survey of medical informatics cs 493 – fall 2004
TRANSCRIPT
Course Book – Primary focus
PATIENT SAFETYACHIEVING A NEW STANDARD FOR CARE
Committee on Data Standards for Patient SafetyBoard on Health Care Services
Philip Aspden, Janet M. Corrigan, Julie Wolcott, andShari M. Erickson, Editors
Institute Of MedicineTo purchase this content as a printed book or as a
PDF file go to http://books.nap.edu/catalog/10863.html
Summary
Goal of the IOM report is help in identifying an information technology plan that will improve patient safety in this nation
The health system needs to be able to prevent errors and when they do occur to be in a position to take corrective action
The IT plan basically calls for the establishment of a National Health Information Infrastructure
NHII – why do you need it
To provide access to all clinically pertinent information and to decision support tools for both clinicians and patients
Automatically capture patient safety information during the process care is given
Dictionary Definition ofIatrogenic:
induced by a physician's words or therapy (used
especially for a complication resulting
from treatment)
Drumbeat of negative reports IOM Reports
“To Err is Human” – 1998 98,000 deaths attributed to
medical errors “Crossing the Quality Chasm”
- 2001 “Patient Safety – Achieving a
new standard of care” – 2004 JAMA Article – July 2000
Barbara Starfield – Is US Health Really the Best in the World 225,000 Deaths per year
from Iatrogenic causes
The number of deaths due to
medical errors is equivalent to
crashing a fully loaded jumbo jet every day of the
year
Airplane is the safest spot to be and a hospital bed is the most dangerous place to be
“To err is Human”
Near Miss *: “An act of commission or omission that could have harmed the patient but did not do so as a result of chance, prevention or mitigation”
Adverse Events: those care events that cause harm to patients (Iatrogenic)
* IOM report on “Patient Safety – Achieving a new standard of Care”, pg 2
Common factors associated with errors Not following renal function decline and
altering treatment appropriately Ignoring patient history of allergy to a certain
class of medicines Wrong drug name, dosage or abbreviation Mistake in calculating drug dosage Mistakes in dosage frequency calculations
Crossing the Quality Chasm:A new health system for the 21st
Century IOM Report that identified six major quality
goals: Safety Effectiveness Patient Centeredness Timeliness Efficiency Equitable
Safety Statistics
McGlynn, E. A., S. M. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E. A. Kerr. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348 (26):2635–2645. Only 55% get appropriate care
Comparison to airline industry Pilots have access to all information needed to
make decision Airplanes information systems are integrated with air
traffic control systems Wrong decisions by pilots will lead to his/her death Black boxes record all decisions so errors can be
analyzed. Every near miss and fatal errors are examined
thoroughly by NTSB to ensure those can be avoided in future
Joint Commission on Accreditation of Healthcare Organization www.jcaho.org An organization whose mission is to promote
safety and quality of care through the process of accreditation.
Accredits more than 15,000 health care organizations in US
Variety of programs supporting quality measurements including root-cause analysis of adverse events
Recommendation 1
Establishment of patient safety systems that rely on Access to complete EHR and decision support
tools at the point of care Capture safety information – near misses and
adverse events as a by-product of delivering care
Recommendation 2
Develop a National Health Information Infrastructure (NHII) that will serve as the foundation for all care
Federal Government should provide incentives for the creation of NHII
Healthcare providers should invest in EHR systems that support key capabilities facilitating safe delivery of care and implement a process of continuous improvement
EHR System
Longitudinal collection of health information pertinent to care received by a person
Access to any authorized person Knowledge and decision support tools Tools and infrastructure to provide efficient
support for care delivery process
Recommendation 3
This recommendation focuses on roles and responsibilities of various government agencies Department of Health and Human Services (DHHS) – to
promote standards supporting patient safety Consolidated Health Informatics (CHI) initiative with
National Committee on Vital and Health Statistics (NCVHS) identify appropriate data standards and needs for standardizations
Agency for Healthcare Research and Quality (AHRQ) to oversee and support implementation efforts
The National Library of Medicine (NLM) to be the lead organization dealing with national clinical terminologies
Data Standards
Data Interchange Formats X12 – Administrative/Financial HL7 – Clinical Data DICOM – Medical Images NCPDP – Prescription Data MIB – Medical device data
Coding/Terminologies ICD, CPT, SNOMED, LOINC
Knowledge Representations
Recommendation 4
Federal Government to encourage acceleration and adoption of standards in: Clinical Data Interchange
Eg. HL7 CDA Clinical Terminologies
Initially focusing on 20 priority areas Knowledge Representation
Develop standards for supporting evidence-based medicine practice and clinical guidelines
Recommendation 5
All healthcare systems should establish patient safety programs that: Identify failures Analyze failures Redesign processes to prevent such failures from
happening again
Recommendation 6
The federal government should pursue an applied research agenda that focuses on: Knowledge Generation
Identifying patients at high risk Analyze near-misses to improve overall safety Hazard analysis – retrospective and prospective techniques Identifying approaches that work the best Identifying the role of the patient
Develop tools To support early detection, prevention, data mining
techniques Dissemination
Knowledge and tools
Recommendation 7
Entrust AHRQ with developing: Adverse and near miss events taxonomy Standardized format for reporting such event Identifying data elements that needs to be used in
such reporting and use of Eindhoven Classification Model – Medical Version
Clinical context documentation