standardizing a patient safety taxonomy: a consensus report.

There is consensus that standardization of patient safety data would facilitate improvements in incident reporting, tracking, and analysis [ 7, 8 ]. The core set of terms in patient safety, like other health disciplines, should incorporate both theoretical concepts and generally accepted vocabulary.

Full Answer

What is a taxonomy in healthcare?

The concept of a taxonomy combines terminology and the science of classification—in the case of patient safety, the identification and classification of things that go wrong in health care, the reasons why they occur, and the preventive strategies that can minimize their future occurrence.

What is the patient safety event taxonomy?

The Patient Safety Event Taxonomy developed and tested in this study represents a synthesis of traditional, hierarchical classifications represented by single topic areas and settings and the heuristic, multidimensional/multisetting classifications that rely on a systems approach to understanding patient safety [ 38 ].

What are the limitations of standardization in healthcare?

Failure to link the lack of standardization with the occurrence of errors and patient harm, High reliance on human vigilance rather than investing in technological innovations that improve the safety of high-risk processes, Lack of appropriate training for those expected to follow standardized processes,

Why is it so difficult to standardize patient safety data?

Among reporting systems, there are often disparate data fields, conflicting patient safety terminologies, classifications, characteristics, and uses that make standardization difficult. In addition, each source of data on near misses and adverse events usually requires different methods for interpreting and deconstructing these events [ 3 ].

What is Patient Safety Event Taxonomy?

The taxonomy, which has been widely accepted since its publication, consists of 5 primary classifications that can be used to classify an error: impact, type, domain, cause, and prevention or mitigation.

How is patient safety impacted by standardizing methods?

From a healthcare manager's perspective, standardization helps foster an environment of quality patient care. Standardization, especially in healthcare, minimizes the risk of errors, increases patient safety, and can actually improve the patient experience.

Why is it important that health professionals share a common understanding of patient safety standards and practices?

It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events. Patient safety is fundamental to delivering quality essential health services.

What are the NQF 34 safe practices?

There are practices aimed at: leadership and teamwork; preventing illness and infections; creating and sustaining a culture of safety; matching care needs to service capability; improving information transfer and communication; improving medication management; healthcare associated infections; and specific care ...

What is an example of standardization in healthcare?

For example, we have standard practices and protocols we follow for hand hygiene, infection control, blood transfusions, and surgical sterilization. We have standardized tools to assess patients for falls or pressure ulcers. We would consider deviation from these standards unacceptable.

Why is standardization necessary?

Standardization brings innovation and spreads knowledge Standardization also brings innovation, first because it provides structured methods and reliable data that save time in the innovation process and, second, because it makes it easier to disseminate groundbreaking ideas and knowledge about leading edge techniques.

What are three of the universal guidelines for patient safety?

The Universal Protocol provides guidance for health care professionals. It consists of three key steps: conducting a pre-procedure verification process, marking the procedure site, and performing a time-out.

What are the key elements of patient safety?

The key elements of a culture of safety include (1) a shared belief that although health care is a high-risk undertaking, delivery processes can be designed to prevent failures and harm to participants; (2) an organizational commitment to detecting and analyzing patient injuries and near misses; and (3) an environment ...

How can you improve patient safety and quality?

5 Patient-Centered Strategies to Improve Patient SafetyAllow patients access to EHR data, clinician notes. ... Care for hospital environment. ... Create a safe patient experience. ... Create simple and timely appointment scheduling. ... Encourage family and caregiver engagement.

What are the key principles of TeamSTEPPS?

TeamSTEPPS has five key principles. It is based on team structure and four teachable-learnable skills: Communication, Leadership, Situation Monitoring, Mutual Support. The arrows depict a two-way dynamic interplay between the four skills and the team-related outcomes.

Which issue does the National Quality Forum NQF list of safe practices address?

NQF's mission is to improve the quality of healthcare. Patient safety is central to achieving our mission. We know that reducing harm and preventable medical errors saves lives and lowers healthcare costs, a goal shared by everyone that touches the healthcare system.

What are two of the five rights of clinical decision support?

By defining a set of goals and objectives for the development of a CDS intervention, a practice can make use of the five rights to determine the what (information), who (recipient), how (intervention), where (format), and when (workflow) for a proposed intervention.

What is the patient safety event taxonomy?

The Patient Safety Event Taxonomy developed and tested in this study represents a synthesis of traditional, hierarchical classifications represented by single topic areas and settings and the heuristic, multidimensional/multisetting classifications that rely on a systems approach to understanding patient safety [ 38 ]. It includes all events that are not due to an underlying physiological or pathological process and is sensitive to minor variations among similar events. This approach compels the user to make explicit, a priori decisions about the key variations in structure and process that relate to any given patient safety event. It also allows others to judge whether important variables were overlooked. Finally, it makes explicit the relationships between these variables and their relevance as valid markers of patient safety.

What is the Joint Commission Patient Safety Event Taxonomy?

The Joint Commission Patient Safety Event Taxonomy focuses on the most salient terminologies and classifications. Its design will permit the progressive incorporation of new patient safety data and information over time. However, additional field-testing will be required to bring the taxonomy to full maturity and permit it to realize its overall objectives.

What are some examples of health care error classification systems?

Health care error classification systems are not free of their own problems. For example, they partition categories more coarsely than do keywords, and users, who are accustomed to the everyday colloquial language of patient safety used in the workplace environment, may not be fluent in the terminology of the classifications. The finite number of elements in the Taxonomy nevertheless encompasses a broad range of areas that could possibly be classified, but there are still likely many areas that could escape detection and reporting. Furthermore, because the anatomy of an event is multidimensional, its deconstructed components may not be mutually exclusive to each of the classifications, subclassifications, coded categories, and narrative fields in the taxonomy. In addition, the multi-tiered features may be too complicated for some audiences to use. For example, wrong-site surgery not only results in physical harm, but may also affect the emotional (psychological) and functional status of the patient, and his or her ability to return to work (economics). Near misses in the taxonomy are assumed to have the same root causes as the much smaller subset that actually develops into adverse events. Arguably, the very advantage of using near-miss data to provide information on how an incident ‘recovered’ from a potential adverse event also has a downside. Adverse events are by definition near misses that failed to be recovered in time [ 43 ]. By contrast, the events that a hospital successfully prevents from occurring will be just those events that will never be identified in a near-miss information system. Thus, the Taxonomy must be clear on just what near misses have in common, or not, with adverse events. Notwithstanding the potential limitations of near-miss data, near misses are sufficiently clear precursors of adverse events to point the way to identification of specific individual and systems failures.

What is the concept of taxonomy?

The concept of a taxonomy combines terminology and the science of classification— in the case of patient safety, the identification and classification of things that go wrong in health care, the reasons why they occur, and the preventive strategies that can minimize their future occurrence.

Is patient safety based on a common language?

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.

Why is standardization important in health care?

Standardization better enables investigators to compare data and to interpret the relevance and efficacy of an intervention; Through standardization health care workers are able to relate to one another in meaningful ways (including the standardization of terms used);

What is patient safety?

Patient safety is a fundamental principle of excellent patient care and a critical component of health care quality management. Execution of this principle is often perceived as being an individual responsibility of health care practitioners and is often not translated into health care process and system design.

What are some examples of standardization?

Standardization in non-health care industries. The most commonly referenced examples of standardization are among ‘high reliability’ organizations and in other safety critical industrie s. High reliability organizations have well-ingrained safety cultures and standardized management approaches toward risk.

Is process standardization in healthcare a success?

Despite its success in other industries, process standardization in health care has been slow to gain traction or to demonstrate a positive impact on the safety of care.

What are the practices considered to have sufficient evidence to include in the category of patient safety practices?

Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows:12. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.

What is the most important contribution of nursing to patient safety?

The most critical contribution of nursing to patient safety, in any setting, is the ability to coordinate and integrate the multiple aspects of quality within the care directly provided by nursing, and across the care delivered by others in the setting.

What are the types of errors and harm?

The types of errors and harm are further classified regarding domain, or where they occurred across the spectrum of health care providers and settings. The root causes of harm are identified in the following terms:8 1 Latent failure—removed from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources 2 Active failure—direct contact with the patient 3 Organizational system failure—indirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factors 4 Technical failure—indirect failure of facilities or external resources

What is the cornerstone of high quality health care?

Conclusion. Patient safety is the cornerstone of high-quality health care. Much of the work defining patient safety and practices that prevent harm have focused on negative outcomes of care, such as mortality and morbidity. Nurses are critical to the surveillance and coordination that reduce such adverse outcomes.

Who won the Patient Safety and Quality Award?

We can only improve what we can measure and report on. No one knows this better than our John M. Eisenberg Patient Safety and Quality Award winners. Their efforts inspire us and others to become champions of patient safety and improvement.

Why is NQF reporting important?

NQF has published a number of reports to encourage providers to adopt best practices and eliminate serious reportable events (SREs). State based reporting has also been enacted in 26 states and the District of Columbia to help providers identify and learn from serious reportable events.

Introduction

Methods

Results

Discussion

• The Patient Safety Event Taxonomy developed and tested in this study represents a synthesis of traditional, hierarchical classifications represented by single topic areas and settings and the heuristic, multidimensional/multisetting classifications that rely on a systems approach to understanding patient safety [38]. It includes all events that are...

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Conclusion

Acknowledgements