Abstract
This chapter presents the overview of the current status and developmental stages of the PSIS technology and consensus around the patient safety issues as they emerge, grow, and mature globally. The first section gives the general description of the patient safety reporting system (PSRS), and then provides the brief summary of 23 patient safety information classifications and terminologies to date. In the next section, the development of the international classification of patient safety (ICPS) is overviewed, which evolved from the local to an international level by the joint initiatives of WHO. The essential elements of the PSIS and the clinical decision support system (CDSS) functionalities are explained to make the future goals of PSIS clearer. The patient safety indicator (PSI) is explained in a separate section, which provides the opportunity to assess the incidence of adverse events and in-hospital complications using administrative data found in the typical discharge record. The ultimate goals of PSIS and PSI are to improve the quality of healthcare and ensure patient safety.
TopPatient Safety Reporting System
There are many ways to improve patient safety using information technology (Bates & Gawande, 2003). One way of improving safety is improving detection and reporting systems for error and adverse event (IOM, 2003). In small studies, computerized reporting systems have been associated with an increased rate of spontaneous reporting (Dixon, Wielgosz, & Pires, 2002). Computerized reporting streamlines subsequent evaluation by making it is easier to perform analyses and categorize reports in different ways. One university hospital treating more than 25,000 patients annually reported a feasibility study of a computerized voluntary based medical error reporting system in the ambulatory setting (Plews-Ogan et al., 2004). The findings showed that the voluntary based medical error reporting system resulted in a 20-fold increased reporting rate, and physicians reported many of these errors. Also the study suggested that new medical error reporting systems should combine reporting with analytic functions to facilitate analysis. A study by Furakawa et al from Japan found that a computerized medical error reporting system was effective and acceptable to providers, and facilitated analysis (Furukawa, Bunko, Tsuchiya, & Miyamoto, 2003). In another study, a web-based reporting system was developed and implemented for medical workers of 54 hospitals who were working in neonatal intensive care units (Suresh et al., 2004). This system was both voluntary and anonymous. Evaluation of the feasibility and utility of this approach revealed that it was well received, and effective for identifying a wide variety of medical errors. In addition, the approach facilitated cooperative, multidisciplinary studies.
In developing a medical error reporting system, the key factors to consider are objectives of the system, challenges associated with such objectives, classification system, reporting process, and how the errors will be analyzed (Beasley, Escoto, & Karsh, 2004). In addition, systems should ideally be non-punitive, and voluntary to the greatest extent possible and with certain exceptions.
Key Terms in this Chapter
Adverse Event: An incident which results in harm to a patient.
Event: Something that happens to or involves a patient.
Safety: Freedom from hazard.
Root Cause Analysis (RCA): A systematic iterative process whereby the factors which contribute to an incident are identified by reconstructing the sequence of events and repeatedly asking “why?” until the underlying root causes have been elucidated.
Patient Safety Reporting System (PSRS): A system that collect, analyze, communicate, and report the adverse events as well as near misses. This should be a voluntary, confidential, and non-punitive reporting system, and the staffs are invited to voluntarily report any events or concerns they have, which involve patient safety.
Patient Safety Event Taxonomy (PSET): A taxonomy that identifies the severity or degree of physical and psychological harm, ranging from the least harm to the most harm, resulting from adverse events. It also categorizes other potential consequences due to error and systems failure, and was developed by the Joint Commission.
Hazard: A circumstance, agent or action that can lead to or increase risk.
Patient Safety Indicator (PSI): A set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth using administrative data found in the typical discharge record.
Harm: Impairment of structure or function of the body and/or any deleterious effect arising there from.
Patient Safety: Freedom, for a patient, from unnecessary harm or potential harm associated with healthcare.
Clas sification: An arrangement of concepts into classes and their subdivisions to express the semantic relationships between them.
Near Miss: An incident that did not cause harm. Events for which a recovery step (planned or unplanned) allows for interruption and correction of the error.
International Classification of Patient Safety (ICPS): A logically oriented hierarchical framework of concepts designed to translate patient safety incident data collected from a range of sources into a standardized classification developed by the World Alliance of Patient Safety, WHO.
Error: Failure to carry out a planned action as intended or application of an incorrect plan.
Patient Safety Information System (PSIS): A system that provides an understanding of the magnitude of specific patient safety issues, and baseline and trend data to support institutional and national patient safety improvement initiatives. The main features include incident reporting and patient safety data management and utilization to assess, analyze, diagnose, plan, intervene, evaluate and prevent the patient safety problems.
Patient Safety Incident: An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient.