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The results suggest that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Patient Safety Event Taxonomy could facilitate a common approach for patient safety information systems. Having access to standardized data would make it easier to file patient safety event reports and to conduct root cause analyses in a consistent fashion.

Effective communication with patients is critical to the safety and quality of care. Barriers to this communication include differences in language, cultural differences, and low health literacy. Evidence-based practices that reduce these barriers must be integrated into, rather than just added to, health care work processes.KEY WORDS: language differences; cultural differences; low health literacy; health care; information management; accreditation. J Gen Intern Med 22(Suppl 2):360-1 DOI: 10.1007/s11606-007-0365-3 © Society of General Internal Medicine 2007 W hen a patient sees a clinician member of a treatment team, the clinician uses the available knowledge base (derived from her education and training, the literature, experience, decision-support systems, and protocols) to decide what data to collect about the patient and how to collect them. The clinician and other members of the team collect these data through conversations with the patient and the patient's family, observation of the patient, a physical and mental examination, laboratory testing, and imaging. The treatment team then synthesizes these patient-specific data with the evidence-based information in the available knowledge base to create new information: the patient's diagnosis and prognosis and, in the dialog with the patient, a treatment plan. Finally, the team disseminates this newly created information to the patient, the patient's family, other members of the treatment team, other professional caregivers, pharmacists, insurance companies, and others. Dissemination occurs through oral communication (e.g., in conversations with the patient, patient's family, and health care professionals), through writing (e.g., in consent forms, instructions, educational materials for patients, and in notes and instructions for other professional caregivers and pharmacists), and through electronic transmission (e.g., in pharmacy orders, insurance claims, and computerized, patient-accessible personal health records).This collection of data, transformation of data into information, storage of data and information, and dissemination of information are the key processes that comprise information management. Today, in health care, much of this information management is in the form of oral and written communications between team members, patients, and patients' families. The more the care is patient-and family-centered, the more frequent the communication with the patient and the patient's family to understand the patient's perspective and to involve the patient in the treatment team itself.Because much of medical care is really information management, this communication between treatment team members and the patient and patient's family is a core component of health care-it is more than an adjunct or facilitator of health care. Collection of accurate and comprehensive patientspecific data that are the basis for proper diagnosis and prognosis; involving the patient in treatment planning; eliciting informed consent; providing explanations, instructions, and educat...

We articulate an intellectual history and a definition, description and model of patient safety. We define patient safety as a discipline in the health care professions that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. We also define patient safety as an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events. Our description includes: why the field of patient safety exists (the high prevalence of avoidable adverse events); its nature; its essential focus of action (the microsystem); how patient safety works (e.g., high-reliability design, use of safety sciences, methods for causing change, including cultural change); and who its practitioners are (i.e., all health care workers, patients and advocates). Our simple and overarching model identifies four domains of patient safety (recipients of care, providers, therapeutics and methods) and the elements that fall within the domains. Eleven of these elements are described in this paper.