An international language for patient safety.pdf
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Editorial An international language for patient safety Global progress in patient safety requires classification of key concepts The past 10 years has seen a rapid growth in research and action on patient safety throughout the world [1]. This is a welcome development. However, comparative analysis of risks to patient safety has been constrained by the absence of a common, internationally agreed set of patient safety con- cepts. In fact, patient safety appears to be a field of scientific endeavour in which identical terms are often understood to mean quite different things, depending on the standpoint of individuals involved. Such ambiguity frustrates progress. Since its inception in 2004, the WHO World Alliance for Patient Safety has recognized the importance of addressing this problem [2]. Over the past 3 years, careful, comprehen- sive work involving a wide range of experts from across the world has focussed on identifying and agreeing upon safety-related concepts, definitions and preferred terms based on solid theoretical and analytical foundations [3]. This has led to the development of a conceptual framework for an International Classification for Patient Safety (ICPS). Despite its many complexities, the central goal has been clear throughout—to enable categorization of patient safety infor- mation into a standardized set of concepts with agreed defi- nitions and preferred terms. The importance of being able to classify more consistently the major concepts associated with patient safety cannot be under-estimated. The ICPS is not simply part of the semantics of patient safety. Illnesses and drugs, for example, are classi- fied in order to aid diagnosis and help patients recover from their disease. Patient safety is no different. Classification is the means to better understand and communicate about hazards, common sources of risk and strategies to improve patient safety. The consistent use of key patient safety concepts with agreed definitions and preferred terms, in conjunction with a comprehensive but adaptable classification, paves the way for the systematic collection, aggregation and analysis of relevant information. In short, classification must be deeply integrated in all work on patient safety around the world. The World Alliance for Patient Safety has had a particular interest in reaching a wide range of interested audiences and potential users of the ICPS. This not only includes develo- pers and managers of safety-reporting systems, but also the researchers, policy makers and patient groups who will use this information to better understand risks to patients to develop strategies to improve patient safety. The three companion papers published in this issue of the journal mark an important step in bringing the future direc- tion of the programme of work to develop the ICPS to a wider audience. Each paper outlines a different aspect of the work that has been undertaken to date. The first paper by Sherman et al. provides an overview of the initiative including the formation of a Drafting Group and the development of guiding principles The second paper, by Thomson et al., describes how a web-based two-phase modified Delphi process ensured substantial input from interested parties throughout the world and informed the development of an agreed conceptual framework and related concepts The third paper by Runciman et al. describes in more detail the result- ing definitions and preferred terms for the 48 key concepts and how they relate to each other. Much remains to be done. Patient safety is a relatively new and emerging area of scientific discovery. A pragmatic and dynamic view must be taken of the ongoing development of the ICPS so as to incorporate new insights and knowledge. The ultimate vision is simple and consistent. The ICPS will be a solid foundation for global efforts to ensure rapid and systematic learning from the experiences of patient harm to make care safer for future patients everywhere. Sir Liam Donaldson Chairman WHO World Alliance for Patient Safety References 1. World Alliance for Patient Safety, World Health Organization. Research for Patient Safety . http://www.who.int/patientsafety/ research/en (1 September 2008, date last accessed). 2. World Alliance for Patient Safety, World Health Organization. http://www.who.int/patientsafety/en (1 September 2008, date last accessed). 3. World Alliance for Patient Safety, World Health Organization. Taxonomy for Patient Safety . http://www.who.int/patientsafety/tax- onomy/en (1 September 2008, date last accessed). International Journal for Quality in Health Care vol. 21 no. 1 Published by Oxford University Press 2009 The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact [email protected] 1 International Journal for Quality in Health Care 2009; Volume 21, Number 1: p. 1 10.1093/intqhc/mzn056 by guest on June 27, 2012 http://intqhc.oxfordjournals.org/ Downloaded from
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Transcript of An international language for patient safety.pdf
Editorial
An international language for patient safety
Global progress in patient safety requires classificationof key concepts
The past 10 years has seen a rapid growth in research andaction on patient safety throughout the world [1]. This is awelcome development. However, comparative analysis ofrisks to patient safety has been constrained by the absence ofa common, internationally agreed set of patient safety con-cepts. In fact, patient safety appears to be a field of scientificendeavour in which identical terms are often understood tomean quite different things, depending on the standpoint ofindividuals involved. Such ambiguity frustrates progress.
Since its inception in 2004, the WHO World Alliance forPatient Safety has recognized the importance of addressingthis problem [2]. Over the past 3 years, careful, comprehen-sive work involving a wide range of experts from across theworld has focussed on identifying and agreeing uponsafety-related concepts, definitions and preferred terms basedon solid theoretical and analytical foundations [3]. This hasled to the development of a conceptual framework for anInternational Classification for Patient Safety (ICPS). Despiteits many complexities, the central goal has been clearthroughout—to enable categorization of patient safety infor-mation into a standardized set of concepts with agreed defi-nitions and preferred terms.
The importance of being able to classify more consistentlythe major concepts associated with patient safety cannot beunder-estimated. The ICPS is not simply part of the semanticsof patient safety. Illnesses and drugs, for example, are classi-fied in order to aid diagnosis and help patients recover fromtheir disease. Patient safety is no different. Classification is themeans to better understand and communicate about hazards,common sources of risk and strategies to improve patientsafety. The consistent use of key patient safety concepts withagreed definitions and preferred terms, in conjunction with acomprehensive but adaptable classification, paves the way forthe systematic collection, aggregation and analysis of relevantinformation. In short, classification must be deeply integratedin all work on patient safety around the world.
The World Alliance for Patient Safety has had a particularinterest in reaching a wide range of interested audiences andpotential users of the ICPS. This not only includes develo-pers and managers of safety-reporting systems, but also theresearchers, policy makers and patient groups who will use
this information to better understand risks to patients todevelop strategies to improve patient safety.
The three companion papers published in this issue of thejournal mark an important step in bringing the future direc-tion of the programme of work to develop the ICPS to awider audience. Each paper outlines a different aspect of thework that has been undertaken to date. The first paper bySherman et al. provides an overview of the initiative includingthe formation of a Drafting Group and the development ofguiding principles The second paper, by Thomson et al.,describes how a web-based two-phase modified Delphiprocess ensured substantial input from interested partiesthroughout the world and informed the development of anagreed conceptual framework and related concepts The thirdpaper by Runciman et al. describes in more detail the result-ing definitions and preferred terms for the 48 key conceptsand how they relate to each other.
Much remains to be done. Patient safety is a relatively newand emerging area of scientific discovery. A pragmatic anddynamic view must be taken of the ongoing development ofthe ICPS so as to incorporate new insights and knowledge.The ultimate vision is simple and consistent. The ICPS willbe a solid foundation for global efforts to ensure rapid andsystematic learning from the experiences of patient harm tomake care safer for future patients everywhere.
Sir Liam Donaldson
ChairmanWHO World Alliance for Patient Safety
References
1. World Alliance for Patient Safety, World Health Organization.Research for Patient Safety. http://www.who.int/patientsafety/research/en (1 September 2008, date last accessed).
2. World Alliance for Patient Safety, World Health Organization.http://www.who.int/patientsafety/en (1 September 2008, datelast accessed).
3. World Alliance for Patient Safety, World Health Organization.Taxonomy for Patient Safety. http://www.who.int/patientsafety/tax-onomy/en (1 September 2008, date last accessed).
International Journal for Quality in Health Care vol. 21 no. 1
Published by Oxford University Press 2009
The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open
access version of this article for non-commercial purposes provided that: the original authorship is properly and fully attributed; the Journal and Oxford
University Press are attributed as the original place of publication with the correct citation details given; if an article is subsequently reproduced or
disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact
International Journal for Quality in Health Care 2009; Volume 21, Number 1: p. 1 10.1093/intqhc/mzn056
by guest on June 27, 2012http://intqhc.oxfordjournals.org/
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