CONTENTS
EXECUTIVE SUMMARY = 1
1 A COMPREHENSIVE APPROACH TO IMPROVING PATIENT SAFETY = 17
Patient Safety : A Critical Component of Quality = 18
Organization of the Report = 21
2 ERRORS IN HEALTH CARE : A LEADING CAUSE OF DEATH AND INJURY = 26
Introduction = 27
How Frequently Do Errors Occur? = 29
Factors That Contribute to Errors = 35
The Cost of Errors = 40
Public Perceptions of Safety = 42
3 WHY DO ERRORS HAPPEN? = 49
Why Do Accidents Happen? = 51
Are Some Types of Systems More Prone to Accidents? = 58
Research on Human Factors = 63
Summary = 65
4 BUILDING LEADERSHIP AND KNOWLEDGE FOR PATIENT SAFETY = 69
Recommendations = 69
Why a Center for Patient Safety Is Needed = 70
How Other Industries Have Become Safer = 71
Options for Establishing a Center for Patient Safety = 75
Functions of the Center for Patient Safety = 78
Resources Required for a Center for Patient Safety = 82
5 ERROR REPORTING SYSTEMS = 86
Recommendations = 87
Review of Existing Reporting Systems in Health Care = 90
Discussion of Committee Recommendations = 101
6 PROTECTING VOLUNTARY REPORTING SYSTEMS FROM LEGAL DISCOVERY = 109
Recommendation = 111
Introduction = 112
The Basic Law of Evidence and Discoverability of Error-Related Information = 113
Legal Protections Against Discovery of Information About Errors = 117
Statutory Protections Specific to Particular Reporting Systems = 121
Practical Protections Against the Discovery of Data on Errors = 124
Summary = 127
7 SETTING PERFORMANCE STANDARDS AND EXPECTATIONS FOR PATIENT SAFETY = 132
Recommendations = 133
Current Approaches for Setting Standards in Health Care = 136
Performance Standards and Expectations for Health Care Organizations = 137
Standards for Health Professionals = 141
Standards for Drugs and Devices = 148
Summary = 151
8 CREATING SAFETY SYSTEMS IN HEALTH CARE ORGANIZATIONS = 155
Recommendations = 156
Introduction = 158
Key Safety Design Concepts = 162
Principles for the Design of Safety Systems in Health Care Organizations = 165
Medication Safety = 182
Summary = 197
APPENDIXES
A Background and Methodology = 205
B Glossary and Acronyms = 210
C Literature Summary = 215
D Characteristics of State Adverse Event Reporting Systems = 254
E Safety Activities in Health Care Organizations = 266
INDEX = 273
EXECUTIVE SUMMARY = 1
1 A COMPREHENSIVE APPROACH TO IMPROVING PATIENT SAFETY = 17
Patient Safety : A Critical Component of Quality = 18
Organization of the Report = 21
2 ERRORS IN HEALTH CARE : A LEADING CAUSE OF DEATH AND INJURY = 26
Introduction = 27
How Frequently Do Errors Occur? = 29
Factors That Contribute to Errors = 35
The Cost of Errors = 40
Public Perceptions of Safety = 42
3 WHY DO ERRORS HAPPEN? = 49
Why Do Accidents Happen? = 51
Are Some Types of Systems More Prone to Accidents? = 58
Research on Human Factors = 63
Summary = 65
4 BUILDING LEADERSHIP AND KNOWLEDGE FOR PATIENT SAFETY = 69
Recommendations = 69
Why a Center for Patient Safety Is Needed = 70
How Other Industries Have Become Safer = 71
Options for Establishing a Center for Patient Safety = 75
Functions of the Center for Patient Safety = 78
Resources Required for a Center for Patient Safety = 82
5 ERROR REPORTING SYSTEMS = 86
Recommendations = 87
Review of Existing Reporting Systems in Health Care = 90
Discussion of Committee Recommendations = 101
6 PROTECTING VOLUNTARY REPORTING SYSTEMS FROM LEGAL DISCOVERY = 109
Recommendation = 111
Introduction = 112
The Basic Law of Evidence and Discoverability of Error-Related Information = 113
Legal Protections Against Discovery of Information About Errors = 117
Statutory Protections Specific to Particular Reporting Systems = 121
Practical Protections Against the Discovery of Data on Errors = 124
Summary = 127
7 SETTING PERFORMANCE STANDARDS AND EXPECTATIONS FOR PATIENT SAFETY = 132
Recommendations = 133
Current Approaches for Setting Standards in Health Care = 136
Performance Standards and Expectations for Health Care Organizations = 137
Standards for Health Professionals = 141
Standards for Drugs and Devices = 148
Summary = 151
8 CREATING SAFETY SYSTEMS IN HEALTH CARE ORGANIZATIONS = 155
Recommendations = 156
Introduction = 158
Key Safety Design Concepts = 162
Principles for the Design of Safety Systems in Health Care Organizations = 165
Medication Safety = 182
Summary = 197
APPENDIXES
A Background and Methodology = 205
B Glossary and Acronyms = 210
C Literature Summary = 215
D Characteristics of State Adverse Event Reporting Systems = 254
E Safety Activities in Health Care Organizations = 266
INDEX = 273