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Medical Errors and Patient Safety


  • •  ‘Unusual Occurrence’ – The definitions of reportable events is provided in California Code of Regulations, Title 22 Division 5 Chapter 1 Article 7, CCR Title 22: §70737:
    • ◊   “Any occurrence such as epidemic outbreak, poisoning, fire, major accident, disaster, other catastrophe or unusual occurrence which threatens the welfare, safety or health of patients, personnel or visitors shall be reported as soon as reasonably practical,...”
    • ◊   CCR Title 22: §70738 – Infant Security [California Code of Regulations, Title 22 Division 5 Chapter 1 Article 7] provides for establishing a program to address Infant Security, and these events would fall under the broad umbrella of ‘unusual occurences’ defined above.
  • •  Medication-related errors’ are defined separately in statutes per California Health and Safety Code, § 1339.63(d) as:
    • ◊   ". . any preventable medication-related event that adversely affects a patient in a facility listed in subdivision (a), and that is related to professional practice, or health care products, procedures, and systems, including, but not limited to, prescribing, prescription order communications, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use."
    • ◊   The legislative roots of ‘Medication-related Errors’ are provided in a synopsis of SB 1875 and SB 801.
  • •  CABG Outcomes Reporting program – Definitions for outcomes available from 51 data element definitions that are provided in the CCORP Training Handbook [PDF file, pp 9-29].
  • •  CALICO Reporting Program

    Data variables for outcomes assessment are listed in section 2 of the October 2004 report [PDF file]. Data are collected from OSHPD's Post Discharge Database (PDD), which is based on hospital submissions of ICD-9 discharge information. The CALICO program was designed to assess the clinical performance of 4 different risk-adjustment models

    • –  Mortality Probability Model II at admission or "zero hours" (MPM0 II),
    • –  the Simplified Acute Physiology Score II (SAPS II),
    • –  the Acute Physiology and Chronic Health Evaluation, versions II (APACHE II), and
    • –  the Acute Physiology and Chronic Health Evaluation, versions III (APACHE III)

    The different models utilize the PDD to assess up to 78 separate diagnostic conditions occurring in ICUs, with exclusion of certain conditions (e.g. patients sustaining burns, trauma, CABG surgery, readmissions, determined not to have sustained myocardial infarctions, etc.) described in the initial report.

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