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Page 273
Index
A
Access to health care, 24
Accidents, 50, 51
airline, 42
cerebrovascular, 31, 37
Challenger accident, 51, 52, 55
defined, 52, 53(n), 210
environmental influences model, 18
human error, 50
motor vehicle, 1, 26
safety defined, 4, 58
Three Mile Island, 51, 52, 55
see also Adverse events, general; Error analysis
Accountability, general, 8, 13, 101, 166, 167, 168, 205 see also Leadership; Reporting systems
Accreditation, see Licensure and accreditation
Accreditation Council for Graduate Medical Education, 269
Active errors, see Error, general
Adverse events, general
classification/standardization of, 9, 10, 28-29, 88
cost of, 1-2, 7
defined, 4, 28, 29, 210
number of, 1, 26-27, 30, 32, 41, 182-183 191, 194-195, 248-253
sentinel events, 93-94, 104-105, 119-120, 125, 128, 194
studies of, 1, 26, 30-32, 35-37, 40, 218-253
see also Preventable adverse events; Reporting systems
Affordances, 163, 171-172
Agency for Health Care Research and Quality (AHRQ), 77-78, 82, 83
Center for Patient Safety (proposed), 7-8, 69-71, 75-84, 135
Centers for Education and Research in Therapeutics, 77-78, 83
Consumer Assessment of Health Plans, 20
Aircraft carriers, 57, 160-161
Air transport, see Aviation
Alaska, 142
Alcoa, Inc., 160
Allergic reactions, drugs, 33, 192
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Page 273
Index
A
Access to health care, 24
Accidents, 50, 51
airline, 42
cerebrovascular, 31, 37
Challenger accident, 51, 52, 55
defined, 52, 53(n), 210
environmental influences model, 18
human error, 50
motor vehicle, 1, 26
safety defined, 4, 58
Three Mile Island, 51, 52, 55
see also Adverse events, general; Error analysis
Accountability, general, 8, 13, 101, 166, 167, 168, 205 see also Leadership; Reporting systems
Accreditation, see Licensure and accreditation
Accreditation Council for Graduate Medical Education, 269
Active errors, see Error, general
Adverse events, general
classification/standardization of, 9, 10, 28-29, 88
cost of, 1-2, 7
defined, 4, 28, 29, 210
number of, 1, 26-27, 30, 32, 41, 182-183 191, 194-195, 248-253
sentinel events, 93-94, 104-105, 119-120, 125, 128, 194
studies of, 1, 26, 30-32, 35-37, 40, 218-253
see also Preventable adverse events; Reporting systems
Affordances, 163, 171-172
Agency for Health Care Research and Quality (AHRQ), 77-78, 82, 83
Center for Patient Safety (proposed), 7-8, 69-71, 75-84, 135
Centers for Education and Research in Therapeutics, 77-78, 83
Consumer Assessment of Health Plans, 20
Aircraft carriers, 57, 160-161
Air transport, see Aviation
Alaska, 142
Alcoa, Inc., 160
Allergic reactions, drugs, 33, 192
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Ambulatory health care settings, 29, 50-51, 168
costs, 41
drug errors, 32-33, 34-35, 39
home care, 2, 29, 51, 254
reporting systems, 88, 257
training, 165
American Academy of Pediatrics, 146
American Accreditation Healthcare Commission/URAC, 138, 139
American Board of Medical Specialties, 148
American College of Cardiology, 145
American College of Obstetricians and Gynecologists, 145-146
American College of Surgeons, 270
American Heart Association, 145, 147
American Hospital Association
National Patient Safety Partnership, 78, 81-82, 183, 191, 196
American Medical Accreditation Program Association, 143
American Medical Association, 147
National Patient Safety Foundation, 6, 57, 70, 71, 76, 81, 147, 193
National Patient Safety Partnership, 78, 81-82, 183, 191, 196
American National Standards Institute, 178
American Nurses Association, 143
National Patient Safety Partnership, 78, 81-82, 183, 191, 196
American Nurses Credentialing Center, 143
American Society of Health-System Pharmacists, 145, 183, 193
Ames Research Center, 65, 73
Anesthesia, 6, 32, 144-145, 164, 171, 222-225
infusion pumps, 50-66 (passim)
mortality, 164, 222-225
Anesthesia Patient Safety Foundation, 6, 145
Antibiotics, 33, 171
Anticipating the unexpected, 52, 150, 161, 162, 166, 170, 174-176, 197
Anticoagulants, 35
Antidiarrheals, 34
Anti-inflammatory drugs, 35, 253-254
Association of American Medical Colleges, 148
National Patient Safety Partnership, 78, 81-82, 183, 191, 196
Attitudes
fear, 22, 42, 111, 125, 127, 157, 160, 163, 167, 189
patient trust, 2
professionals, 2, 10, 23, 60, 112
public opinion, 2, 29, 42-43, 70, 167
Australia, 32, 35
Authority gradient, 178, 180-181
Automation, see Computer systems
Autopsies, 269
Aviation, 60, 180
accidents, general, 53
aircraft carriers, 57, 160-161
risk level, 42
safety efforts, ix, 5, 6-7, 42, 71-73, 80
team training, 173-174
see also National Aeronautics and Space Administration
Aviation Safety Action Programs, 97
Aviation Safety Reporting System (ASRS), 72-73, 76, 91, 95-97, 104, 105-106, 125, 127
B
Bar coding, 175, 188, 189, 195-196
Benchmarking, 81, 182, 259
Best practices, 18, 32, 77, 79, 145, 152, 182, 193 see also Clinical practice guidelines
Billings, Charles, 73
Budgetary issues, see Funding
Bureau of Labor Statistics, 73-74, 97
C
California
peer review statute, 127-128
reporting system, 254-255
Cancer, 1, 26, 209
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Cardiac arrest, 31, 37, 220-221
Cardiovascular agents, 35
Center for Patient Safety (proposed), 7-8, 69-71, 75-84, 135
funding, 7-8, 70, 76, 78-79, 83-84, 106
reporting systems, 9-10, 79, 102-103, 106, 135
Centers for Disease Control and Prevention (CRC), 99, 268
Centers for Education and Research in Therapeutics (CERTS), 77-78, 83
Cerebrovascular accident, 31, 37, 220-221, 257, 263
Challenger accident, 51, 52, 55
Checklists, 158, 171, 172, 180, 187, 194
Chemotherapy, 1, 51, 260
protocols, 164, 171, 194
Children, 79, 94, 260, 268
medication, 33-34, 38, 171, 226-227, 242-245
Clinical practice guidelines, 32, 135, 145-146, 171 see also Best practices; Protocols
Cognitive processes, 147, 162-163, 181
checklists, 158, 171, 172, 180, 187, 194
cockpit resource management, 65, 72, 147, 176-177
crew resource management, 79, 97, 147, 157, 161, 162, 173, 176, 179
memory, 54, 158, 163, 170, 171, 172, 185
problem solving, 162, 163, 172, 179
simplification, 53, 60, 157, 158, 163, 164, 166, 170, 171, 172, 185, 197
vigilance, 5, 158, 164, 170, 172
see also Protocols
Colorado
hospital studies, 1, 26, 30-31, 36-37, 40, 248-249
reporting system, 92, 255-256
Commonwealth Fund, x
Communication, 7, 22, 180-181
non-health sectors, 6-7
professional societies, 12
see also Feedback; Information systems; Reporting systems
Complaints, 21
Complexity, see Systems, general
Computer systems, 77, 80, 177, 178
bar coding, 175, 188, 189, 195-196
drugs, 34, 39-40, 77, 80, 171, 172, 175, 183, 184-185, 191-193, 195
errors caused by complexity of, 61, 62-63, 65
simulation training, 65, 79, 145, 163, 176-177, 178, 179
see also Databases; Internet
Confidentiality, reporting systems
anonymous reporting, 95, 96, 100, 111, 124, 125-126
de-identification, 97, 111, 125, 126-127, 128
mandatory, 8, 10, 92, 101, 255-264 (passim)
patient data, general, 178
Privacy Act, 123
voluntary, 94, 95, 109-131, 256
Connecticut, 91, 256
Consumer Assessment of Health Plans, 20
Cost and cost-benefit factors, 29, 40-42, 248-253
ambulatory care settings, errors, 41
Center for Patient Safety (proposed), 76
drugs and drug errors, 2, 27, 30, 32, 41, 182-183, 191, 194-195, 248-253
national, 1-3, 27, 40-42
National Medical Expenditure Survey, 38, 234-235
uninsured persons, 24
see also Funding
Court cases, see Litigation
Critical incident analysis, see Human factors
Cultural factors, 4, 146
access to care, 24
organizational, culture of safety, 12-13, 14, 155-156, 159-162, 166-168, 178, 179, 189
public opinion, 2, 29, 42-43, 70, 167
see also Attitudes
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Culture of medicine, 21-22, 179
Cytotoxics, 35
D
Databases
Aviation Safety Reporting System (ASRS), 72-73, 76, 91, 95-97, 104, 105-106, 125, 127
drugs, 34, 39-40, 77, 80, 171, 172, 175, 183, 184-185, 191-193, 195
HEDIS, 20, 139, 140
National Practitioner Data Bank, 121-123
patient records, general, 177, 178, 236-239
professional organizations, 147
see also Reporting systems
Death, see Mortality
Default mode, 62, 171, 176
Definitional issues, 4, 22, 49
accident, 52, 53(n), 210
adverse drug event, 33
adverse event, 4, 28, 29, 210
classification/standardization of adverse events, 9, 10, 28-29, 88
error, 28, 54, 55, 78, 210
glossary, 210-213
hindsight bias, 53
human factors, 63, 210
iatrogenic illness, 31
misuse, 19
negligence, 217
patient safety, 57, 155, 211
pharmaceutical safety, 57
reporting systems, 88, 99
safety, general, 4, 58
systems, general, 52, 211
underuse, 19
Denmark, 240-241
Department of Defense, 72, 82
U.S. Navy, 57, 160-162
Department of Health and Human Services (DHHS)
Centers for Disease Control and Prevention, 99, 268
Health Care Financing Administration, 19-20, 82, 139, 140-141
reporting systems, 121-123
see also Agency for Health Care Research and Quality; Food and Drug Administration
Department of Labor, see Bureau of Labor Statistics
Department of Transportation, see Federal Aviation Administration; National Transportation Safety Board
Department of Veterans Affairs
National Patient Safety Partnership, 78, 81-82, 183, 191, 196
Veterans Health Administration, 80, 83, 123
Devices and equipment, 82, 184-185, 190-191, 260
affordances, 163, 171-172
default mode, 62, 171, 176
forcing functions, 158, 164, 170, 171
home care, 63
human-machine interface, 62-63, 175
infusion pumps, 50-66 (passim), 150, 171, 172, 183, 255, 257
natural mapping, 163-164, 171
outpatient care, 165
standards and standardization, 23, 62, 144, 148-151, 156, 164, 172-173, 197
see also Food and Drug Administration
Diagnostic errors, 36, 79
Diphenhydramine hydrochloride, 34
Disabilities, 1-2, 30, 220-221, 261
Drugs, 1, 221
allergic reactions, 33, 192
antibiotics, 33, 171
anticoagulants, 35
antidiarrheals, 34
anti-inflammatory drugs, 35, 253-254
Centers for Education and Research in Therapeutics, 77-78, 79
chemotherapy, 1, 51, 164, 171, 194, 260
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children, 33-34, 38, 171, 226-227, 242-245
computer tracking/databases, 34, 39-40, 77, 80, 171, 172, 175, 183, 184-185, 191-193, 195
cost of adverse effects, 2, 27, 30, 32, 41, 182-183, 191, 194-195, 248-253
errors on, 13, 14, 27, 28, 29, 32-35, 36, 37-40, 176, 182-197, 224-248
ambulatory care settings, 32-33, 34-35, 39
emergency departments, 35, 39, 238-239
hospital errors, general, 33-35, 38, 39-40, 41-42, 168, 171, 182-197, 224-253
mortality, 28, 32-33, 42, 227, 229, 233, 248-249
nursing homes, 42
surgery, 34, 40, 228-229; see also Anesthesia
see also "reporting systems" infra
infusion devices, 50-66 (passim), 150, 171, 172, 183, 193, 255, 257
Medication Errors Reporting (MER) program, 95, 97, 100, 125, 126-127, 194
MedMARx, 95, 100, 126
MedWatch, 99, 123, 148-149
mortality, 28, 32-33, 42, 227, 229, 233, 248-249
naloxone hydrochloride, 34
names of, 29, 37, 136, 148, 149, 151, 184, 231
National Patient Safety Pannership, 82
nursing homes, 42
order entry systems, 33, 40, 62, 80, 172, 175, 183, 184, 185, 188-189, 190, 191-192
organizational factors, 13, 14, 157-158, 168, 171, 172, 174, 175, 177, 182-197
packaging and labeling, 13, 64, 136, 148, 151, 185, 187, 193
bar coding, 175, 188, 189, 195-196
patient compliance, 35, 37, 39, 174, 236-237
pharmacies, 2, 27, 32, 51, 183, 186-187, 192-193
pharmacists, 2, 13, 27, 34, 39, 145, 183, 186-187, 193, 194-195, 224-225, 230-233, 236-237, 240-245
potassium chloride, 171, 187, 194
prescription writing, 33, 37-39, 54, 183, 184, 190, 231, 241
protocols, 6, 77, 92, 141, 158, 164, 171, 173, 177, 183, 186, 187, 193-194
chemotherapy, 164, 171, 194
reporting systems, 34, 93, 95, 98-99, 100
FDA, 93, 95, 98-99, 100, 104, 105, 123, 148-149
selected states, descriptions, 255, 257, 261
standards and standardization, 13, 14, 23, 29, 171, 183, 184-185, 190-191
surgery, 34, 40, 228-229; see also Anesthesia
unit dosing, 183, 184-185, 193
see also Food and Drug Administration
E
Economic factors
ambulatory care, 165
incentives, 18, 19-20, 21
market-based initiatives, 6, 17, 19-20, 21
uninsured persons, 24
worker productivity losses, 2-3
see also Cost and cost-benefit factors; Employment factors; Funding: Insurance; Purchasers
Education, see Patient education; Professional education; Public education
E.I. du Pont de Nemours and Company, 159-160
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Elderly persons, 79, 234-235, 250-251
see also Medicare; Nursing homes
Emergency departments, 36-37, 60, 79, 165
adverse drug events, 35, 39, 238-239
Employment factors
worker productivity losses, 2-3
workload, 24, 42, 60
see also Occupational health
Equipment, see Devices and equipment
Error, general
active errors, 55-56, 65-66, 181
defined, 28, 54, 55, 78, 210
latent errors, 55-56, 65, 66, 155, 181-182
national reduction goals, 7, 70, 78
near-misses, 28, 87, 96, 101, 110, 127, 160, 177, 190
pathophysiology of error, 162-163
Error analysis, 4, 10, 32, 87, 181
active errors, 55-56, 65-66, 181
critical incident analysis, 63-64
latent errors, 55-56, 65, 66, 155, 181-182
literature review, 21-22, 26-48, 205, 206, 215-253
naturalistic decision-making, 64
organizational factors, 8, 10, 166, 168
systems approach, 49, 50, 52-66
see also Reporting systems
Evidence-Based Practice Centers, 83
F
Fatigue, 24, 42, 60, 163
Fear, 22, 42, 111, 125, 127, 157, 160, 163, 167, 189
see also Punitive responses
Federal Aviation Administration, 72-73, 96, 125
Feedback, 58-59, 62, 143, 176, 177, 178, 181-182, 189
autopsies, 269
reporting systems, 90, 98, 99, 100, 105
see also Learning environment
Flight Safety Foundation, 72
Florida, 92, 115, 257
Food and Drug Administration (FDA), 13, 71, 79, 82
Centers for Education and Research in Therapeutics, 77-78, 83
MedWatch, 99, 123
Office of Post-Marketing Drug Risk Assessment (OPDRA), 149, 150
reporting systems, 93, 95, 98-99, 100, 104, 105, 123, 148-149
standards, 13, 136, 148-151
Forcing functions, 158, 164, 170, 171
Foreign countries, see specific countries
Freedom of Information Act, 123
Free flow, medication, 51-66 (passim), 171, 172
Funding, 82-83
Aviation Safety Program, 83
Aviation Safety Reporting System (ASRS), 72-73
Center for Patient Safety (proposed), 7-8, 70, 76, 78-79, 83-84, 106
NIH, 82
NIOSH, 83
organizational safety environment, 166, 168
reporting systems, 9, 10, 72-73, 88, 89, 106
study at hand, x
H
Harvard Medical Practice Study, 5, 30
Health Care Financing Administration, 19-20, 82, 139, 140-141
Health Care Quality Improvement Act, 121-122, 129
Health insurance, see Insurance
Health Insurance Portability and Accountability Act (HIPAA), 104
Health maintenance organizations (HMOs), 39, 99
Health Plan Employer Data and Information Set (HEDIS), 20, 139, 140
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Health Resources and Services Administration
National Practitioner Data Bank, 121-123
High-reliability theory, 57
High-risk industries, 5, 13, 22, 57, 60, 80, 159-162, 166 see also Aviation; National Aeronautics and Space Administration; Nuclear power industry
Hindsight bias, 53
Home care, 2, 29, 51, 254
Hospitals, 1, 26, 29, 165, 168
adverse events, 30-31, 36-37, 40-42, 216-223
drugs, 32, 33-35, 38, 39-40, 41-42, 168, 171, 182-197, 224-253
costs of adverse effects, 2, 27, 30, 248-253
licensure and accreditation, 71, 103, 137-139, 151, 152, 168, 266
Joint Commission on Accreditation of Healthcare Organizations, 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266
reporting systems described, selected states, 255-265 (passim)
occupational safety in, 168
reporting systems, 9, 87-88, 91, 105, 124, 254-265 (passim)
see also Autopsies; Emergency departments; Infections and infection control; Intensive care units; Life Safety Code; Operating rooms; Risk management
Hours of work, see Workload
Human factors, 22, 53-54, 63-66, 145, 162-166, 170-173
aviation, 72
critical incident analysis, 63-64
defined, 63, 210
fatigue, 24, 42, 60, 163
human-machine interface, 62-63, 175
infusion pumps, case study, 50-66
naturalistic decision-making, 64
vigilance, 5, 158, 164, 170, 172
see also Cognitive processes; Error, general; Error analysis; Incompetent practitioners; Organizational factors
I
Incompetent practitioners, 30, 36-37
negligent adverse events, 28, 30, 37, 114-131
organizational safety environment, 166, 169
public opinion, 42, 43
standards, 134, 142, 261
systems approach, 49
unlicensed, 261
see also Malpractice
Infections and infection control, 30, 35, 42, 165, 267-268
Infectious diseases, 267-268
Information systems, 7, 74-75, 80-81, 177-178, 180-181, 188-189, 195-196
clinical, 3
Internet, 92, 134
performance standards, 134, 138-139
role in errors, 61, 65
see also Computer systems; Confidentiality, reporting systems; Feedback; Media; Professional education; Public education; Reporting systems
Infusion pumps, 50-51, 55-66 (passim), 150, 171, 172, 183, 193, 255, 257
Institute for Healthcare Improvement, 183
Institute for Safe Medication Practices (ISMP), 95, 104
Insurance, 2, 6, 139
HMOs, 39, 99
organizational performance standards, 3, 139-141
malpractice, 164
managed care, general, 168
Medicaid, 139, 141, 142, 252-253
Medicare, 39, 128, 138, 140, 141, 142
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preferred provider organizations (PPOs), 139
uninsured persons, 24
see also Purchasers
Intensive care units, 31, 79, 105, 228-229
neonatal and pediatric, 34
Interdisciplinary approaches, 14, 135-136
practice guidelines, 145-146
professional conferences, 146
see also Teams
International perspectives, see specific countries
Internet, 206
patient care, 175, 177
reporting systems, 92, 95, 258, 259
standards, 134
J
Job design, 61, 62-63, 70, 170, 171, 172-173, 176-177
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266
K
Kansas, reporting system, 257-258
L
Labeling, see Packaging and labeling, drugs
Latent error, 55-56, 65, 66, 155, 181-182
Leadership, 69, 138, 156-157, 162, 166, 167, 168, 180-181, 197
authority gradient, 178, 180-181
committee recommendations, 6, 14, 69
see also Center for Patient Safety (proposed)
Learning environment, 8, 23, 57, 62, 166, 178-182, 197
team training, 14, 79, 156, 170, 173-174, 176-177, 179, 189, 197
see also Professional education
Legal issues, 23
negligent adverse event, 28, 30, 37
see also Confidentiality, reporting systems; Liability issues; Litigation; Malpractice
Legislation, in force
Agency for Health Care Research and Quality, 78
Freedom of Information Act, 123
Health Care Quality Improvement Act, 121-122, 129
Health Insurance Portability and Accountability Act (HIPAA), 104
model of environmental factors, 17, 18, 19, 21
Occupational Safety and Health Act, 73, 136
Privacy Act, 123
Safe Medical Device Act, 150-151
state reporting systems, 113-121, 254-265 (passim)
see also Regulatory issues
Legislation, proposed, x, 6
Center for Patient Safety (proposed), 7-8, 69-71
peer review, 10, 111
reporting, 104, 111-112, 128
Leukopenia, 34
Liability issues, 3, 10, 22, 43, 167
enterprise liability and no-fault compensation, 111
model of environmental factors, 19
see also Litigation; Malpractice
Licensure and accreditation, 19, 23, 71, 79, 133, 134, 135
organizations, 71, 103, 137-139, 151, 152, 168, 266
Joint Commission on Accreditation of Healthcare Organizations, 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266
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reporting systems described, selected states, 255-265 (passim)
professionals, 3, 10-12, 134, 141-144, 151-152
malpractice, 12, 43, 113-117, 142, 169, 262
unlicensed, 261
reporting systems, 91, 93-94, 103, 255-265 (passim)
Life Safety Code, 267
Litigation
mandatory reporting, 262
voluntary reporting, 23, 109-131
Long-term care, 209 see also Nursing homes
Louisiana, 142
M
Malpractice, 12, 43, 113-117, 142, 164, 169, 262 see also Incompetent practitioners; Litigation
Managed care, 168
HMOs, 39, 99
PPOs, 139
Massachusetts, 39, 183, 224-225, 232-233, 246-251
reporting system, 258-259
Media, 20, 43
specific incidents, 1, 3, 51
Medicaid, 139, 141, 142, 252-253
Medical devices and equipment, see Devices and equipment
Medicare, 39, 128, 138, 140, 141, 142
Medication and medication safety, see Drugs
Medication Errors Reporting (MER) program, 95, 97, 100, 125, 126-127, 194
MedMARx, 95, 100, 126
MedWatch, 99, 123, 148-149
Memory, 54, 158, 163, 170, 171, 172, 185
checklists, 158, 171, 172, 180, 187, 194
simplification, 53, 60, 157, 158, 163, 164, 166, 170, 171, 172, 185, 197
see also Protocols
Mississippi, reporting system, 259
Models and modeling
environmental influences on quality, 17-21
reporting hierarchy, 101
Mortality, x, 30, 31-32, 37, 221-223, 248-249, 269
airline fatality rates, 5
anesthesia, 164, 222-225
drug errors, 28, 32-33, 42, 227, 229, 233, 248-249
infectious disease, 267-268
national, 1-2, 26, 27, 31, 248-249
reporting systems, 93, 96, 98, 101, 257, 258, 260, 262, 264
suicide, 35, 94, 257, 260, 262
Motivation, see Attitudes
Multidisciplinary approaches, see Interdisciplinary approaches
N
Naloxone hydrochloride, 34
National Academy for State Health Policy, x, 92-93
National Aeronautics and Space Administration, 72, 96
Ames Research Center, 65, 73
Aviation Safety Reporting System (ASRS), 72-73, 76, 91, 95-97, 104, 105-106, 125, 127
Challenger accident, 51, 52, 55
National Cancer Policy Board, 209
National Committee for Quality Assurance, 20, 138, 139
National Coordinating Council for Medication Error Reporting and Prevention, 183
National Fire Prevention Association, 267
National Forum for Health Care Quality Measurement and Reporting, 9, 10, 88, 89, 101, 103-104
National Institute for Occupational Safety and Health (NIOSH), 73, 74, 82
National Institute of Standards and Technology, 178
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National Institutes of Health (NIH), 74, 77
National Medical Expenditure Survey, 38, 234-235
National Occupational Research Agenda, 74
National Patient Safety Foundation, 6, 57, 70, 71, 76, 81, 147, 193
National Patient Safety Partnership, 78, 81-82, 183, 191, 196
National Practitioner Data Bank, 121-123
National Roundtable on Health Care Quality, 208-209
National Transportation Safety Board, 72, 76, 96
Naturalistic decision-making, 64
Natural mapping, 163-164, 171
Navy, see U.S. Navy
Near-misses, 28, 87, 96, 101, 110, 127, 160, 177, 190; see also Errors, general
New Jersey, reporting system, 260
New York State
hospital studies, 1, 26, 30, 220-221, 238-239
outpatient surgery, 165
reporting system, 92, 124, 260-261
Norman, Donald, 163
Nuclear power industry, 60
Three Mile Island, 51, 52, 55
Nurses
error studies, 216-217, 228-229, 232-237, 243-245
infusion pumps, 50-51, 56
organizational accreditation, 138
professional accreditation, 143-144
reporting, 34, 256
Nursing homes, 2, 91, 209, 250-251, 254, 256
drug errors, 42
O
Occupational health, 6-7, 24, 27, 73-74, 80, 159-162, 168
HEDIS, 20, 139, 140
National Occupational Research Agenda, 74
NIOSH, 73, 74, 82
patient safety and, 155-156
worker productivity losses, 2-3
workload, 24, 42, 60
Occupational Safety and Health Act, 73, 136
Occupational Safety and Health Administration, 73-74, 76, 90, 91, 97-98
Office of Post-Marketing Drug Risk Assessment (OPDRA), 149, 150
Ohio, 261-262
Oklahoma, 128
Operating rooms, 31, 36, 50, 52, 56, 79, 157
Order entry systems, 33, 40, 62, 80, 172, 175, 183, 184-185, 188-189, 190, 191-192
Organizational factors, 3, 6-7, 13-14, 17, 22, 23, 60, 155-201, 266-271
access to health care, 24
accountability, 8, 13, 101, 166, 167, 168, 205
authority gradient, 178, 180-181
culture of medicine, 21-22, 179
culture of safety, 12-13, 14, 155-156, 159-162, 166-168, 178, 179, 189
design for recovery, 176-177
drugs, 13, 14, 157-158, 168, 171, 172, 174, 175, 177, 182-197
error analysis, 8, 10, 166, 168
high reliability theory, 57
job design, 61, 62-63, 70, 170, 171, 172-173, 176-177
licensure and accreditation, 71, 103, 137-139, 151, 152, 168, 266
Joint Commission on Accreditation of Healthcare Organizations, 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266
reporting systems described, selected states, 255-265 (passim)
peer review, 10, 111, 112, 119-121, 126-128, 140-141, 143, 234-235, 263-264
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performance standards, 3, 14, 23, 132-134, 136-141, 143-144, 157, 162, 166, 172-173, 254-265
professional organizations, 6, 12, 20, 79, 135-136, 144-148, 152, 167, 181, 183-184; see also specific organizations
reporting systems, 9, 87-88, 91, 105, 124, 156, 160, 166, 254-265
staffing, 138, 165, 166, 167, 170, 172, 175-176, 190
see also Center for Patient Safety (proposed); Interdisciplinary approaches; Leadership; Staffing; Systems, general; Teams
Oryx system, 138-139
Outpatient treatment, see Ambulatory health care settings
P
Packaging and labeling, drugs, 13, 64, 136, 148, 151, 185, 187, 193
bar coding, 175, 188, 189, 195-196
see also Food and Drug Administration
Pathophysiology of error, 162-163
Patient education, 183, 188-189, 196-197
Patient safety, definition of, 57, 155, 211
Patients, role in reducing errors, 174
drug therapy, 35, 37, 39, 174, 236-237
Peer review, 234-235
organizations, 140-141
professional performance standards, 143; see also American Medical Accreditation Program Association
reporting systems, 10, 111, 112, 119-121, 126-128, 263-264
Pennsylvania, 262-263
Perrow, Charles, 51-52, 57, 60
Pew Health Professions Commission, 144
Pharmaceuticals, see Drugs
Pharmacies, 2, 27, 32, 51, 183, 186-187, 192-193
Pharmacists, 2, 13, 27, 39, 145, 183, 186-187, 193, 194-195, 224-225, 230-233, 236-237, 240-245
reporting, 34
Physician order entry, see Order entry systems
Physicians Desk Reference, 177
Phytonadione, 34
Pneumonia, 31, 220-221
Point-of-service plans, 139
Potassium chloride, 171, 187, 194
Practice guidelines, see Clinical practice guidelines
Preferred provider organizations (PPOs), 139
Prescription writing, 33, 37-39, 54, 183, 184, 190, 231, 241
Preventable adverse events, 4, 5, 7, 35-37, 39, 41, 182, 191
children, 34
defined, 28
studies of, 1-2, 26, 27, 30-31, 216-225, 228-229, 234-237, 246-249
Preventive interventions
design for recovery, 176-177
errors in, 36
Privacy, see Confidentiality, reporting systems
Privacy Act, 123
Problem solving, 162, 163, 172, 179
simplification, 53, 60, 157, 158, 163, 164, 166, 170, 171, 172, 185, 197
Professional education, 12, 15, 57, 60, 134, 146-147, 161
ambulatory care, 165
Center for Patient Safety (proposed), 70, 76, 79, 82
culture of medicine, 179
curricula on patient safety, 12, 134, 146-147
National Patient Safety Foundation, 71
reporting systems, 99
simulation training, 65, 79, 145, 163, 176-177, 178, 179
standards, 12, 142-143
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team training, 14, 79, 146, 156, 170, 173-174, 176-177, 179, 189, 197
see also Feedback; Learning environment; Licensure and accreditation
Professional organizations, 6, 12, 20, 79, 135-136, 144-148, 152, 167, 181, 183-184 see also specific organizations
Protocols, 6, 77, 92, 141, 158, 171, 173, 177, 183, 186, 187, 193-194
checklists, 158, 171, 172, 180, 187, 194
chemotherapy, 164, 171, 194
clinical practice guidelines, 32, 135, 145-146, 171
Public education, 15
Center for Patient Safety (proposed), 70, 76, 79, 82
committee mission, xi, 205
patient education, 183, 188-189, 196-197
see also Media
Public opinion, 2, 29, 42-43, 70, 167
Punitive responses, 56, 157, 180, 197
Purchasers, 2, 3, 6, 11, 19-20, 23, 79, 152, 167, 206
organizational performance standards, 3, 139-141
reporting systems, 89
see also Health Care Financing Administration; Insurance
Q
Quality Improvement Organizations (QIOs), 123; see also Peer review, organizations
Quality Interagency Coordinating Committee, 78
R
Reason, James, 4, 52, 54, 58, 60, 162
Redundancy, 57, 60, 158, 161-162
Regulatory issues, x, 6, 17, 18, 75
committee recommendations, 10-11
mandatory reporting systems, 6, 8, 9, 10, 79, 86, 87-88, 90, 91-93, 97-98, 102-104, 166
confidentiality, 8, 10, 92, 101, 255-264 (passim)
descriptions, selected states, 255-265
model of environmental factors, 17, 18, 19, 20-21
see also Food and Drug Administration; Licensure and accreditation; Standards and standardization
Reporting systems, 8-9, 14, 22-23, 32, 86-131, 270
ambulatory care settings, 88, 257
anesthesia errors, 255, 256, 258
Aviation Safety Reporting System (ASRS), 72-73, 76, 91, 95-97, 104, 105-106, 125, 127
autopsies, 269
best practices, 9, 88, 93, 102-103
Center for Patient Safety (proposed), 9-10, 79, 102-103, 106, 135
confidentiality, 8, 10, 92, 94, 95, 96, 97, 100, 101, 109-131
anonymous reporting, 95, 96, 100, 111, 124, 125-126
de-identification, 97, 111, 125, 126-127, 128
descriptions, selected states, 255-265 (passim)
mandatory systems, 8, 10, 92, 101, 255-264 (passim)
voluntary systems, 94, 95, 109-131, 256
DHHS, 9, 73-74, 88, 121-123
drug errors, 34, 93, 95, 98-99, 100
FDA, 93, 95, 98-99, 100, 104, 105, 123, 148-149
selected states, descriptions, 255, 257, 261
external, 8, 91-93
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feedback, 90, 98, 99, 100, 105
Internet, 92, 95, 258, 259
JCAHO, 91, 93-94, 104-105, 116, 125, 128
legislation,
in force, 113-121, 254-265 (passim)
proposed, 104, 111-112, 128
licensure and accreditation, 91, 93-94, 103, 255-265 (passim)
mandatory, 6, 8, 9, 10, 79, 86, 87-88, 90, 91-93, 97-98, 102-104, 166
confidentiality, 8, 10, 92, 101, 255-264 (passim)
descriptions, selected states, 255-265
Medication Errors Reporting (MER) program, 95, 97, 100, 125, 126-127, 194
MedMARx, 95, 100, 126
MedWatch, 99, 123, 148-149
mortality, 93, 96, 98, 101, 257, 258, 260, 262, 264
National Forum for Health Care Quality Measurement and Reporting, 9, 10, 88, 89, 101, 103-104
National Practitioner Data Bank, 121-123
nationwide, 9, 10, 87-88, 89, 101, 103-106, 121-123
near misses, 87, 96, 101, 110, 127, 160
nurses, 34, 256
occupational health, 73-74
organizational factors, 9, 87-88, 91, 105, 124, 156, 160, 166, 254-265
peer review, 10, 111, 112, 119-121, 126-127
punitive responses for reporting failures, 255, 258
sentinel events, 93-94, 104-105, 119-120, 125, 128, 194
standards and standardization, 9, 28-29, 73, 88-89, 99, 101-102, 104
state reporting systems, 254-265
surgery, 257, 263
voluntary, 8, 9-10, 23, 41-42, 79, 87, 89-90, 93-97, 98, 99, 102, 104-106, 178, 179-180, 182, 188-189
confidentiality, 94, 95, 109-131, 256
litigation, 23, 109-131
Rhode Island, reporting system, 263-264
Risk management, general, 57, 58-59, 112, 137, 149, 270 see also High-risk industries
S
Safe Medical Device Act, 150-151
Sentinel events, 93-94, 104-105, 119-120, 125, 128, 194
Simplification, 53, 60, 157, 158, 163, 164, 166, 170, 171, 172, 185, 197 see also Protocols
Simulation training, 65, 79, 145, 163, 176-177, 178, 179
Software, see Computer systems
South Dakota, reporting system, 264-265
Special Initiative on Health Care Quality, 208
Specialists and specialization, 3, 12, 20, 36, 58-59, 80, 142-143, 146, 148, 173 see also Anesthesia; Emergency departments; Intensive care units; Surgery; Teams
Staffing, 138, 166, 167, 170, 172, 175-176, 190
ambulatory care, 165
Standards and standardization, 6, 9
adverse events taxonomies, 9, 10, 28-29, 88
best practices, 9, 18, 32, 77, 79, 88, 93, 102-103, 145, 152, 182, 193
design for recovery, 176
devices and equipment, 23, 62, 144, 148-151, 156, 164, 172-173, 197
drugs, 13, 14, 23, 29, 171, 183, 184-185, 190-191
environmental influences model, 19
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information systems, 134, 138-139
insurance, organizational performance, 3, 139-141
Life Safety Code, 267
organizational, 3, 14, 23, 132-134, 136-141, 143-144, 157, 162, 166, 172-173, 254-265
patient records, 178
performance, 10-12, 132-154
professional, 23, 132, 133, 134-136, 141-148
professional education, 12, 142-143
reporting systems, 9, 28-29, 73, 88-89, 99, 101-102, 104
classification/standardization of, 9, 10, 28-29, 88
see also Clinical practice guidelines; Food and Drug Administration; Licensure and accreditation; Protocols
State government, x, 5
hospital studies, 1, 26, 30-31, 36-37, 40, 238-239, 248-249
reporting systems, 9, 79, 87-88, 91-93, 94, 102-103, 111, 113-114, 118, 119, 123, 124, 126-127
descriptions, selected states, 254-265
see also Licensure and accreditation; specific states
State-level data, 1, 26, 30-31, 36-37, 40 see also specific states
Suicide, 35, 94, 257, 260, 262
Surgery, 2, 35, 79, 218-219, 232-233, 269, 270
complexity, 36
drug errors, 34, 40, 228-229; see also Anesthesia
infusion pumps, 50-66 (passim), 150, 171, 172
operating rooms, 31, 36, 50, 52, 56, 79, 157
outpatient, 2, 165
postsurgical complications, 31-32
reporting systems, 257, 263
Switzerland, 177
Systems, general, 49, 50, 56-66, 71, 157, 158, 188-189, 190
aviation, 71-72
complex systems, 2, 36, 39, 53, 58-60, 61, 62-63, 65, 182-183
critical incident analysis, 63-64
defined, 52, 211
drugs, 182-183
redundancy, 57, 60, 158, 161-162
tightly coupled systems, 58-60, 161, 179
see also Error analysis; Feedback; Models and modeling; Organizational factors; Teams
T
Teams
crew resource management, 79, 97, 147, 157, 161, 162, 173, 176, 179
patient as part of, 174
risk management, 270
technology as part of, 62-63
training in, 14, 79, 156, 170, 173-174, 176-177, 179, 189, 197
working in, 37, 50, 51, 56-57, 59, 60, 62-63, 64, 146-147, 166, 170, 197
Technological factors, 61-62, 80, 144, 159
anticipating new errors, 174-175
complexity, 36, 61, 62-63, 65
human-machine interface, 62-63, 175
professional licensing and, 135
protocols, updating of, 171
see also Computer systems; Devices and equipment; High-risk industries; Information systems
Texas, 126-127
Three Mile Island, 51, 52, 55
Tiger teams, 175
Time-series measures, 182 see also Benchmarking
Training, see Professional education
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U
Unit dosing, 183, 184-185, 193
United Kingdom, 32, 38-39, 226-227, 244-245
University of Southern California, 72
User-centered design, 62, 78, 89, 150, 159, 163, 164, 171, 192
User Liaison Program, 78
U.S. Navy, 160-162
U.S. Pharmacopeia, 95, 104, 194
Medication Errors Reporting (MER) program, 95, 97, 100, 125, 126-127, 194
Utah, hospital studies, 1, 26, 30-31, 36-37, 40, 238-239, 248-249
V
Veterans Health Administration, 80, 83, 123
Vigilance, 5, 158, 164, 170, 172
Virginia, 142
W
Workload, 24, 42, 60
World Wide Web, see Internet
Wristbands, 177, 195
Y
Y2K issues, 82
Representative terms from entire chapter:
national patient
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