedures, reducing errors at care transitions, and developing human–computer interfaces. It is likely that many of the lessons learned in these industries will be relevant to health care delivery. As a consequence, the committee believes workshops and studies should take place regularly so that safety experts in health care can share experiences with safety experts in other industries.


The committee endorses the recommendation in the IOM’s patient safety report (IOM, 2004) that the Agency for Healthcare Research and Quality develop a standard (or common) event taxonomy for data storage and analysis. Specifically, this event taxonomy should address near misses and ADEs, cover errors of both omission and commission, and include hazardous conditions. The report format should include both standardized data elements and free-text narratives.

The committee views the work of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in this area as an important development. JCAHO has taken a leadership role (Chang et al., 2005) by developing a Patient Safety Event Taxonomy (NQF, 2005), which was endorsed by the NQF in August 2005 (see also Chapter 8).

The committee also endorses the recommendation of the IOM’s patient safety report that further studies on the cost/benefit of reporting systems be undertaken. In particular, there is a need for in-depth studies of the value of various reporting systems with regard to learning about errors and new problems, gaining knowledge from the reports, communicating guidance, and changing care delivery processes.


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Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, Small SD, Sweitzer BJ, Leape L. 1997. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. Journal of the American Medical Association 277(4):307–311.

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