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Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

Suggested Citation:"Index." Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. doi: 10.17226/9728.
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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

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To Err Is Human: Building a Safer Health System Get This Book
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Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.

To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.

This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes.

Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?"

Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care.

To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves.

First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

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