The JCAHO Patient Safety Event Taxonomy

Patient Safety Event Taxonomy

Homogeneous elements of models in the literature were categorized into five complementary root nodes, or primary classifications:

1. Impact -- the outcome or effects of medical error and systems failure, commonly referred to as harm to the patient.
2. Type -- the implied or visible processes that were faulty or failed.
3. Domain -- the characteristics of the setting in which an incident occurred and the type of individuals involved.
4. Cause -- the factors and agents that led to an incident
5. Prevention and mitigation -- the measures taken or proposed to reduce incidence and effects of adverse occurrences

The root nodes were then divided into 21 subclassifications, which were in turn subdivided into more than 200 coded categories and an indefinite number of non-coded text fields to capture narrative information about specific incidents.

Impact

The impact classification comprised three subclassifications that could discriminate between 18 types of outcomes or effects (harm). The harm index was based on the NCC MERP Medication Error Taxonomy [1], ranging from no harm to temporary or permanent impairment of physical or psychological function. Broad distinctions were also made between medical (psychological or physical) and non-medical (legal, social, or economic) impacts.

• MEDICAL
  • Psychological
    1. No Harm and No Undetectable Harm:
       sufficient information or able to determine that no harm occurred
    2. No Undetectable Harm:
       insufficient information or unable to determine any harm
    3. Mild-Temporary Harm:
       requires little or not intervention
    4. Mild-Permanent Harm:
       requires initial but not prolonged intervention
    5. Moderate-Temporary Harm:
       requires initial but not prolonged hospitalization
    6. Moderate-Permanent Harm:
       requires intensive but not prolonged hospitalization
    7. Severe-Temporary Harm:
       requires intervention necessary to sustain life but not prolonged hospitalization
    8. Severe-Permanent Harm:
       requires intervention necessary to sustain life and prolonged hospitalization or long-term care
    9. Profound Mental Harm
  • Physical
    1. No Harm and No Undetectable Harm:
       sufficient information or able to determine that no harm occurred
    2. No Detectable Harm:
       insufficient information or unable to determine any harm
    3. Minimal-Temporary Harm:
       requires little or no intervention
    4. Minimal-Permanent Harm:
       requires initial but not prolonged intervention
    5. Moderate-Temporary Harm:
       requires initial but not prolonged hospitalization
    6. Moderate-Permanent Harm:
       requires intensive but not prolonged hospitalization
    7. Severe-Temporary Harm:
       requires intervention necessary to sustain life but not prolonged hospitalization
    8. Severe-Permanent Harm:
       requires intervention necessary to sustain life and prolonged hospitalization, long-term care, or hospice
    9. Death
• NON-MEDICAL
  • Legal
  • Social
  • Economic

Type

This includes three levels that address communication, patient management, and clinical performance. The 'communication' subclassification identified communication problems that exist between provider and patient, provider and patient's proxy, provider and non-medical staff, and among providers. The 'patient management' node classified substandard patient management that involved improper delegation, failure in tracking or follow-up, wrong referral or consultation, or questionable use of resources. The 'clinical performance' subclassification included the full range of failures that could lead to iatrogenic events during the pre-intervention, intervention, and post-intervention phases of care.

• Level 1: Communication
  • Inaccurate and Incomplete Information
  • Questionable Advice or Interpretation
  • Questionable Consent Process
  • Questionable Disclosure Process
  • Questionable Documentation
• Level 2: Patient Management
  • Questionable Delegation
  • Questionable Tracking or Follow-up
  • Questionable Referral or Consultation
  • Questionable Use of Resources
• Level 3: Clinical Performance
  • Pre-Intervention
    1. Correct Diagnosis, Questionable Intervention
    2. Inaccurate Diagnosis
    3. Incomplete Diagnosis
    4. Questionable Diagnosis
  • Intervention
    1. Correct Procedure, With Complication
    2. Correct Procedure, Incorrectly Performed
    3. Correct Procedure, But Untimely
    4. Omission of Essential Procedure
    5. Procedure Contraindicated
    6. Procedure Not Indicated
    7. Wrong Patient
  • Post-Intervention
    1. Correct Prognosis
    2. Inaccurate Prognosis
    3. Incomplete Prognosis
    4. Questionable Prognosis

Domain

This classification included the types of health care professionals commonly involved in patient care and the demographics of patients in a variety of health care settings where events might have occurred. A link was postulated between where the event took place and which medical specialty was involved.

• Setting
  • Hospital
    • Emergency Department
    • Ambulatory Care
    • Skilled Nursing Facility
    • OR
    • Clinical Laboratory
    • Diagnostic Procedures
    • Psychiatric Unit
    • Rehabilitation
    • Pharmacy
    • Hospice
    • Interventional Radiology
    • Cath.Lab
    • Outpatient Behavioral Health
    • Other
  • Practitioner Office
  • Ambulatory Care Clinic
  • Nursing Home
  • Home
  • Hospice
  • Rehabilitation Facility
  • Mental Health Facility
  • Long Term Care Facility
  • Psychiatric Hospital
• Staff
  • Physician-Intern/Resident
  • Physician
  • Dentist
  • Psychologist
  • Chiropractor
  • Podiatrist
  • Physician Assistant
  • Health Profession Student
  • Other Caregiver
  • Nurses Aide
  • Nurse-LPN
  • Nurse-RN
  • Nurse Practitioner
  • Physical Therapist
  • Occupational Therapist
  • Speech Therapist
  • Pharmacist
  • Pharmacy Technician
  • Radiation Technician
  • Optometrist
  • Other
• Patient
  • Age
  • Gender
  • Diagnosis
  • Coexisting Conditions
  • Duration of Disease
  • Social Economic Status
  • Education Level
  • Race and Ethnicity
  • Other
• Target
  • Therapeutic
  • Diagnostic
  • Rehabilitative
  • Preventive
  • Palliative
  • Research
  • Cosmetic
  • Other

Causes

Root cause analyses of sentinel events in all categories showed that the underlying causes of these events could be classified into two principal groupings: system (process/structure) failures and human failures. System failures are remote from the direct control of the clinician and are usually the distal cause of structure and process failures among reported sentinel events (e.g. orientation/training, availability of information, staffing levels; physical environment, alarm systems, organizational culture). System failures are errors in the design, organization, or maintenance that lead to operator errors. Those failures involving direct contact with the patient -- human failures -- are often part of the proximate cause of an event. The root cause analysis data yielded groupings that included communication, patient assessment, and continuum of care, among others. The subclassification, 'latent organizational failure', included five coded categories: (i) management, (ii) organizational culture, (iii) protocols and processes, (iv) transfer of knowledge, and (v) external factors. Two categories for latent technical failure -- facilities and external factors -- were derived from the Eindhoven Classification System.

• Systems (Structure/Process)
  • Organizational
    • External. Organizational failures that are beyond the control and responsibility of the organization.
    • Internal: Management
      1. Maintenance of Organizational Resources:
         • Selection
         • Training
         • Staffing
      2. Monetary Safety Budgets
    • Internal: Organizational Culture
      1. Chain of Command
      2. Delegation of Authority and Responsibility
      3. Communication Channels
      4. Formal Accountability
      5. Culture of Safety
    • Internal: Protocols / Processes
      1. Processes
         • Time Pressures
         • Incentive Systems
         • Schedules
      2. Procedures (Organizational)
         • Performance Standards
         • Objectives
         • Documentation
         • Instructions about Procedures
      3. Oversight
         • Risk Management
         • Establishment and use of safety programs
    • Internal: Transfer of Knowledge
      • Supervision
      • Training
  • Technical
    • Facilities
      1. Equipment / Materials
         • Design
         • Construction
      2. Equipment / Materials
         • Malfunction
         • Obsolescence
      3. Equipment / Materials
         • Availability
    • External: technical failures that are beyond the control and responsibility of the organization
• Human
  • Error (Actual and Near Misses)
    • Patient
      • Patient Factors: Failures related to patient characteristics or actions that are beyond the control of the practitioner
    • Practitioner
      • Skill-based: failure in execution of "pre-programmed" and stored instructions or routine tasks
      • Rule-based: failure in retrieval and usage of stored instructions or in performing familiar tasks
      • Knowledge-based: failure due to resource limitation (e.g. insufficient time), and incorrect or incomplete knowledge
      • Unclassifiable
    • External
      • Human failures that are beyond the control and responsibility of the organization

Prevention (P) and Mitigation (M)

In this classification, three types of prevention and mitigation were identified: universal, selective, and indicated. The 'universal' subclassification covered preventive and corrective emasures that are designed for everyone in the eligible population. Prevention and mitigation measures that are directed toward a subgroup of the population whose risk of adverse events is above average were grouped in the 'selective' subclassification. Lastly, the 'indicated' subclassification combined interventions that are targeted to specific high-risk individuals identified as having a minimal but detectable risk for sustaining an adverse event.

• Universal
  • Improve the accuracy of patient identification (P)
    • Use at least two patient identifiers (neither to be the patient's room number) whenever taking blood samples or administering medications or blood products
    • Confirm the correct patient, procedure and site, using active, not passive communication techniques
  • Improve the effectiveness of communication among caregivers (P)
    • Implement a process for taking verbal or telephone orders or critical test results that require a verification "read-back" of the complete order or test result by the person receiving the order or test result
    • Standardize the abbreviations, acronyms and ysmbols used throughout the organization, including a list of abbreviations, acronyms, and symbols not to use
  • Improve the effectiveness of clinical alarm systems (P)
    • Implement regular preventive maintenance and testing of alarm systems
    • Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit
  • Reduce the risk of health care-acquired infections (M)
    • Comply with current CDC hand hygiene guidelines
    • Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection
• Selective
  • Eliminate wrong-site, wrong-patient, wrong-procedure surgery (M)
    • Create and use a preoperative verification process
    • Implement a process to mark the surgical site and involve the patient in the marking process
• Indicated
  • Improve the safety of using high-alert medications (P)
    • Remove concentrated electrolytes
    • Standardize and limit the number of drug concentrations available in the organizations
  • Improve the safety of using infusion pumps (P)
    • Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization

References

1. National Coordinating Council for Medication Error Reporting and Prevention. USA. NCC MERP Taxonomy of Medication Errors, 2001. [Online at www.nccmerp.org/pdf/taxo2001-07-31.pdf ]