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hierarchy of severity (Table 1). In comparing these two methods of classification, the difference between outcome and process measurement is salient. Although various patient safety incidents could be caused by a number of factors, Leape’s taxonomy reflects specific problem behaviors. The most common types of preventable errors resulting in adverse events have been identified as: technical errors (44 percent); errors in diagnosis (17 percent); failures of prevention (12 percent); and errors in the use of a drug (10 percent).5 In terms of overall numbers, preventable technical complications of surgery (10,891) and wound infections (9,659) were most common, indicating areas where hospitals should focus their intervention efforts. A more recent report6 suggests that almost 60 percent of all patient safety incidents include: failure to rescue (delayed diagnosis and treatment); decubitus ulcer (bed sores); or postoperative sepsis (blood infection). This report also suggests the most lethal patient safety incidents—or those most closely associated with mortality—include failure to rescue and unexpected death during a low-risk hospitalization. Between 1995 and 2000, an increasing trend of certain types of events suggested a need for special attention. These included postoperative medical- and nursing-related adverse events, such as respiratory failure (31 percent); infection due to medical care (14 percent); decubitus ulcer (19 percent); septicemia (41 percent); thromboembolism (42 percent); and accidental punctures and lacerations (7 percent).7 Certain signs of progress are also noteworthy. Specifically, anesthesia reactions and complications decreased by 18 percent, and foreign bodies left during procedures were reduced 2 Table 1. Two widely used taxonomies for patient-safety incidents and medical errors AHRQ PSIs Leape Typology of Errors 1. Accidental puncture or laceration Domain Error 2. Complications of anesthesia 3. Death in low-mortality Diagnostic Related Groupings (DRGs) 4. Decubitus ulcer 5. Failure to rescue 6. Foreign body left during procedure 7. Iatrogenic pneumothorax Diagnostic 1. Error or delay in diagnosis 2. Failure to employ indicated tests 3. Use of outmoded tests or therapy 4. Failure to act on the results of monitoring or testing 8. Selected infections due to medical care 9. Postoperative hemorrhage or hematoma 10. Postoperative physiologic and metabolic derangement 11. Postoperative pulmonary embolism or deep vein thrombosis 12. Postoperative respiratory failure 13. Postoperative sepsis 14. Postoperative wound dehiscence 15. Transfusion reaction Treatment 5. Technical error in the performance of a procedure 6. Error in administering treatment 7. Error in dose or method of use of a drug 8. Avoidable delay in treatment or in response to an abnormal test 9. Inappropriate care 16. Birth trauma and obstetric trauma (3 types related to delivery methods) Preventive 10. Failure to provide indicated prophylactic treatment 11. Inadequate treatment monitoring or followup Other 12. Failure in communication 13. Equipment failure 14. Other systems failure by 7 percent. While small, these improvements are encouraging in terms of current proactive efforts to address patient safety. Preventing Errors in Health Care As depicted in Figure 1, patient safety outcomes are influenced by a number of factors, including several sources external to the hospital (e.g., relevant legislation, agency mandates, and special interest groups). Within-hospital sources include the health care culture, the institutional patient safety agenda, the specific environmental context in which the health care worker operates (which includes the patient), and the focus of this paper—the behavior of the caregiver. These multiple influences are, in turn, affected by patient safety outcomes in a reciprocal system most certainly affected by innumerable additional factors in varying degrees. 3 Figure 1. An overall model of patient safety. Domains of influence relevant to OBM are shown enlarged and in italics. Errors Addressed by System Change Medical mistakes caused by latent errors, such as similar sounding drug names or delays in treatment due to lack of staff, are best addressed by system change. For
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