The International Classification for Patient
Safety: an overview
In collaboration with WHO Classifications, Standards and
Terminology
March 2011
Every year, an inadmissible
number of patients suffer
injuries or die because of
health care. Most of these
injuries are preventable
A systemic problem that harms patients
DEFENCES
Procedures
Physical barriers
Training
THE GAPS
Culture
Disease manage
protocols missing
or not actioned
Patient
harmed
Poor compliance, poor
supplies
Inadequate knowledge, lack
of training opportunities
No clear leadership, no
cohesive team structure
“Humans fail because the
systems, tasks and
processes in which they
work and operate are
wrongly designed"
Dr Lucian Leape, testifying to the US President’s Commission
on Consumer Protection and Quality in Health
The International Classification for Patient Safety (ICPS)
aspires to become the shared global language necessary
to facilitate the learning from unsafe acts as well as to
develop solutions for improving patient safety.
The ICPS is intended to define, harmonize and
group patient safety concepts into an
internationally agreed classification in a way
that is conducive to learning and improving
patient safety across time and borders.
An International Initiative
WHO started work on patient safety in 2004, aiming to
develop a taxonomy, leading to the International
Classification for Patient Safety (ICPS)
The purpose is to enable categorization of patient safety
information using
■ standardized sets of concepts with agreed definitions,
■ A domain ontology
The World Alliance For Patient Safety Drafting Group; H Sherman, G Castro, M Fletcher, M Hatlie, P Hibbert, R
Jakob, R Koss, P Lewalle, J Loeb, T Perneger, W Runciman, R Thomson, T van der Schaarf, M Virtanen.
Towards an International Classification for, Patient Safety: the conceptual framework. International Journal
for Quality in Health Care 2009; Volume 21, Number 1: pp. 2–8
ICPS
Conceptual framework
Influences
Informs
Contributing Factors/Hazards
Influences
Incident Type
Incident
Characteristics
Informs
Detection
Influences
Informs
Mitigating Factors
Informs
Informs
Organizational
Outcomes
Patient
Outcomes
Influences
Informs
Ameliorating Actions
Actions Taken to Reduce Risk
Actions Taken to Reduce Risk
Patient
Characteristics
Incident Types
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
http://www.who.int/patientsafety/taxonomy/icps_full_report.pdf
NON HIERARCHICAL TREES
NON HIERARCHICAL TREES
ICPSMedinfoCapetown130910
NON FORMAL DEFINITIONS
NON FORMAL DEFINITIONS
NON FORMAL DEFINITIONS
A Patient Safety Classification
ICPS Print version(s) "fit for use" in multiple settings and languages.
ICPS Computer version usable in electronic health record systems
ICPS Web Platform that allows to
access and browse the classification with descriptive characteristics
maintain and update classification using a Collaborative Authoring Tool
with established workflows
ICPS with operational linkages to other WHO-FIC classifications and
standard terminologies like SNOMED-CT
Principles of ICPS development
■ The ICPS will be a member of WHO Family of International Classifications a
■ It will meaningfully link with other WHO Classifications and Terminologies.
■ The development will be harmonized and synchronized with the
development of other WHO Classifications such as the ICD-11, ICF and
ICHI
■ Modern methods in terminology and classification sciences will be utilized
■ The ICPS will be extensively field tested for relevance, applicability, quality
and utility in practice in different countries
■ Main goal of the ICPS is to respond to the user needs for reporting,
analyzing, monitoring, investigating patient safety incidents, facilitating safer
patient management, improving patient safety practices in organizations,
and building up patient safety indicators into existing health information
systems to produce appropriate statistics and reporting systems.
From Conceptual Framework to Content Model
■ Development and population of ICPS Content Model. To organize
patient safety knowledge in a consistent & structured way and
enable ICPS for use with computerized terminologies and ontologies
a ICPS Content Model (CM) is needed. The CM captures the key
parameters for the definition of an ICPS category in a standard &
systematic way:
■ What is a concept – category in PS? (e.g. Incident Type: Nutrition);
■ How do you define it: basic properties? (e.g. entity, process and
problem involved in Incident Type: Nutrition);
■ What different values it can take? e.g. entity -> general or specific
diet; process -> delivery, storage; problem -> wrong patient or wrong
storage.
Tentative Timeline
2011: Alpha version
■ +1 YR : Commentaries and consultations
2012 : Beta version & Field Trials Version
■ +2 YR : Field trials
2014
: Final version for public viewing
■ 2015 : WHA Approval
2016+ implementation
In 2010-2011
■ Creation of Web based Collaborative Authoring Tool (iCAT-PS). The
tool (see Fig 4) will allow ICPS developers to enter, edit, structure and
discuss content of each ICPS category & value sets.
■ Pre-population of iCAT-PS
■ Peer review process
It is imperative to build
safer systems
Because behind every unsafe
act, there are patients, families,
health care professionals