Assessing patient safety in the United States: Challenges and opportunities

Medical Care

Volumn 43, Issue 3 SUPPL., 2005, Pages

  Zhan, Chunliu ^a   Kelley, Ed ^a   Yang, Hannah P ^b   Keyes, Marge ^a   Battles, James ^a   Borotkanics, Robert J ^a   Stryer, Daniel ^a  

^a AGENCY FOR HEALTHCARE RESEARCH AND QUALITY   (United States)

^b HEALTH RESOURCES AND SERVICES ADMINISTRATION   (United States)

Author keywords

National Healthcare Quality Report; Patient safety

Indexed keywords

DATA ANALYSIS; DRUG SAFETY; HEALTH CARE POLICY; HEALTH CARE QUALITY; HOSPITAL INFECTION; PATIENT CARE; PERFORMANCE; PUBLIC HEALTH; RELIABILITY; REVIEW; RISK ASSESSMENT; SAFETY; UNITED STATES; COMPARATIVE STUDY; CROSS INFECTION; GOVERNMENT; HEALTH CARE MANAGEMENT; HUMAN; INFORMATION PROCESSING; LEGAL ASPECT; MEDICAID; MEDICAL ERROR; MEDICAL RECORD; MEDICARE; PATIENT;

ANNUAL REPORTS; CROSS INFECTION; DATA COLLECTION; HUMANS; MEDICAID; MEDICAL ERRORS; MEDICAL RECORDS SYSTEMS, COMPUTERIZED; MEDICARE; PATIENTS; QUALITY ASSURANCE, HEALTH CARE; SAFETY; SAFETY MANAGEMENT; UNITED STATES; UNITED STATES AGENCY FOR HEALTHCARE RESEARCH AND QUALITY;

EID: 14844312133     PISSN: 00257079     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Review

References (46)

1. Institute of Medicine, Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
2. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384.
3. Leape LL, Lawthers AG, Brennan TA, et al. Preventing medical injury. Qual Rev Bull. 1993;19:144-149.
4. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261-271.
5. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376.
6. McNutt RA, Abrams RI. A model of medical error based on a model of disease: interactions between adverse events, failures, and their errors. Qual Manag Health Care. 2002;10:23-28.
7. Dovey SM, Meyers DS, Phillips RL Jr, et al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002;11:233-238.
8. Cole T. Medical errors vs medical injuries: physicians seek to prevent both. JAMA. 2000;284:2175-2177.
9. Layde PM, Cortes LM, Teret SP, et al. Patient safety efforts should focus on medical injuries. JAMA. 2002;287:1993-1997.
10. Zhan C, Miller M. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290: 1868-1874.
11. Steel K, Gertman PM, Crescenzi C, et al. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304:638-642.
12. Bedell SE, Deitz DC, Leeman D, et al. Incidence and characteristics of preventable iatrogenic cardiac arrests. JAMA. 1991;265:2815-2820.
13. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29-34.
14. Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;169:73-76.
15. Battles J, Lilford R. Organizing patient safety research to identify risks and hazards. Qual Saf Health Care. 2003;12(suppl 2):II2-II7.
16. Fleming ST. Complications, adverse events, and iatrogenesis: classifications and quality of care assessment issues. Clin Perform Qual Health Care. 1996;4:137-147.
17. Reason JT. Human Error. Cambridge, England: Cambridge University Press; 1990.
18. Iezzoni LI. Assessing quality using administrative data. Ann Intern Med. 1997;127:666-674.
19. Report to the President on Medical Errors. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Quality Interagency Coordination Task Force; February 2000.
20. McNutt RA, Abrams R, Arons DC. Patient safety efforts should focus on medical errors. JAMA. 2002;287:1997-2001.
21. Donabedian A. Explorations in Quality Assessment and Monitoring: The Definition of Quality and Approaches to Its Assessments, vol I. Ann Arbor, MI: Health Administration Press; 1980.
22. Institute of Medicine, Committee on Data Standards for Patient Safety. Patient Safety: Achieving a New Standard for Care. Washington, DC: National Academy Press; 2003.
23. McGlynn EA. Choosing and evaluating clinical performance measures. Jt Comm J Qual Improv. 1998;24:470-479.
24. Holbrook J. The criminalisation of fatal medical mistakes. BMJ. 2003; 327:1118-1119.
25. McDonald KM. Measures of Patient Safety Based on Hospital Administrative Data: The Patient Safety Indicators. Rockville, MD: Agency for Healthcare Research and Quality; 2002.
26. Romano PS, Geppert JJ, Davies S, et al. A national profile of patient safety in US hospitals. Health Affairs. 2003;22:154-166.
27. Zhan C, Miller MR. Administrative data based patient safety research: a critical review. Qual Saf Health Care. 2003;12(suppl 2):II58-II63.
28. Lawthers AG, McCarthy EP, Davis RB, et al. Identification of inhospital complications from claims data. Is it valid? Med Care. 2000; 38:785-795.
29. Bates DW, O'Neil AC, Petersen LA, et al. Evaluation of screening criteria for adverse events in medical patients. Med Care. 1995;33:452-462.
30. Weingart SN, Iezzoni LI, Davis RB, et al. Use of administrative data to find substandard care: validation of the complication screening program. Med Care. 2000;38:796-806.
31. McCarthy EP, lezzoni LI, Davis RB, et al. Does clinical evidence support ICD-9-CM diagnosis coding of complications? Med Care. 2000;38:868-876.
32. Romano PS, Chan BK, Schembri ME, et al. Can administrative data be used to compare postoperative complication rates across hospitals? Med Care. 2002;40:856-867.
33. Emori TG, Culver DH, Horan TC, et al. National nosocomial infections surveillance system (NNIS): description of surveillance methods. Am J Infect Control. 1991;19:19-35.
34. Centers for Disease Control and Prevention. About NNIS 2001. Available at: http://www.cdc.gov/ncidod/hip/NNIS/@nnis.htm. Accessed December 17, 2003.
35. Kent P, McDonald M, Harris O, et al. Post-discharge surgical wound infection surveillance in a provincial hospital: follow-up rates, validity of data and review of the literature. A N Z J Surg. 2001;71:583-589.
36. Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey Homepage. July 2003. Available at: http://www.meps.ahrq. gov/. Accessed December 17, 2003.
37. Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA. 2001;286:2823-2829.
38. Institute of Medicine, Committee on the National Quality Report on Health Care Delivery. Envisioning the National Healthcare Quality Report. Washington, DC: National Academy Press; 2001.
39. Panel on Monitoring Progress and Maintaining Vigilance. Monitoring Progress and Maintaining Vigilance: Summit Panel Issue Paper. Second National Summit on Patient Safety Research; Crystal City, VA; 2003.
40. Woolf A, Litovitz T. Reporting of adverse events. N Engl J Med. 2003;348:1410-1411; author reply 1410-1411.
41. Williams LK, Pladevall M, Fendrick AM, et al. Differences in the reporting of care-related patient injuries to existing reporting systems. Jt Comm J Qual Saf. 2003;29:460-467.
42. Joint Commission on the Accreditation of Healthcare Organizations. Sentinel Event Report Policy and Procedures. Available at: http://www.jcaho.org/ accredited+organizations/ambulatory+care/sentinel+ events/se_pp.htm. Accessed December 17, 2003.
43. National Quality Forum. Serious Reportable Events in Healthcare: A Consensus Report. 2003.
44. Second National Summit on Patient Safety Research. Epidemiology of Patient Safety Risks and Hazards: Summit Panel Issue Paper. 2003.
45. Stein R. Teenage girl in botched organ transplant dies. Washington Post. Washington, DC; 2003.
46. Thomas EJ, Studdert DM, Newhouse JP, et al. Costs of medical injuries in Utah and Colorado. Inquiry. 1999;36:255-264.