Patient Safety: Achieving a New Standard for Care

Every day, tens if not hundreds of thousands of errors occur in the health care system. Some can cause disastrous effects, while others--the "near misses"--slip by almost unnoticed. In recent years, patient safety reporting systems have proliferated in health care, and many hospitals now routinely capture information on "near misses" as well as disasters. However, the utility of these reporting systems is limited. The data they collect is neither complete nor standardized, and reporting is cumbersome, costly, and sporadic at best. Improving patient safety will require much more than information systems, even if they are comprehensive and well functioning, for reporting and analyzing errors. An enhanced care delivery system must be built, one that can prevent errors from occurring in the first place. To do this, the health care industry must simultaneously set up an easy and streamlined way for health care professionals to acquire and share information related to error prevention and quality improvement. Building on the revolutionary Institute of Medicine reports "To Err is Human and "Crossing the Quality Chasm, Patient Safety puts forward a road map for the development and adoption of key health care data standards to support both information exchange and the reporting and analysis of patient safety data.