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The nomenclature of safety and quality of care for patients with congenital cardiac disease: a report of the Society of Thoracic Surgeons Congenital Database Taskforce Subcommittee on Patient Safety

Part of: The International Society for Nomenclature of Paediatric and Congenital Heart Disease (ISNPCHD)

Published online by Cambridge University Press:  01 December 2008

Jeffrey Phillip Jacobs ,
Oscar J. Benavidez ,
Emile A. Bacha ,
Henry L. Walters III  and
Marshall Lewis Jacobs
Jeffrey Phillip Jacobs*
Affiliation:
The Congenital Heart Institute of Florida (CHIF), Division of Thoracic and Cardiovascular Surgery, All Children’s Hospital and Children’s Hospital of Tampa, University of South Florida College of Medicine, Cardiac Surgical Associates (CSA), Saint Petersburg and Tampa, Florida, United States of America
Oscar J. Benavidez
Affiliation:
Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
Emile A. Bacha
Affiliation:
Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
Henry L. Walters III
Affiliation:
Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan, United States of America
Marshall Lewis Jacobs
Affiliation:
Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America
*
Correspondence to: Jeffrey P. Jacobs, MD, FACS, FACC, FCCP, Cardiovascular and Thoracic Surgeon, Surgical Director of Heart Transplantation and ECMO, The Congenital Heart Institute of Florida (CHIF), Clinical Associate Professor, University of South Florida (USF), Cardiac Surgical Associates (CSA), 603 Seventh Street South, Suite 450, Saint Petersburg, FL 33701, United States of America. Tel: (727) 822 6666; Fax: (727) 821 5994; Cell Phone: (727) 235 3100; E-mail: [email protected]; http://www.heartsurgery-csa.com/; http://www.CHIF.us/
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Abstract

A large body of literature devoted to “patient safety” and error prevention exists and utilizes a nomenclature that can be applied specifically to the field of congenital cardiac disease and aid in the goals of increasing the safety of patients, decreasing medical error, minimizing mortality and morbidity, and evaluating quality of care. The purpose of this manuscript is to suggest and document a quality of health care taxonomy and the appropriate application of this nomenclature of “patient safety” to the specialty of congenital cardiac disease, with special emphasis on the following ten terms: morbidity, complication, medical error, adverse event, harm, near miss, iatrogenesis, iatrogenic complication, medical injury, and sentinel event. Each of these terms is commonly utilized in the medical literature without universal agreement on their meaning and relationship. It is our hope that the standardization of the definitions of these terms, as they are applied to the analysis of outcomes of the treatments applied to patients with congenital and paediatric cardiac disease, will facilitate improved methodologies to assess and improve quality of care in our profession.

Keywords

Congenital heart diseasecomplicationsmedical errorsurgical outcomesregistry
Type
Original Article
Information
Cardiology in the Young , Volume 18 , Issue S2: Databases and the assessment of complications associated with the treatment of patients with congenital cardiac disease , December 2008 , pp. 81 - 91
Copyright
Copyright © Cambridge University Press 2008

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References

1.Jacobs, JP, Mavroudis C Jacobs, ML, et al. What is operative mortality? Defining death in a surgical registry database: a report of the STS Congenital Database Taskforce and the Joint EACTS-STS Congenital Database Committee. Ann Thorac Surg 2006; 81: 1937–1941.CrossRefGoogle Scholar
2.Jacobs, JP, Jacobs, ML, Mavroudis, C, et al. What is operative morbidity? Defining complications in a surgical registry database: a report from the STS Congenital Database Task Force and the Joint EACTS-STS Congenital Database Committee. Ann Thorac Surg 2007; 84: 1416–1421.CrossRefGoogle Scholar
3. Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database – Second Harvest – (1998–2001) Beta Site Test. The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Fall 2002 Harvest.Google Scholar
4. Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database – Third Harvest – (1998–2002). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Spring 2003 Harvest.Google Scholar
5. Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database – Fourth Harvest – (2002-2003). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Spring 2004 Harvest.Google Scholar
6.Jacobs, JP, Mavroudis, C, Jacobs, ML, et al. Lessons learned from the data analysis of the second harvest (1998–2001) of the Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database. Eur J Cardiothorac Surg 2004; 26: 18–37.Google Scholar
7. Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database – Fifth Harvest – (2002–2004). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Spring 2005 Harvest.Google Scholar
8.Jacobs, JP, Maruszewski, B, Tchervenkov, CI, et al. The current status and future directions of efforts to create a global database for the outcomes of therapy for congenital heart disease. Cardiol Young 2005; 15 (Suppl 1): 190–197.Google Scholar
9.Jacobs, JP, Lacour-Gayet, FG, Jacobs, ML, et al. Initial application in the STS congenital database of complexity adjustment to evaluate surgical case mix and results. Ann Thorac Surg 2005; 79: 1635–1649.Google Scholar
10.Jacobs, JP, Maruszewski, B; European Association for Cardio-thoracic Surgery-Society of Thoracic Surgeons Joint Congenital Heart Surgery Nomenclature and Database Committee. Computerized outcomes analysis for congenital heart disease. Curr Opin Pediatr 2005; 17: 586–591.CrossRefGoogle ScholarPubMed
11.Jacobs, JP, Jacobs, ML, Maruszewski, B, et al. Current status of the European Association for Cardio-Thoracic Surgery and the Society of Thoracic Surgeons Congenital Heart Surgery Database. Ann Thorac Surg 2005; 80: 2278–2284.Google Scholar
12. Jacobs JP, Jacobs ML, Mavroudis C, Lacour-Gayet FG, Tchervenkov CI. Executive Summary: The Society of Thoracic Surgeons Congenital Heart Surgery Database – Sixth Harvest – (2002–2005). The Society of Thoracic Surgeons (STS) and Duke Clinical Research Institute (DCRI), Duke University Medical Center, Durham, North Carolina, United States, Spring 2006 Harvest.Google Scholar
13.Webster’s New World Dictionary of the American Language. The World Publishing Company, Cleveland and New York, 1957.Google Scholar
14.Kohn, LT, Corrigan, JM, Donaldson, M (eds). Committee on Quality of Health Care in America, Institute of Medicine (IOM) Report – To Err Is Human: Building a Safer Health System. Washington, DC: National Academy of Sciences; 2000. (Free Executive Summary). http://www.nap.edu/catalog/9728.htmlGoogle Scholar
15. QuIC Fact Sheet. [http://www.quic.gov/about/quicfact.htm], accessed July 19, 2008.Google Scholar
16. QuIC report to the President. Doing what counts for patient safety: Federal actions to reduce medical errors and their impact. February 21, 1999. [http://www.quic.gov/report/mederr4.htm#definitions], accessed July 19, 2008.Google Scholar
17.Brennan, TA, Leape, LL, Laird, NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370–376.CrossRefGoogle ScholarPubMed
18.Brennan, TA, Leape, LL, Laird, NM, Hebert, L, Localio, AR, Lawthers, AG, Newhouse, JP, Weiler, PC, Hiatt, HH. Harvard Medical Practice Study I. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care 2004; 13: 145–151; discussion 151–152.CrossRefGoogle ScholarPubMed
19.Andrews, LB, Stocking, C, Krizek, T, Gottlieb, L, Krizek, C, Vargish, T, Siegler, M. An alternative strategy for studying adverse events in medical care. Lancet 1997; 349: 309–313.Google Scholar
20.Leape, LL. From the Harvard School of Public Health, Boston. Health Policy Report: Patient safety – Reporting of adverse events. N Engl J Med 2002; 347: 1633–1638; November 14, www.nejm.orgGoogle Scholar
21.Murff, HJ, Forster, AJ, Peterson, JF, Fiskio, JM, Heiman, HL, Bates, DW. Electronically screening discharge summaries for adverse medical events. J Am Med Inform Assoc 2003; 10: 339–350.Google Scholar
22.Hiatt, HH, Barnes, BA, Brennan, TA, et al. A study of medical injury and medical malpractice. N Engl J Med 1989; 321: 480–484.Google Scholar
23.Woods, D, Thomas, E, Holl, J, Altman, S, Brennan, T. Adverse events and preventable adverse events in children. Pediatrics 2005; 115: 155–160. http://www.pediatrics.org/cgi/content/full/115/1/155CrossRefGoogle ScholarPubMed
24.Weingart, S, Wilson, R, Gilbberd, R, Harrison, B. Epidemiology of medical error. BMJ 2000; 320: 774–777.Google Scholar
25.Shah, RK, Kentala, E, Healy, GB, Roberson, DW. Classification and consequences of errors in otolaryngology. Laryngoscope 2004; 114: 1322–1335.CrossRefGoogle ScholarPubMed
26.Van der Schaaf, TW, Lucas, DA, Hale, AR (eds). Near miss reporting as a safety tool. Butterworth-Heinemann, Oxford, 1991.Google Scholar
27.Van der Schaaf, TW. Medical applications of industrial safety science. Qual Saf Health Care 2002; 11: 205–206.Google Scholar
28.Wright, L, van der Schaaf, T. Accident versus near miss causation: a critical review of the literature, an empirical test in the UK railway domain, and their implications for other sectors. J Hazard Mater 2004; 111: 105–110. Review. PMID: 15231354 [PubMed – indexed for MEDLINE].CrossRefGoogle ScholarPubMed
29.Kanse, L, van der Schaaf, TW, Vrijland, ND, van Mierlo, H. Related Articles, Error recovery in a hospital pharmacy. Ergonomics 2006; 49: 503–516. PMID: 16717007 [PubMed – indexed for MEDLINE].Google Scholar
30.Barach, P, Small, SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000; 320: 759–763.Google Scholar
31.Cole, T. Medical errors vs medical injuries: physicians seek to prevent both. JAMA 2000; 284: 2175–2177.Google Scholar
32.Layde, PM, Cortes, LM, Teret, SP, et al. Patient safety efforts should focus on medical injuries. JAMA 2002; 287: 1993–1997.Google Scholar
33.Layde, PM, Meurer, LN, Guse, C, et al. Medical injury identification using hospital discharge data. In: Henriksen, K, Battles, JB, Marks, ES, Lewin, DI (eds). Advances in patient safety: From research to implementation. Vol. 2, Concepts and methodology. Agency for Healthcare Research and Quality, Rockville, Maryland, 2005, pp 119–132. [http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=aps.section.1975] accessed July 19, 2008.Google Scholar
34.Galvan, C, Bacha, EA, Mohr, J, Paul, Barach. A human factors approach to understanding patient safety during pediatric cardiac surgery. Progr Pediatr Cardiol 2005; 20: 13–20.Google Scholar
35.http://www.jointcommission.org/SentinelEvents/, accessed December 25, 2006.Google Scholar