Standardizing a Patient Safety Taxonomy

Process

Through the NQF Consensus Development Process (CDP), this project resulted in an NQF-endorsed™ standardized taxonomy for patient safety. Having a standardized taxonomy will facilitate the management of patient safety data across reporting systems and should support patient safety data management innovation.

Background

Widespread efforts are now underway to identify and report healthcare errors and other patient safety-related information. Until now there has been an inability to combine or aggregate, compare, and analyze data from across the many public and private reporting systems because there has been no standardized taxonomy for classifying the data. With its August 2005 endorsement of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) Patient Safety Event Taxonomy (PSET)™, NQF took an important step toward providing the common framework needed for aggregating, classifying and reporting data that will ultimately provide for system and national patient safety improvement. The 2003 report by the Institute of Medicine (IOM), Patient Safety: Achieving a New Standard of Care, reviewed some existing patient safety reporting systems and taxonomies and proposed a set of domain areas for a common patient safety reporting format. This set of domain areas was endorsed as the minimum data set that should be used in any patient safety reporting system. Along with the taxonomy and IOM domains, NQF endorsed a set of basic definitions for patient safety, threat to patient safety, patient safety taxonomy, harm, risk and hazard.

Also endorsed were principal and secondary purposes of a standardized patient safety taxonomy as follows:

• Primary purpose: to support better decisionmaking and the prevention of harm in patient care settings by enabling better information collection and aggregation, across information systems, on threats to patient safety from all healthcare settings and sources of information of such events.
• Secondary purpose: to enable analyses of that information so that evidence-based improvement of healthcare for individuals and populations will become an intrinsic property of the healthcare system and of national policy.

Guiding principles for improving the taxonomy will be effected immediately by operationalizing an NQF Patient Safety Taxonomy Consensus Standards Maintenance Committee. The guiding principles affirm that the taxonomy should:

• be actively maintained and continually updated and improved by JCAHO, with input from an outside user’s group.
• be subjected to periodic reconsideration through the NQF Consensus Development Process (CDP), as necessary.
• undergo immediate testing, with support from both government and private entities, to examine how well data from various reporting systems can map to it.

Funding

This project was supported in part by the California HealthCare Foundation and the Agency for Healthcare Research and Quality.

For more information, contact the National Quality Forum at 202.783.1300 or info@qualityforum.org.