NQF endorses Patient Safety Event Taxonomy
NQF endorses Patient Safety Event Taxonomy
Organization’s leader calls it a good first step’
Before long, the nation’s patient safety professionals all will be speaking the same language, based on recent legislative developments and the endorsement by the National Quality Forum (NQF) of a voluntary system for classifying patient safety incidents to enable different patient safety reporting systems to communicate with each other.
The new national voluntary consensus standard for patient safety taxonomy also will allow users to analyze and compare information across systems to learn from patient safety events.
Called PSET, or the Patient Safety Event Taxonomy, it was formally unveiled by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) in the February 21, 2005, issue of the International Journal for Quality in Health Care.1
Five root nodes
PSET represents the consensus of more than 260 health care providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality improvement organizations.
PSET categorizes safety issues into five root nodes, or primary classifications:
- Impact: The outcome or effects of medical error and systems failure, commonly referred to as harm to the patient — i.e., psychological, physical, legal, social, economic.
- Type: The implied or visible processes which were faulty or failed — i.e., communication, patient management, clinical performance.
- Domain: The characteristics of the setting in which an incident occurred and the type of individuals involved — i.e., setting, staff, patient, target.
- Cause: The factors and agents that led to an incident — i.e., systems, human factors.
- Prevention and mitigation: The measures taken or proposed to reduce incidence and effects of adverse occurrences — i.e., universal, selective, indicated.
To support full implementation of the taxonomy, NQF also endorsed definitions of key patient safety terms, standard reporting elements for patient safety reporting systems, and recommendations for principles to guide improvement of the taxonomy.
PSET is "a good first step," according to Kenneth Kizer, MD, president and chief executive officer of NQF. "It’s a very basic taxonomy which, frankly, needs a lot of work, and will evolve substantially in the future, but of various options, as far as something to begin with, this was judged to be the best option," he says.
What the endorsement means
The NQF endorsement, coming as it does on the heels of the passage of Senate Bill 544, carries great significance in terms of the future adoption of PSET by health care organizations, says Kizer.
"Under the legislation that passed, in section 923 is a requirement that a basic [patient safety] categorization be adopted by the federal government," Kizer explains. "In the role under which we operate, the federal government is obligated to use what comes out of our process."
In this case, he explains, the Agency for Healthcare Research and Quality (AHRQ) would be the entity that operationalizes’ the system. "While they will do their due diligence, they would have to come up with a very good reason why something that is government-specific is better than this, since the health care industry, by our endorsement as its consensus setting body, is endorsing it," Kizer continues. "We have said this should be the standard, and one would certainly have expectations that this is what they will end up using. And if the government says something, it has a certain magnetic effect on other folks."
What PSET will do
What PSET will do, in short, is enable health care professionals analyzing patient safety to report their findings in the same language. "Right now, there are a number of systems that categorize and name things differently," Kizer explains.
"There’s real work to do, but it’s absolutely critical to move forward; it’s absolutely essential to have a single infrastructure."
PSET, he continues, will allow everyone to map what they’re doing to do the standard. "Over time, things will morph so we will be using a standard taxonomy," says Kizer. "But to begin with, whatever system one has or is using can map it to this and then start aggregating data."
Once this occurs, Kizer observes, there will be a large number of patients in the aggregate data — "and we will be able to interpret and make more meaning out of these otherwise infrequent events."
It also will eventually enable patient safety benchmarking, he says. "It allows you to put a stake in the ground as far as this is what’s happening at this point in time,’" Kizer notes. "The only caveat I would issue is that these things are grossly under-reported now. If the number of incidents increases over the next few years, it may not mean things are getting worse, but just that more are being reported, so we will have to interpret the numbers very carefully."
Since PSET was developed by JCAHO, will it eventually be incorporated into that organization’s standards? "That’s something they would have to answer," says Kizer, "But insofar as they will be hosting an international center on patient safety, this has a high likelihood of becoming international nomenclature; but those decisions have not been made."
For his part, Kizer is clear on the next logical step. "Now, we have to get the real-world experience," he says. "Dozens of systems have to start mapping to it and bringing forward their suggestions as to what needs be changed. This is version 1.0 Then, we will see 2.0, 2.5, and so on."
Reference
- Chang A, Schyve PM, Croteau RJ, O’Leary DS and Loeb JM. The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. International Journal for Quality in Health Care 2005 17(2):95-105.
Need More Information?
For more information on PSET:
- Go to www.qualityforum.org. Or contact Kenneth Kizer, MD, President and Chief Executive Officer, National Quality Forum, 601 13th St. N.W., Suite 500 N, Washington, DC 20005. Phone: (202) 783-1300. Fax: (202) 783-3434.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.