Page 273

Index

A

Access to health care, 24

Accidents, 50, 51

airline, 42

cerebrovascular, 31, 37

Challenger accident, 51, 52, 55

defined, 52, 53(n), 210

environmental influences model, 18

human error, 50

motor vehicle, 1, 26

safety defined, 4, 58

Three Mile Island, 51, 52, 55

see also Adverse events, general; Error analysis

Accountability, general, 8, 13, 101, 166, 167, 168, 205  see also Leadership; Reporting systems

Accreditation, see Licensure and accreditation

Accreditation Council for Graduate Medical Education, 269

Active errors, see Error, general

Adverse events, general

classification/standardization of, 9, 10, 28-29, 88

cost of, 1-2, 7

defined, 4, 28, 29, 210

number of, 1, 26-27, 30, 32, 41, 182-183 191, 194-195, 248-253

sentinel events, 93-94, 104-105, 119-120, 125, 128, 194

studies of, 1, 26, 30-32, 35-37, 40, 218-253

see also Preventable adverse events; Reporting systems

Affordances, 163, 171-172

Agency for Health Care Research and Quality (AHRQ), 77-78, 82, 83

Center for Patient Safety (proposed), 7-8, 69-71, 75-84, 135

Centers for Education and Research in Therapeutics, 77-78, 83

Consumer Assessment of Health Plans, 20

Aircraft carriers, 57, 160-161

Air transport, see Aviation

Alaska, 142

Alcoa, Inc., 160

Allergic reactions, drugs, 33, 192



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Index A cost of, 1-2, 7 defined, 4, 28, 29, 210 Access to health care, 24 number of, 1, 26-27, 30, 32, 41, 182- Accidents, 50, 51 183, 191, 194-195, 248-253 airline, 42 sentinel events, 93-94, 104-105, 119- cerebrovascular, 31, 37 120, 125, 128, 194 Challenger accident, 51, 52, 55 studies of, 1, 26, 30-32, 35-37, 40, 218- defined, 52, 53(n), 210 253 environmental influences model, 18 see also Preventable adverse events; human error, 50 Reporting systems motor vehicle, 1, 26 Affordances, 163, 171-172 safety defined, 4, 58 Agency for Health Care Research and Three Mile Island, 51, 52, 55 Quality (AHRQ), 77-78, see also Adverse events, general; Error 82, 83 analysis Center for Patient Safety (proposed), Accountability, general, 8, 13, 101, 166, 7-8, 69-71, 75-84, 135 167, 168, 205 Centers for Education and Research in see also Leadership; Reporting systems Therapeutics, 77-78, 83 Accreditation, see Licensure and Consumer Assessment of Health accreditation Plans, 20 Accreditation Council for Graduate Aircraft carriers, 57, 160-161 Medical Education, 269 Air transport, see Aviation Active errors, see Error, general Alaska, 142 Adverse events, general Alcoa, Inc., 160 classification/standardization of, 9, 10, Allergic reactions, drugs, 33, 192 28-29, 88 273

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274 INDEX Ambulatory health care settings, 29, 50- Antidiarrheals, 34 51, 168 Anti-inflammatory drugs, 35, 253-254 costs, 41 Association of American Medical drug errors, 32-33, 34-35, 39 Colleges, 148 home care, 2, 29, 51, 254 National Patient Safety Partnership, reporting systems, 88, 257 78, 81-82, 183, 191, 196 training, 165 Attitudes American Academy of Pediatrics, 146 fear, 22, 42, 111, 125, 127, 157, 160, American Accreditation Healthcare 163, 167, 189 Commission/URAC, 138, 139 patient trust, 2 American Board of Medical Specialties, professionals, 2, 10, 23, 60, 112 148 public opinion, 2, 29, 42-43, 70, 167 American College of Cardiology, 145 Australia, 32, 35 American College of Obstetricians and Authority gradient, 178, 180-181 Gynecologists, 145-146 Automation, see Computer systems American College of Surgeons, 270 Autopsies, 269 American Heart Association, 145, 147 Aviation, 60, 180 American Hospital Association accidents, general, 53 National Patient Safety Partnership, aircraft carriers, 57, 160-161 78, 81-82, 183, 191, 196 risk level, 42 American Medical Accreditation Program safety efforts, ix, 5, 6-7, 42, 71-73, 80 Association, 143 team training, 173-174 American Medical Association, 147 see also National Aeronautics and National Patient Safety Foundation, 6, Space Administration 57, 70, 71, 76, 81, 147, 193 Aviation Safety Action Programs, 97 National Patient Safety Partnership, Aviation Safety Reporting System (ASRS), 78, 81-82, 183, 191, 196 72-73, 76, 91, 95-97, 104, 105- American National Standards Institute, 106, 125, 127 178 American Nurses Association, 143 B National Patient Safety Partnership, 78, 81-82, 183, 191, 196 Bar coding, 175, 188, 189, 195-196 American Nurses Credentialing Center, Benchmarking, 81, 182, 259 143 Best practices, 18, 32, 77, 79, 145, 152, American Society of Health-System 182, 193 Pharmacists, 145, 183, 193 see also Clinical practice guidelines Ames Research Center, 65, 73 Billings, Charles, 73 Anesthesia, 6, 32, 144-145, 164, 171, 222- Budgetary issues, see Funding 225 Bureau of Labor Statistics, 73-74, 97 infusion pumps, 50-66 (passim) mortality, 164, 222-225 Anesthesia Patient Safety Foundation, 6, C 145 Antibiotics, 33, 171 California Anticipating the unexpected, 52, 150, peer review statute, 127-128 161, 162, 166, 170, 174-176, 197 reporting system, 254-255 Anticoagulants, 35 Cancer, 1, 26, 209

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275 INDEX Cardiac arrest, 31, 37, 220-221 see also Feedback; Information Cardiovascular agents, 35 systems; Reporting systems Center for Patient Safety (proposed), 7-8, Complaints, 21 69-71, 75-84, 135 Complexity, see Systems, general funding, 7-8, 70, 76, 78-79, 83-84, 106 Computer systems, 77, 80, 177, 178 reporting systems, 9-10, 79, 102-103, bar coding, 175, 188, 189, 195-196 106, 135 drugs, 34, 39-40, 77, 80, 171, 172, 175, Centers for Disease Control and 183, 184-185, 191-193, 195 Prevention (CRC), 99, 268 errors caused by complexity of, 61, 62- Centers for Education and Research in 63, 65 Therapeutics (CERTS), 77-78, simulation training, 65, 79, 145, 163, 83 176-177, 178, 179 Cerebrovascular accident, 31, 37, 220- see also Databases; Internet 221, 257, 263 Confidentiality, reporting systems Challenger accident, 51, 52, 55 anonymous reporting, 95, 96, 100, Checklists, 158, 171, 172, 180, 187, 194 111, 124, 125-126 Chemotherapy, 1, 51, 260 de-identification, 97, 111, 125, 126- protocols, 164, 171, 194 127, 128 Children, 79, 94, 260, 268 mandatory, 8, 10, 92, 101, 255-264 medication, 33-34, 38, 171, 226-227, (passim) 242-245 patient data, general, 178 Clinical practice guidelines, 32, 135, 145- Privacy Act, 123 146, 171 voluntary, 94, 95, 109-131, 256 see also Best practices; Protocols Connecticut, 91, 256 Cognitive processes, 147, 162-163, 181 Consumer Assessment of Health Plans, checklists, 158, 171, 172, 180, 187, 20 194 Cost and cost-benefit factors, 29, 40-42, cockpit resource management, 65, 72, 158, 248-253 147, 176-177 ambulatory care settings, errors, 41 crew resource management, 79, 97, Center for Patient Safety (proposed), 147, 157, 161, 162, 173, 176, 76 179 drugs and drug errors, 2, 27, 30, 32, 41, memory, 54, 158, 163, 170, 171, 172, 182-183, 191, 194-195, 248-253 185 national, 1-3, 27, 40-42 problem solving, 162, 163, 172, 179 National Medical Expenditure Survey, simplification, 53, 60, 157, 158, 163, 38, 234-235 164, 166, 170, 171, 172, 185, uninsured persons, 24 197 see also Funding vigilance, 5, 158, 164, 170, 172 Court cases, see Litigation see also Protocols Critical incident analysis, see Human Colorado factors hospital studies, 1, 26, 30-31, 36-37, Cultural factors, 4, 146 40, 248-249 access to care, 24 reporting system, 92, 255-256 organizational, culture of safety, 12-13, Commonwealth Fund, x 14, 155-156, 159-162, 166-168, Communication, 7, 22, 180-181 178, 179, 189 non-health sectors, 6-7 public opinion, 2, 29, 42-43, 70, 167 professional societies, 12 see also Attitudes

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276 INDEX Culture of medicine, 21-22, 179 Health Care Financing Cytotoxics, 35 Administration, 19-20, 82, 139, 140-141 reporting systems,121-123 D see also Agency for Health Care Research and Quality; Food and Databases Drug Administration Aviation Safety Reporting System Department of Labor, see Bureau of (ASRS), 72-73, 76, 91, 95-97, Labor Statistics 104, 105-106, 125, 127 Department of Transportation, see drugs, 34, 39-40, 77, 80, 171, 172, 175, Federal Aviation 183, 184-185, 191-193, 195 Administration; National HEDIS, 20, 139, 140 Transportation Safety Board National Practitioner Data Bank, 121- Department of Veterans Affairs 123 National Patient Safety Partnership, patient records, general, 177, 178, 236- 78, 81-82, 183, 191, 196 239 Veterans Health Administration, 80, professional organizations, 147 83, 123 see also Reporting systems Devices and equipment, 82, 184-185, 190- Death, see Mortality 191, 260 Default mode, 62, 171, 176 affordances, 163, 171-172 Definitional issues, 4, 22, 49 default mode, 62, 171, 176 accident, 52, 53(n), 210 forcing functions, 158, 164, 170, 171 adverse drug event, 33 home care, 63 adverse event, 4, 28, 29, 210 human-machine interface, 62-63, 175 classification/standardization of infusion pumps, 50-66 (passim), 150, adverse events, 9, 10, 28-29, 88 171, 172, 183, 255, 257 error, 28, 54, 55, 78, 210 natural mapping, 163-164, 171 glossary, 210-213 outpatient care, 165 hindsight bias, 53 standards and standardization, 23, 62, human factors, 63, 210 144, 148-151, 156, 164, 172- iatrogenic illness, 31 173, 197 misuse, 19 see also Food and Drug negligence, 217 Administration patient safety, 57, 155, 211 Diagnostic errors, 36, 79 pharmaceutical safety, 57 Diphenhydramine hydrochloride, 34 reporting systems, 88, 99 Disabilities, 1-2, 30, 220-221, 261 safety, general, 4, 58 Drugs, 1, 221 systems, general, 52, 211 allergic reactions, 33, 192 underuse, 19 antibiotics, 33, 171 Denmark, 240-241 anticoagulants, 35 Department of Defense, 72, 82 antidiarrheals, 34 U.S. Navy, 57, 160-162 anti-inflammatory drugs, 35, 253-254 Department of Health and Human Centers for Education and Research in Services (DHHS) Therapeutics, 77-78, 79 Centers for Disease Control and chemotherapy, 1, 51, 164, 171, 194, Prevention, 99, 268 260

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277 INDEX children, 33-34, 38, 171, 226-227, 242- patient compliance, 35, 37, 39, 174, 245 236-237 computer tracking/databases, 34, 39- pharmacies, 2, 27, 32, 51, 183, 186- 40, 77, 80, 171, 172, 175, 183, 187, 192-193 184-185, 191-193, 195 pharmacists, 2, 13, 27, 34, 39, 145, cost of adverse effects, 2, 27, 30, 32, 183, 186-187, 193, 194-195, 41, 182-183, 191, 194-195, 248- 224-225, 230-233, 236-237, 240- 253 245 errors on, 13, 14, 27, 28, 29, 32-35, 36, potassium chloride, 171, 187, 194 37-40, 176, 182-197, 224-248 prescription writing, 33, 37-39, 54, ambulatory care settings, 32-33, 34- 183, 184, 190, 231, 241 35, 39 protocols, 6, 77, 92, 141, 158, 164, emergency departments, 35, 39, 171, 173, 177, 183, 186, 187, 238-239 193-194 hospital errors, general, 33-35, 38, chemotherapy, 164, 171, 194 39-40, 41-42, 168, 171, 182-197, reporting systems, 34, 93, 95, 98-99, 224-253 100 mortality, 28, 32-33, 42, 227, 229, FDA, 93, 95, 98-99, 100, 104, 105, 233, 248-249 123, 148-149 nursing homes, 42 selected states, descriptions, 255, surgery, 34, 40, 228-229; see also 257, 261 Anesthesia standards and standardization, 13, 14, see also “reporting systems” infra 23, 29, 171, 183, 184-185, 190- infusion devices, 50-66 (passim), 150, 191 171, 172, 183, 193, 255, 257 surgery, 34, 40, 228-229; see also Medication Errors Reporting (MER) Anesthesia program, 95, 97, 100, 125, 126- unit dosing, 183, 184-185, 193 127, 194 see also Food and Drug MedMARx, 95, 100, 126 Administration MedWatch, 99, 123, 148-149 mortality, 28, 32-33, 42, 227, 229, 233, E 248-249 naloxone hydrochloride, 34 Economic factors names of, 29, 37, 136, 148, 149, 151, ambulatory care, 165 184, 231 incentives, 18, 19-20, 21 National Patient Safety Partnership, market-based initiatives, 6, 17, 19-20, 82 21 nursing homes, 42 uninsured persons, 24 order entry systems, 33, 40, 62, 80, worker productivity losses, 2-3 172, 175, 183, 184, 185, 188- see also Cost and cost-benefit factors; 189, 190, 191-192 Employment factors; Funding: organizational factors, 13, 14, 157-158, Insurance; Purchasers 168, 171, 172, 174, 175, 177, Education, see Patient education; 182-197 Professional education; Public packaging and labeling, 13, 64, 136, education 148, 151, 185, 187, 193 E.I. du Pont de Nemours and Company, bar coding, 175, 188, 189, 195-196 159-160

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278 INDEX Elderly persons, 79, 234-235, 250-251 Florida, 92, 115, 257 see also Medicare; Nursing homes Food and Drug Administration (FDA), Emergency departments, 36-37, 60, 79, 13, 71, 79, 82 165 Centers for Education and Research in adverse drug events, 35, 39, 238-239 Therapeutics, 77-78, 83 Employment factors MedWatch, 99, 123 worker productivity losses, 2-3 Office of Post-Marketing Drug Risk workload, 24, 42, 60 Assessment (OPDRA), 149, 150 see also Occupational health reporting systems, 93, 95, 98-99, 100, Equipment, see Devices and equipment 104, 105, 123, 148-149 Error, general standards, 13, 136, 148-151 active errors, 55-56, 65-66, 181 Forcing functions, 158, 164, 170, 171 defined, 28, 54, 55, 78, 210 Foreign countries, see specific countries latent errors, 55-56, 65, 66, 155, 181- Freedom of Information Act, 123 182 Free flow, medication, 51-66 (passim), national reduction goals, 7, 70, 78 171, 172 near-misses, 28, 87, 96, 101, 110, 127, Funding, 82-83 160, 177, 190 Aviation Safety Program, 83 pathophysiology of error, 162-163 Aviation Safety Reporting System Error analysis, 4, 10, 32, 87, 181 (ASRS), 72-73 active errors, 55-56, 65-66, 181 Center for Patient Safety (proposed), critical incident analysis, 63-64 7-8, 70, 76, 78-79, 83-84, 106 latent errors, 55-56, 65, 66, 155, 181- NIH, 82 182 NIOSH, 83 literature review, 21-22, 26-48, 205, organizational safety environment, 206, 215-253 166, 168 naturalistic decision-making, 64 reporting systems, 9, 10, 72-73, 88, 89, organizational factors, 8, 10, 166, 168 106 systems approach, 49, 50, 52-66 study at hand, x see also Reporting systems Evidence-Based Practice Centers, 83 H Harvard Medical Practice Study, 5, 30 F Health Care Financing Administration, Fatigue, 24, 42, 60, 163 19-20, 82, 139, 140-141 Fear, 22, 42, 111, 125, 127, 157, 160, 163, Health Care Quality Improvement Act, 167, 189 121-122, 129 see also Punitive responses Health insurance, see Insurance Federal Aviation Administration, 72-73, Health Insurance Portability and 96, 125 Accountability Act (HIPAA), Feedback, 58-59, 62, 143, 176, 177, 178, 104 181-182, 189 Health maintenance organizations autopsies, 269 (HMOs), 39, 99 reporting systems, 90, 98, 99, 100, 105 Health Plan Employer Data and see also Learning environment Information Set (HEDIS), 20, Flight Safety Foundation, 72 139, 140

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279 INDEX Health Resources and Services see also Cognitive processes; Error, Administration general; Error analysis; National Practitioner Data Bank, 121- Incompetent practitioners; 123 Organizational factors High-reliability theory, 57 High-risk industries, 5, 13, 22, 57, 60, 80, I 159-162, 166 see also Aviation; National Aeronautics Incompetent practitioners, 30, 36-37 and Space Administration; negligent adverse events, 28, 30, 37, Nuclear power industry 114-131 Hindsight bias, 53 organizational safety environment, Home care, 2, 29, 51, 254 166, 169 Hospitals, 1, 26, 29, 165, 168 public opinion, 42, 43 adverse events, 30-31, 36-37, 40-42, standards, 134, 142, 261 216-223 systems approach, 49 drugs, 32, 33-35, 38, 39-40, 41-42, unlicensed, 261 168, 171, 182-197, 224-253 see also Malpractice costs of adverse effects, 2, 27, 30, Infections and infection control, 30, 35, 248-253 42, 165, 267-268 licensure and accreditation, 71, 103, Infectious diseases, 267-268 137-139, 151, 152, 168, 266 Information systems, 7, 74-75, 80-81, 177- Joint Commission on Accreditation 178, 180-181, 188-189, 195-196 of Healthcare Organizations, clinical, 3 71, 91, 93-94, 104-105, 116, Internet, 92, 134 125, 128, 138, 193, 194, 266 performance standards, 134, 138-139 reporting systems described, role in errors, 61, 65 selected states, 255-265 (passim) see also Computer systems; occupational safety in, 168 Confidentiality, reporting reporting systems, 9, 87-88, 91, 105, systems; Feedback; Media; 124, 254-265 (passim) Professional education; Public see also Autopsies; Emergency education; Reporting systems departments; Infections and Infusion pumps, 50-51, 55-66 (passim), infection control; Intensive care 150, 171, 172, 183, 193, 255, units; Life Safety Code; 257 Operating rooms; Risk Institute for Healthcare Improvement, management 183 Hours of work, see Workload Institute for Safe Medication Practices Human factors, 22, 53-54, 63-66, 145, (ISMP), 95, 104 162-166, 170-173 Insurance, 2, 6, 139 aviation, 72 HMOs, 39, 99 critical incident analysis, 63-64 organizational performance standards, defined, 63, 210 3, 139-141 fatigue, 24, 42, 60, 163 malpractice, 164 human-machine interface, 62-63, 175 managed care, general, 168 infusion pumps, case study, 50-66 Medicaid, 139, 141, 142, 252-253 naturalistic decision-making, 64 Medicare, 39, 128, 138, 140, 141, 142 vigilance, 5, 158, 164, 170, 172

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280 INDEX preferred provider organizations Learning environment, 8, 23, 57, 62, 166, (PPOs), 139 178-182, 197 uninsured persons, 24 team training, 14, 79, 156, 170, 173- see also Purchasers 174, 176-177, 179, 189, 197 Intensive care units, 31, 79, 105, 228-229 see also Professional education neonatal and pediatric, 34 Legal issues, 23 Interdisciplinary approaches, 14, 135-136 negligent adverse event, 28, 30, 37 practice guidelines, 145-146 see also Confidentiality, reporting professional conferences, 146 systems; Liability issues; see also Teams Litigation; Malpractice International perspectives, see specific Legislation, in force countries Agency for Health Care Research and Internet, 206 Quality, 78 patient care, 175, 177 Freedom of Information Act, 123 reporting systems, 92, 95, 258, 259 Health Care Quality Improvement standards, 134 Act, 121-122, 129 Health Insurance Portability and Accountability Act (HIPAA), J 104 model of environmental factors, 17, Job design, 61, 62-63, 70, 170, 171, 172- 18, 19, 21 173, 176-177 Occupational Safety and Health Act, Joint Commission on Accreditation of 73, 136 Healthcare Organizations Privacy Act, 123 (JCAHO), 71, 91, 93-94, 104- Safe Medical Device Act, 150-151 105, 116, 125, 128, 138, 193, state reporting systems, 113-121, 254- 194, 266 265 (passim) see also Regulatory issues Legislation, proposed, x, 6 K Center for Patient Safety (proposed), 7-8, 69-71 Kansas, reporting system, 257-258 peer review, 10, 111 reporting, 104, 111-112, 128 L Leukopenia, 34 Liability issues, 3, 10, 22, 43, 167 Labeling, see Packaging and labeling, enterprise liability and no-fault drugs compensation, 111 Latent error, 55-56, 65, 66, 155, model of environmental factors, 19 181-182 see also Litigation; Malpractice Leadership, 69, 138, 156-157, 162, 166, Licensure and accreditation, 19, 23, 71, 167, 168, 180-181, 197 79, 133, 134, 135 authority gradient, 178, 180-181 organizations, 71, 103, 137-139, 151, committee recommendations, 6, 152, 168, 266 14, 69 Joint Commission on Accreditation see also Center for Patient Safety of Healthcare Organizations, (proposed) 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266

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281 INDEX reporting systems described, Mississippi, reporting system, 259 selected states, 255-265 (passim) Models and modeling professionals, 3, 10-12, 134, 141-144, environmental influences on quality, 151-152 17-21 malpractice, 12, 43, 113-117, 142, reporting hierarchy, 101 169, 262 Mortality, x, 30, 31-32, 37, 221-223, 248- unlicensed, 261 249, 269 reporting systems, 91, 93-94, 103, 255- airline fatality rates, 5 265 (passim) anesthesia, 164, 222-225 Life Safety Code, 267 drug errors, 28, 32-33, 42, 227, 229, Litigation 233, 248-249 mandatory reporting, 262 infectious disease, 267-268 voluntary reporting, 23, 109-131 national, 1-2, 26, 27, 31, 248-249 Long-term care, 209 reporting systems, 93, 96, 98, 101, 257, see also Nursing homes 258, 260, 262, 264 Louisiana, 142 suicide, 35, 94, 257, 260, 262 Motivation, see Attitudes Multidisciplinary approaches, see M Interdisciplinary approaches Malpractice, 12, 43, 113-117, 142, 164, 169, 262 N see also Incompetent practitioners; Litigation Naloxone hydrochloride, 34 Managed care, 168 National Academy for State Health HMOs, 39, 99 Policy, x, 92-93 PPOs, 139 National Aeronautics and Space Massachusetts, 39, 183, 224-225, 232-233, Administration, 72, 96 246-251 Ames Research Center, 65, 73 reporting system, 258-259 Aviation Safety Reporting System Media, 20, 43 (ASRS), 72-73, 76, 91, 95-97, specific incidents, 1, 3, 51 104, 105-106, 125, 127 Medicaid, 139, 141, 142, 252-253 Challenger accident, 51, 52, 55 Medical devices and equipment, see National Cancer Policy Board, 209 Devices and equipment National Committee for Quality Medicare, 39, 128, 138, 140, 141, 142 Assurance, 20, 138, 139 Medication and medication safety, see National Coordinating Council for Drugs Medication Error Reporting Medication Errors Reporting (MER) and Prevention, 183 program, 95, 97, 100, 125, 126- National Fire Prevention Association, 267 127, 194 National Forum for Health Care Quality MedMARx, 95, 100, 126 Measurement and Reporting, 9, MedWatch, 99, 123, 148-149 10, 88, 89, 101, 103-104 Memory, 54, 158, 163, 170, 171, 172, 185 National Institute for Occupational Safety checklists, 158, 171, 172, 180, 187, 194 and Health (NIOSH), 73, 74, simplification, 53, 60, 157, 158, 163, 82 164, 166, 170, 171, 172, 185, 197 National Institute of Standards and see also Protocols Technology, 178

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282 INDEX National Institutes of Health (NIH), 74, National Occupational Research 77 Agenda, 74 National Medical Expenditure Survey, 38, NIOSH, 73, 74, 82 234-235 patient safety and, 155-156 National Occupational Research Agenda, worker productivity losses, 2-3 74 workload, 24, 42, 60 National Patient Safety Foundation, 6, 57, Occupational Safety and Health Act, 73, 70, 71, 76, 81, 147, 193 136 National Patient Safety Partnership, 78, Occupational Safety and Health 81-82, 183, 191, 196 Administration, 73-74, 76, 90, National Practitioner Data Bank, 121-123 91, 97-98 National Roundtable on Health Care Office of Post-Marketing Drug Risk Quality, 208-209 Assessment (OPDRA), 149, 150 National Transportation Safety Board, 72, Ohio, 261-262 76, 96 Oklahoma, 128 Naturalistic decision-making, 64 Operating rooms, 31, 36, 50, 52, 56, 79, Natural mapping, 163-164, 171 157 Navy, see U.S. Navy Order entry systems, 33, 40, 62, 80, 172, Near-misses, 28, 87, 96, 101, 110, 127, 175, 183, 184-185, 188-189, 160, 177, 190; see also Errors, 190, 191-192 general Organizational factors, 3, 6-7, 13-14, 17, New Jersey, reporting system, 260 22, 23, 60, 155-201, 266-271 New York State access to health care, 24 hospital studies, 1, 26, 30, 220-221, accountability, 8, 13, 101, 166, 167, 238-239 168, 205 outpatient surgery, 165 authority gradient, 178, 180-181 reporting system, 92, 124, 260-261 culture of medicine, 21-22, 179 Norman, Donald, 163 culture of safety, 12-13, 14, 155-156, Nuclear power industry, 60 159-162, 166-168, 178, 179, 189 Three Mile Island, 51, 52, 55 design for recovery, 176-177 Nurses drugs, 13, 14, 157-158, 168, 171, 172, error studies, 216-217, 228-229, 232- 174, 175, 177, 182-197 237, 243-245 error analysis, 8, 10, 166, 168 infusion pumps, 50-51, 56 high reliability theory, 57 organizational accreditation, 138 job design, 61, 62-63, 70, 170, 171, professional accreditation, 143-144 172-173, 176-177 reporting, 34, 256 licensure and accreditation, 71, 103, Nursing homes, 2, 91, 209, 250-251, 254, 137-139, 151, 152, 168, 266 256 Joint Commission on Accreditation drug errors, 42 of Healthcare Organizations, 71, 91, 93-94, 104-105, 116, 125, 128, 138, 193, 194, 266 O reporting systems described, selected states, 255-265 (passim) Occupational health, 6-7, 24, 27, 73-74, peer review, 10, 111, 112, 119-121, 80, 159-162, 168 126-128, 140-141, 143, 234-235, HEDIS, 20, 139, 140 263-264

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283 INDEX performance standards, 3, 14, 23, 132- Pharmacists, 2, 13, 27, 39, 145, 183, 186- 134, 136-141, 143-144, 157, 187, 193, 194-195, 224-225, 162, 166, 172-173, 254-265 230-233, 236-237, 240-245 professional organizations, 6, 12, 20, reporting, 34 79, 135-136, 144-148, 152, 167, Physician order entry, see Order entry 181, 183-184; see also specific systems organizations Physicians Desk Reference, 177 reporting systems, 9, 87-88, 91, 105, Phytonadione, 34 124, 156, 160, 166, 254-265 Pneumonia, 31, 220-221 staffing, 138, 165, 166, 167, 170, 172, Point-of-service plans, 139 175-176, 190 Potassium chloride, 171, 187, 194 see also Center for Patient Safety Practice guidelines, see Clinical practice (proposed); Interdisciplinary guidelines approaches; Leadership; Preferred provider organizations (PPOs), Staffing; Systems, general; 139 Teams Prescription writing, 33, 37-39, 54, 183, Oryx system, 138-139 184, 190, 231, 241 Outpatient treatment, see Ambulatory Preventable adverse events, 4, 5, 7, 35-37, health care settings 39, 41, 182, 191 children, 34 defined, 28 P studies of, 1-2, 26, 27, 30-31, 216-225, 228-229, 234-237, 246-249 Packaging and labeling, drugs, 13, 64, Preventive interventions 136, 148, 151, 185, 187, 193 design for recovery, 176-177 bar coding, 175, 188, 189, 195-196 errors in, 36 see also Food and Drug Privacy, see Confidentiality, reporting Administration systems Pathophysiology of error, 162-163 Privacy Act, 123 Patient education, 183, 188-189, 196-197 Problem solving, 162, 163, 172, 179 Patient safety, definition of, 57, 155, 211 simplification, 53, 60, 157, 158, 163, Patients, role in reducing errors, 174 164, 166, 170, 171, 172, 185, drug therapy, 35, 37, 39, 174, 236-237 197 Peer review, 234-235 Professional education, 12, 15, 57, 60, organizations, 140-141 134, 146-147, 161 professional performance standards, ambulatory care, 165 143; see also American Medical Center for Patient Safety (proposed), Accreditation Program 70, 76, 79, 82 Association culture of medicine, 179 reporting systems, 10, 111, 112, 119- curricula on patient safety, 12, 134, 121, 126-128, 263-264 146-147 Pennsylvania, 262-263 National Patient Safety Foundation, Perrow, Charles, 51-52, 57, 60 71 Pew Health Professions Commission, 144 reporting systems, 99 Pharmaceuticals, see Drugs simulation training, 65, 79, 145, 163, Pharmacies, 2, 27, 32, 51, 183, 186-187, 176-177, 178, 179 192-193 standards, 12, 142-143

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284 INDEX team training, 14, 79, 146, 156, 170, Regulatory issues, x, 6, 17, 18, 75 173-174, 176-177, 179, 189, 197 committee recommendations, 10-11 see also Feedback; Learning mandatory reporting systems, 6, 8, 9, environment; Licensure and 10, 79, 86, 87-88, 90, 91-93, 97- accreditation 98, 102-104, 166 Professional organizations, 6, 12, 20, 79, confidentiality, 8, 10, 92, 101, 255- 135-136, 144-148, 152, 167, 264 (passim) 181, 183-184 descriptions, selected states, 255- see also specific organizations 265 Protocols, 6, 77, 92, 141, 158, 171, 173, model of environmental factors, 17, 177, 183, 186, 187, 193-194 18, 19, 20-21 checklists, 158, 171, 172, 180, 187, 194 see also Food and Drug chemotherapy, 164, 171, 194 Administration; Licensure and clinical practice guidelines, 32, 135, accreditation; Standards and 145-146, 171 standardization Public education, 15 Reporting systems, 8-9, 14, 22-23, 32, 86- Center for Patient Safety (proposed), 131, 270 70, 76, 79, 82 ambulatory care settings, 88, 257 committee mission, xi, 205 anesthesia errors, 255, 256, 258 patient education, 183, 188-189, 196- Aviation Safety Reporting System 197 (ASRS), 72-73, 76, 91, 95-97, see also Media 104, 105-106, 125, 127 Public opinion, 2, 29, 42-43, 70, 167 autopsies, 269 Punitive responses, 56, 157, 180, 197 best practices, 9, 88, 93, 102-103 Purchasers, 2, 3, 6, 11, 19-20, 23, 79, 152, Center for Patient Safety (proposed), 167, 206 9-10, 79, 102-103, 106, 135 organizational performance standards, confidentiality, 8, 10, 92, 94, 95, 96, 3, 139-141 97, 100, 101, 109-131 reporting systems, 89 anonymous reporting, 95, 96, 100, see also Health Care Financing 111, 124, 125-126 Administration; Insurance de-identification, 97, 111, 125, 126- 127, 128 descriptions, selected states, 255- Q 265 (passim) mandatory systems, 8, 10, 92, 101, Quality Improvement Organizations 255-264 (passim) (QIOs), 123; see also Peer voluntary systems, 94, 95, 109-131, review, organizations 256 Quality Interagency Coordinating DHHS, 9, 73-74, 88, 121-123 Committee, 78 drug errors, 34, 93, 95, 98-99, 100 FDA, 93, 95, 98-99, 100, 104, 105, 123, 148-149 R selected states, descriptions, 255, 257, 261 Reason, James, 4, 52, 54, 58, 60, 162 external, 8, 91-93 Redundancy, 57, 60, 158, 161-162

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285 INDEX feedback, 90, 98, 99, 100, 105 voluntary, 8, 9-10, 23, 41-42, 79, 87, Internet, 92, 95, 258, 259 89-90, 93-97, 98, 99, 102, 104- JCAHO, 91, 93-94, 104-105, 116, 125, 106, 178, 179-180, 182, 188-189 128 confidentiality, 94, 95, 109-131, 256 legislation, litigation, 23, 109-131 in force, 113-121, 254-265 (passim) Rhode Island, reporting system, 263-264 proposed, 104, 111-112, 128 Risk management, general, 57, 58-59, 112, licensure and accreditation, 91, 93-94, 137, 149, 270 103, 255-265 (passim) see also High-risk industries mandatory, 6, 8, 9, 10, 79, 86, 87-88, 90, 91-93, 97-98, 102-104, 166 S confidentiality, 8, 10, 92, 101, 255- 264 (passim) Safe Medical Device Act, 150-151 descriptions, selected states, 255- Sentinel events, 93-94, 104-105, 119-120, 265 125, 128, 194 Medication Errors Reporting (MER) Simplification, 53, 60, 157, 158, 163, 164, program, 95, 97, 100, 125, 126- 166, 170, 171, 172, 185, 197 127, 194 see also Protocols MedMARx, 95, 100, 126 Simulation training, 65, 79, 145, 163, 176- MedWatch, 99, 123, 148-149 177, 178, 179 mortality, 93, 96, 98, 101, 257, 258, Software, see Computer systems 260, 262, 264 South Dakota, reporting system, 264-265 National Forum for Health Care Special Initiative on Health Care Quality, Quality Measurement and 208 Reporting, 9, 10, 88, 89, 101, Specialists and specialization, 3, 12, 20, 103-104 36, 58-59, 80, 142-143, 146, National Practitioner Data Bank, 121- 148, 173 123 see also Anesthesia; Emergency nationwide, 9, 10, 87-88, 89, 101, 103- departments; Intensive care 106, 121-123 units; Surgery; Teams near misses, 87, 96, 101, 110, 127, 160 Staffing, 138, 166, 167, 170, 172, 175-176, nurses, 34, 256 190 occupational health, 73-74 ambulatory care, 165 organizational factors, 9, 87-88, 91, Standards and standardization, 6, 9 105, 124, 156, 160, 166, 254-265 adverse events taxonomies, 9, 10, 28- peer review, 10, 111, 112, 119-121, 29, 88 126-127 best practices, 9, 18, 32, 77, 79, 88, 93, punitive responses for reporting 102-103, 145, 152, 182, 193 failures, 255, 258 design for recovery, 176 sentinel events, 93-94, 104-105, 119- devices and equipment, 23, 62, 144, 120, 125, 128, 194 148-151, 156, 164, 172-173, 197 standards and standardization, 9, 28- drugs, 13, 14, 23, 29, 171, 183, 184- 29, 73, 88-89, 99, 101-102, 104 185, 190-191 state reporting systems, 254-265 environmental influences model, 19 surgery, 257, 263

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286 INDEX information systems, 134, 138-139 Systems, general, 49, 50, 56-66, 71, 157, insurance, organizational performance, 158, 188-189, 190 3, 139-141 aviation, 71-72 Life Safety Code, 267 complex systems, 2, 36, 39, 53, 58-60, organizational, 3, 14, 23, 132-134, 136- 61, 62-63, 65, 182-183 141, 143-144, 157, 162, 166, critical incident analysis, 63-64 172-173, 254-265 defined, 52, 211 patient records, 178 drugs, 182-183 performance, 10-12, 132-154 redundancy, 57, 60, 158, 161-162 professional, 23, 132, 133, 134-136, tightly coupled systems, 58-60, 161, 141-148 179 professional education, 12, 142-143 see also Error analysis; Feedback; reporting systems, 9, 28-29, 73, 88-89, Models and modeling; 99, 101-102, 104 Organizational factors; Teams classification/standardization of, 9, 10, 28-29, 88 T see also Clinical practice guidelines; Food and Drug Administration; Teams Licensure and accreditation; crew resource management, 79, 97, Protocols 147, 157, 161, 162, 173, 176, State government, x, 5 179 hospital studies, 1, 26, 30-31, 36-37, patient as part of, 174 40, 238-239, 248-249 risk management, 270 reporting systems, 9, 79, 87-88, 91-93, technology as part of, 62-63 94, 102-103, 111, 113-114, 118, training in, 14, 79, 156, 170, 173-174, 119, 123, 124, 126-127 176-177, 179, 189, 197 descriptions, selected states, 254- working in, 37, 50, 51, 56-57, 59, 60, 265 62-63, 64, 146-147, 166, 170, see also Licensure and accreditation; 197 specific states Technological factors, 61-62, 80, 144, 159 State-level data, 1, 26, 30-31, 36-37, 40 anticipating new errors, 174-175 see also specific states complexity, 36, 61, 62-63, 65 Suicide, 35, 94, 257, 260, 262 human-machine interface, 62-63, 175 Surgery, 2, 35, 79, 218-219, 232-233, 269, professional licensing and, 135 270 protocols, updating of, 171 complexity, 36 see also Computer systems; Devices drug errors, 34, 40, 228-229; see also and equipment; High-risk Anesthesia industries; Information systems infusion pumps, 50-66 (passim), 150, Texas, 126-127 171, 172 Three Mile Island, 51, 52, 55 operating rooms, 31, 36, 50, 52, 56, 79, Tiger teams, 175 157 Time-series measures, 182 outpatient, 2, 165 see also Benchmarking postsurgical complications, 31-32 Training, see Professional education reporting systems, 257, 263 Switzerland, 177

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287 INDEX U V Unit dosing, 183, 184-185, 193 Veterans Health Administration, 80, 83, United Kingdom, 32, 38-39, 226-227, 123 244-245 Vigilance, 5, 158, 164, 170, 172 University of Southern California, 72 Virginia, 142 User-centered design, 62, 78, 89, 150, 159, 163, 164, 171, 192 W User Liaison Program, 78 U.S. Navy, 160-162 Workload, 24, 42, 60 U.S. Pharmacopeia, 95, 104, 194 World Wide Web, see Internet Medication Errors Reporting (MER) Wristbands, 177, 195 program, 95, 97, 100, 125, 126- 127, 194 Utah, hospital studies, 1, 26, 30-31, 36-37, Y 40, 238-239, 248-249 Y2K issues, 82