Beyond Babel: prospects for a universal patient safety taxonomy.

In the Biblical story of the Tower of Babel, God foiled man's attempt to build a tower reaching to the heavens. And the Lord said, 'Behold, they are one people, and they have all one language; and this is only the beginning of what they will do. .. Come, let us go down, and there confuse their language, that they may not understand one another's speech'. Genesis 11: 6–7 Those familiar with the field of patient safety will recognize that confusing language does not, in fact, require divine intervention. In the space of a few years, a bewildering language of medical error and iatrogenic injury has evolved, bedeviling efforts to catalogue and understand this phenomenon. The terminology of safety is perplexing on a good day, and near impossible on a bad one. Consider a few examples of patient safety terms in common use. An 'adverse reaction' usually connotes an anticipated side effect of a medication or treatment. It is similar to a 'complication' of care. An 'adverse event', in contrast, signifies the presence of a medical care-related injury (anticipated or not). However, different users require different levels of harm in order to qualify an incident as an adverse event. A 'preventable adverse event' is an error by definition, but it is often difficult to ascertain preventabil-ity. A 'near miss', also called a 'close call', is synonymous with 'potential adverse event' and is always considered to be preventable. A 'sentinel event' refers to an incident that resulted in or might have produced a serious injury. A 'serious report-able event' is often not reported to public authorities, its name notwithstanding. One can see how this thicket of terms and concepts gets in the way of plain talk and thought. Perhaps the Babel-ites had it easy. To create a more coherent basis for patient safety improvement , the Institute of Medicine's Committee on Data Standards for Patient Safety advocated the development of a more thoughtful and consistent approach to the management of patient safety information [1]. A standard vocabulary and classification scheme would provide for comparison of research findings, better benchmarking across health care organizations, the development of reliable regional and national event reporting, and allow for interoperability of computer systems that collect information about these incidents for analysis, public reporting, and policy making. Jumping into the breach, a group of senior leaders from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) …