Patient Safety: Achieving a New Standard for Care
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THE NATIONAL ACADEMIES PRESS This PDF is available at http://nap.edu/10863 SHARE Patient Safety: Achieving a New Standard for Care DETAILS 550 pages | 6 x 9 | HARDBACK ISBN 978-0-309-09077-3 | DOI 10.17226/10863 AUTHORS BUY THIS BOOK Philip Aspden, Janet M. Corrigan, Julie Wolcott, Shari M. Erickson, Editors, Committee on Data Standards for Patient Safety FIND RELATED TITLES Visit the National Academies Press at NAP.edu and login or register to get: – Access to free PDF downloads of thousands of scientific reports – 10% off the price of print titles – Email or social media notifications of new titles related to your interests – Special offers and discounts Distribution, posting, or copying of this PDF is strictly prohibited without written permission of the National Academies Press. (Request Permission) Unless otherwise indicated, all materials in this PDF are copyrighted by the National Academy of Sciences. Copyright © National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care PATIENT SAFETY ACHIEVING A NEW STANDARD FOR CARE Committee on Data Standards for Patient Safety Board on Health Care Services Philip Aspden, Janet M. Corrigan, Julie Wolcott, and Shari M. Erickson, Editors Copyright National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 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 Na- tional Academy of Sciences, the National Academy of Engineering, and the Institute of Medi- cine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. 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. Library of Congress Cataloging-in-Publication Data Patient safety : achieving a new standard for care / Committee on Data Standards for Patient Safety, Board on Health Care Services ; Philip Aspden ... [et al.], editors. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09077-6 (hardcover) 1. Medical records—Standards—United States. 2. Medical informatics. 3. Medical errors— Data processing—Standards—United States. [DNLM: 1. Medical Errors—prevention & control—United States. 2. Health Policy— United States. 3. Information Services—standards—United States. 4. Patient Care—stan- dards—United States. 5. Policy Making—United States. 6. Risk Management—United States. 7. Safety Management—United States. WB 100 P2975 2004] I. Aspden, Philip. II. Institute of Medicine (U.S.). Committee on Data Standards for Patient Safety. R864.P38 2004 651.5′04261—dc22 2004001869 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museum in Berlin. Copyright National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Adviser to the Nation to Improve Health Copyright National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distin- guished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is au- tonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the fed- eral government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering com- munities. The Council is administered jointly by both Academies and the Institute of Medi- cine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. ww.national-academies.org Copyright National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care COMMITTEE ON DATA STANDARDS FOR PATIENT SAFETY PAUL C. TANG (Chair), Chief Medical Information Officer, Palo Alto Medical Foundation, and Associate Clinical Professor, University of California, San Francisco MOLLY JOEL COYE (Vice-Chair), CEO, Health Technology Center SUZANNE BAKKEN, Alumni Professor of Nursing and Professor of Biomedical Informatics, Columbia University E. ANDREW BALAS, Dean, School of Public Health, Saint Louis University DAVID W. BATES, Chief, Division of General Medicine, Brigham & Women’s Hospital; Medical Director of Clinical and Quality Analysis, Partners Healthcare System; and Associate Professor of Medicine, Harvard Medical School JOHN R. CLARKE, Professor of Surgery, Drexel University, and Adjunct Professor of Computer and Information Science, University of Pennsylvania DAVID C. CLASSEN, Vice President, First Consulting Group, and Associate Professor of Medicine, University of Utah SIMON P. COHN, National Director of Health Information Policy, Kaiser Permanente CAROL CRONIN, Consumer Health Information Consultant JONATHAN S. EINBINDER, Assistant Professor, Harvard Medical School, and Corporate Manager, Partners Health Care Information Systems LARRY D. GRANDIA, Executive Vice President and Chief Technology Officer, Premier, Inc. W. ED HAMMOND, Professor, Division of Medical Informatics, Duke University BRENT C. JAMES, Executive Director, Intermountain Health Care Institute for Health Care Delivery Research, and Vice President for Medical Research, Intermountain Health Care KEVIN B. JOHNSON, Associate Professor and Vice Chair, Department of Biomedical Informatics, and Associate Professor, Department of Pediatrics, Vanderbilt University JILL ROSENTHAL, Project Manager, National Academy for State Health Policy TJERK W. van der SCHAAF, Associate Professor of Human Factors in Risk Control, Eindhoven University of Technology, Eindhoven Safety Management Group, Department of Technology Management v Copyright National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care Study Staff PHILIP ASPDEN, Study Director JULIE WOLCOTT, Program Officer SHARI ERICKSON, Research Associate DANITZA VALDIVIA, Senior Project Assistant REBECCA BENSON, Senior Project Assistant Health Care Services Board JANET M. CORRIGAN, Director ANTHONY BURTON, Administrative Assistant Editorial Consultants RONA BRIERE, Briere Associates, Inc. ALISA DECATUR, Briere Associates, Inc. vi Copyright National Academy of Sciences. All rights reserved. Patient Safety: Achieving a New Standard for Care Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s Report Review Commit- tee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report