Patient Safety: Achieving a New Standard for Care (2004)
Chapter: Appendix D: Clinical Domains for Patient Safety
D
Clinical Domains for Patient Safety
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Consolidated Health Informatics Initiative Clinical Domain Areas |
Additional Domains for Patient Safety |
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Demographics |
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Diagnosis/problem lists for: Signs Symptoms Diseases Social problems |
Patient risk factors/precursors (e.g., designation of comorbid diagnosis) |
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Interventions/procedures including: Laboratory orders Laboratory results contents |
Complications associated with specific procedures |
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Encounters |
Episodes |
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Process-specific risk factors (e.g., managing coronary health failure) |
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Departmental risk factors (e.g., delays in the emergency room) |
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Clinical data measures for health conditions |
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Medications including: Clinical drugs Warnings |
Alternative medicines Nutritional supplements Vitamins |
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Consolidated Health Informatics Initiative Clinical Domain Areas |
Additional Domains for Patient Safety |
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Allergic reactions Adverse drug events (ADE) |
Over-the-counter medications Previous known adverse drug reactions Triggers Medication orders Drug interactions Patient-specific drug dosing Diagnosis-specific drug indications Diagnosis-specific drug contraindications |
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Text-based reports including: Clinical document architecture Clinical document naming |
Clinical template |
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History and physical including: History Vital signs Anatomy Exam findings Functional status |
Nutritional status Discharge or treatment plan Determinants for genetic testing/screening of family-related diseases |
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Immunizations |
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Provider information Training level, cultural factors, speaking language, health |
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Population health including: Nosocomial infections reporting Reportable infections reporting Other reportable conditions Hospital errors other than ADE Emergency room trauma reporting Other national health statistics |
Near misses Patient complaints Readmission indicators Performance measurement Causal factors Malpractice claims Risk management reports Potential adverse events assessment through electronic surveillance |
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Genes and proteins |
Pharmacogenomic markers for drug response or drug complication |
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Multimedia including but not limited to: Image Audio Waveforms |
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Consolidated Health Informatics Initiative Clinical Domain Areas |
Additional Domains for Patient Safety |
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Nursing including: Diagnoses Interventions Goals and outcomes |
Process-specific nursing factors Acuity levels for nurse staffing |
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Physiology |
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Knowledge bases (systematic reviews of): Clinical guidelines Medical literature Health outcomes data Disease registries |
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Patient self-management Data set and guidelines for self-care Rx interaction program access |
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Functioning and disability |
Rehabilitation therapies Respiratory Occupational Speech, etc. |
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Supplies including: Ontology for the ordering physician Medical devices |
Medical device simulations and testing |
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Organizational process factors Organizational risk factors Hazard analysis |
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Chemicals (Unified Medical Language System—UMLS) |
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Billing (Health Insurance Portability and Accountability Act, Administrative Simplification, Transactions and Code Sets) |
Data from claims attachment |
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Scientific/fundamental (UMLS) |
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Units (UMLS) |
