ABSTRACT
If done well, proactive risk assessment methods can be effective in identifying and managing risks and still be efficient and rewarding for the participants. However, they can also fail, which suggests the potential usefulness of risk assessing the risk assessment process.
Subject(s)
Delivery of Health Care/organization & administration , Humans , Risk AssessmentABSTRACT
A consortium of organization identified solutions to the problem of enteral feeding misconnections in three areas: (1) education, awareness, and human factors; (2) purchasing strategies; and (3) design changes.
Subject(s)
Enteral Nutrition/instrumentation , Intubation/instrumentation , Medical Errors/methods , Medical Errors/prevention & control , Quality Assurance, Health Care/organization & administration , Enteral Nutrition/adverse effects , Equipment Design , Humans , Intubation/adverse effectsSubject(s)
Accreditation/standards , Continuity of Patient Care/standards , Interdisciplinary Communication , Joint Commission on Accreditation of Healthcare Organizations , Patient Care Team/standards , Safety Management/standards , Guidelines as Topic , Humans , Medical Errors/prevention & control , United StatesABSTRACT
BACKGROUND: The current US national discussions on patient safety are not based on a common language. This hinders systematic application of data obtained from incident reports, and learning from near misses and adverse events. OBJECTIVE: To develop a common terminology and classification schema (taxonomy) for collecting and organizing patient safety data. METHODS: The project comprised a systematic literature review; evaluation of existing patient safety terminologies and classifications, and identification of those that should be included in the core set of a standardized taxonomy; assessment of the taxonomy's face and content validity; the gathering of input from patient safety stakeholders in multiple disciplines; and a preliminary study of the taxonomy's comparative reliability. RESULTS: Elements (terms) and structures (data fields) from existing classification schemes and reporting systems could be grouped into five complementary root nodes or primary classifications: impact, type, domain, cause, and prevention and mitigation. The root nodes were then divided into 21 subclassifications which in turn are subdivided into more than 200 coded categories and an indefinite number of uncoded text fields to capture narrative information. An earlier version of the taxonomy (n = 111 coded categories) demonstrated acceptable comparability with the categorized data requirements of the ICU safety reporting system. CONCLUSIONS: The results suggest that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Patient Safety Event Taxonomy could facilitate a common approach for patient safety information systems. Having access to standardized data would make it easier to file patient safety event reports and to conduct root cause analyses in a consistent fashion.
