Towards an International Classification for Patient Safety: the conceptual framework

Global advances in patient safety have been hampered by the lack of a uniform classification of patient safety concepts. This is a significant barrier to developing strategies to reduce risk, performing evidence-based research and evaluating existing healthcare policies relevant to patient safety. Since 2005, the World Health Organization's World Alliance for Patient Safety has undertaken the Project to Develop an International Classification for Patient Safety (ICPS) to devise a classification which transforms patient safety information collected from disparate systems into a common format to facilitate aggregation, analysis and learning across disciplines, borders and time. A drafting group, comprised of experts from the fields of patient safety, classification theory, health informatics, consumer/patient advocacy, law and medicine, identified and defined key patient safety concepts and developed an internationally agreed conceptual framework for the ICPS based upon existing patient safety classifications. The conceptual framework was iteratively improved through technical expert meetings and a two-stage web-based modified Delphi survey of over 250 international experts. This work culminated in a conceptual framework consisting of ten high level classes: incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors/hazards, organizational outcomes, detection, mitigating factors, ameliorating actions and actions taken to reduce risk. While the framework for the ICPS is in place, several challenges remain. Concepts need to be defined, guidance for using the classification needs to be provided, and further real-world testing needs to occur to progressively refine the ICPS to ensure it is fit for purpos

Towards an International Classification for Patient Safety: the conceptual framework

Global advances in patient safety have been hampered by the lack of a uniform classification of patient safety concepts. This is a significant barrier to developing strategies to reduce risk, performing evidence-based research and evaluating existing healthcare policies relevant to patient safety. Since 2005, the World Health Organization's World Alliance for Patient Safety has undertaken the Project to Develop an International Classification for Patient Safety (ICPS) to devise a classification which transforms patient safety information collected from disparate systems into a common format to facilitate aggregation, analysis and learning across disciplines, borders and time. A drafting group, comprised of experts from the fields of patient safety, classification theory, health informatics, consumer/patient advocacy, law and medicine, identified and defined key patient safety concepts and developed an internationally agreed conceptual framework for the ICPS based upon existing patient safety classifications. The conceptual framework was iteratively improved through technical expert meetings and a two-stage web-based modified Delphi survey of over 250 international experts. This work culminated in a conceptual framework consisting of ten high level classes: incident type, patient outcomes, patient characteristics, incident characteristics, contributing factors/hazards, organizational outcomes, detection, mitigating factors, ameliorating actions and actions taken to reduce risk. While the framework for the ICPS is in place, several challenges remain. Concepts need to be defined, guidance for using the classification needs to be provided, and further real-world testing needs to occur to progressively refine the ICPS to ensure it is fit for purpose

Near-miss analysis

Although near-miss events are much more common than adverse events—as much as 7–100 times more frequent—reporting systems for such events are much less common. As the airline industry has realized, analysis of near-miss data provides an opportunity to design systems that can prevent adverse events. Near-miss data for the health care domain should be analyzed more extensively than is currently the case. The data provide two types of information relevant to patient safety—on weaknesses in the health care system and, equally important, on recovery processes. The latter data are an underutilized source of valuable patient safety information. This chapter examines the functional requirements of near-miss systems and the implications for data standards. With some exceptions, near-miss data (and adverse event data) should be examined in the aggregate to determine priorities for health care improvement. The analysis of aggregate event data requires the use of standardized taxonomies to describe the root causes of failure, recovery processes, and situational contexts uniformly. Since near misses and adverse events are thought to be part of the same causal continuum, there should be identical taxonomies for failure root causes and context variables for both types of events. The development of near-miss systems works best when the systems are initially established and designed for the benefit of those delivering care, for example, a hospital department. Data from this level can be aggregated for higher-level purposes—reports for hospital-wide systems and domain-specific nationwide systems. However, uses of the data require that the same data standards be applicable across all domains and at all levels of aggregation. Near-miss systems should be an integral part of clinical care and quality management information systems. To foster data reuse across all health care applications, the same data standards should be used for all applications

Absent, missed and failed error recovery in medication errors

Abstract. Systematic analysis and understanding of error recovery can provide hospitals with the necessary information to improve their resilience. Because errors will always crop up and 100 % safety can never be achieved, health care systems should be able to prevent patient harm by timely and effective error recovery. In this paper we identified absent, missed and failed recovery opportunities in 56 medication errors, of which 52 resulted in severe patient harm or patient death. At least one recovery opportunity was present in nearly all of the medication errors. In the set of 52 full-blown accidents 127 recovery opportunities were identified. Of these, 94 recovery opportunities were planned recovery opportunities; 33 recovery opportunities were unplanned recovery opportunities. For these recovery opportunities the underlying failure factors were identified and classified according to the Eindhoven Classification Model. The majority of the failure factors underlying the planned recovery opportunities were organisational failure factors; the majority of the failure factors underlying the unplanned recovery opportunities were human failure factors. From this study it can be concluded that accidents can be used as an alternative data source to near misses for the analysis and understanding of error recovery.

How to survive process automation : a case study of integral user participation

This paper describes the background, execution and results of two large ergonomics projects in a Centralized Control Room (CCR) of a highly automated chemical process plant in Rotterdam. Special emphasis will be put on the extensive use of user participation techniques throughout all phases of these projects