Americans should be able to count on receiving health care that is safe.

To achieve this, a new health care delivery system is needed — a system that both prevents errors from occurring, and learns from them when they do occur. The development of such a system requires a commitment by all stakeholders to a culture of safety and to the development of improved information systems for the delivery of health care. This national health information infrastructure is needed to provide immediate access to complete patient information and decision-support tools for clinicians and their patients. In addition, this infrastructure must capture patient safety information as a by-product of care and use this information to design even safer delivery systems. Health data standards are both a critical and time-sensitive building block of the national health information infrastructure.

Building on the Institute of Medicine reports To Err Is Human and Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.

Contents

• THE NATIONAL ACADEMIES
• COMMITTEE ON DATA STANDARDS FOR PATIENT SAFETY
• Reviewers
• Preface
• Foreword
• Acknowledgments
• Executive Summary
• 1. Introduction
  • MAGNITUDE OF THE PROBLEM
  • RESPONSE TO TO ERR IS HUMAN
  • THE IMPORTANCE OF INFORMATION TECHNOLOGY IN DESIGNING A SAFER HEALTH CARE SYSTEM
  • STUDY CONTEXT
  • CHARGE TO THE COMMITTEE
  • OVERVIEW OF THE REPORT
  • REFERENCES
• Part I. Building the National Health Information Infrastructure
  • COMPONENTS OF A NATIONAL HEALTH INFORMATION INFRASTRUCTURE
  • A PUBLIC AND PRIVATE PARTNERSHIP TO SET STANDARDS
  • AN AGENDA FOR DATA STANDARDS
  • REFERENCES
  • 2. Components of a National Health Information Infrastructure
    • CHAPTER SUMMARY
    • GENERAL OVERVIEW
    • CONCEPTUAL MODEL OF STANDARDS-BASED, INTEGRATED DATA SYSTEMS TO SUPPORT PATIENT SAFETY
    • TECHNICAL CONSIDERATIONS: INFORMATICS COMPONENTS OF THE INFORMATION INFRASTRUCTURE
    • IMPLEMENTING THE SYSTEMS
    • PRACTICAL APPROACHES TO MOVING FORWARD WITH STANDARDS-BASED DATA SYSTEMS
    • OVERCOMING CHALLENGES TO IMPLEMENTATION OF INFORMATION TECHNOLOGY FOR THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE
    • CONCLUSIONS
    • REFERENCES
  • 3. Federal Leadership and Public–Private Partnerships
    • CHAPTER SUMMARY
    • CURRENT STANDARDS-SETTING PROCESSING
    • CURRENT STANDARDS ACTIVITIES IN THE FEDERAL AND PRIVATE SECTORS
    • NEED FOR MORE FORMALIZED LEADERSHIP
    • REFERENCES
  • 4. Health Care Data Standards
    • CHAPTER SUMMARY
    • OVERVIEW OF HEALTH CARE DATA STANDARDS
    • TECHNICAL REVIEW OF HEALTH CARE DATA STANDARDS
    • REFERENCES
• Part II. Establishing Comprehensive Patient Safety Programs
  • ESTABLISHMENT OF COMPREHENSIVE PATIENT SAFETY PROGRAMS
  • ADVERSE EVENT ANALYSIS
  • NEAR-MISS ANALYSIS
  • REFERENCES
  • 5. Comprehensive Patient Safety Programs in Health Care Settings
    • CHAPTER SUMMARY
    • A CULTURE OF SAFETY
    • A MODEL FOR INTRODUCING SAFER CARE
    • TWO CASE STUDIES
    • APPLIED RESEARCH AGENDA
    • REFERENCES
  • 6. Adverse Event Analysis
    • CHAPTER SUMMARY
    • INTRODUCTION
    • DETECTION OF ADVERSE EVENTS: MULTIPLE APPROACHES REQUIRING A BROAD SET OF DATA ELEMENTS
    • ANALYSIS OF ADVERSE EVENT SYSTEMS
    • FUTURE VISION
    • REFERENCES
  • 7. Near-Miss Analysis
    • CHAPTER SUMMARY
    • THE IMPORTANCE OF NEAR-MISS REPORTING AND ANALYSIS
    • FUNDAMENTAL ASPECTS OF NEAR-MISS SYSTEMS
    • FUNCTIONAL REQUIREMENTS OF NEAR-MISS SYSTEMS
    • IMPLEMENTATION AND OPERATIONAL CONSIDERATIONS
    • GENERAL FRAMEWORK FOR PROCESSING NEAR-MISS REPORTS
    • GAPS BETWEEN IDEAL AND CURRENT SYSTEMS
    • IMPLICATIONS FOR DATA STANDARDS
    • REFERENCES
• Part III. Streamlining Patient Safety Reporting
  • PATIENT SAFETY DATA APPLICATIONS
  • STANDARDIZED REPORTING
  • REFERENCES
  • 8. Patient Safety Reporting Systems and Applications
    • CHAPTER SUMMARY
    • THE CONTINUUM OF APPLICATIONS
    • ACCOUNTABILITY VERSUS LEARNING: UNDERSTANDING THE CONTINUUM
    • THE NEED TO INVEST MORE RESOURCES IN LEARNING APPROACHES
    • REFERENCES
  • 9. Standardized Reporting
    • CHAPTER SUMMARY
    • THE NEED FOR A STANDARDIZED REPORT FORMAT
    • ESSENTIAL ELEMENTS OF A STANDARDIZED REPORT FORMAT
    • IMPLEMENTATION OF THE REPORT FORMAT
    • DE-IDENTIFICATION AND DATA PROTECTION
    • PRIMARY AND SECONDARY USES OF REPORT DATA
    • CONCLUSIONS
    • REFERENCES
• Appendixes
  • A Biographies of Committee Members
  • B Glossary and Acronym List
  • C Examples of Federal, State, and Private-Sector Reporting Systems
  • D Clinical Domains for Patient Safety
  • E Key Capabilities of an Electronic Health Record System: Letter Report
  • F Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel
  • G Australian Incident Monitoring System Taxonomy

Support for this project was provided by the Agency for Healthcare Research and Quality (AHRQ). The views presented in this report are those of the Institute of Medicine Committee on Data Standards for Patient Safety and are not necessarily those of the funding agencies.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.