Part III
Streamlining Patient Safety Reporting

Concerns about patient safety have led to increased use of reporting systems. Part III of the report examines the different types of patient safety data applications (Chapter 8) and the development of a common report format and set of data standards for use with patient safety reporting systems (Chapter 9).

PATIENT SAFETY DATA APPLICATIONS

Clinical performance data can be used for many purposes—for example, by regulators for accountability purposes, by individual and organizational consumers for making purchasing decisions, and by care providers for designing improved care processes. Each group has different data requirements. Accountability-based applications, on the one hand, generally focus on individual health care providers and the health care delivery institutions in which they work. Learning-based approaches, on the other hand, generally focus on health care delivery processes. Chapter 8 outlines the many uses of clinical performance data and the pitfalls associated with each. The chapter concludes by emphasizing the need to invest more in approaches that can lead to system redesign and improvement.

STANDARDIZED REPORTING

To learn from adverse event and near-miss data, researchers need to aggregate the data to formulate research priorities, identify trends, and com-



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Patient Safety: Achieving a New Standard for Care Part III Streamlining Patient Safety Reporting Concerns about patient safety have led to increased use of reporting systems. Part III of the report examines the different types of patient safety data applications (Chapter 8) and the development of a common report format and set of data standards for use with patient safety reporting systems (Chapter 9). PATIENT SAFETY DATA APPLICATIONS Clinical performance data can be used for many purposes—for example, by regulators for accountability purposes, by individual and organizational consumers for making purchasing decisions, and by care providers for designing improved care processes. Each group has different data requirements. Accountability-based applications, on the one hand, generally focus on individual health care providers and the health care delivery institutions in which they work. Learning-based approaches, on the other hand, generally focus on health care delivery processes. Chapter 8 outlines the many uses of clinical performance data and the pitfalls associated with each. The chapter concludes by emphasizing the need to invest more in approaches that can lead to system redesign and improvement. STANDARDIZED REPORTING To learn from adverse event and near-miss data, researchers need to aggregate the data to formulate research priorities, identify trends, and com-

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Patient Safety: Achieving a New Standard for Care pare various approaches to patient safety. To carry out these data aggregations, researchers need standard, nationally accepted ways of defining, classifying, and characterizing adverse events and near misses. There has been some cross-fertilization among the various reporting systems; to address local needs, however, each system has been developed largely independently of others. Thus one finds across state reporting systems many different definitions for such key patient safety terms as adverse event, many different classifications of adverse events,1 and diverse approaches to collecting and coding data relevant to adverse events and near misses. At the moment, each institution that wants to implement a patient safety reporting system must invent its own system. This effort involves deciding on a process for collecting and analyzing the salient data and then identifying and defining what events are to be reported on; what data elements are to be collected; and how each data element should be defined, classified, and coded. A standardized report format would reduce the burden on providers of complying with outside requests for patient safety information. Today, for example, an adverse event that has been detected in an institution in New York State must, potentially, be reported to the institution’s own system and possibly to voluntary systems such as MedMARX. If the adverse event is serious, it may need to be reported to the New York Patient Occurrence Reporting and Tracking System (NYPORTS), a federal system, and the Joint Commission on Accreditation of Healthcare Organizations. Each of these systems has very different definitions of reportable events and data reporting requirements. This lack of standardization imposes unnecessary burdens and is a major disincentive to reporting adverse events. Chapter 9 addresses the steps needed to establish a standardized reporting format. Recommendation 7. AHRQ should develop an event taxonomy and common report format for submission of data to the national patient safety database. Specifically: The event taxonomy should address near misses and adverse events, cover errors of both omission and commission, allow for the designation of primary and secondary event types for cases in which 1   There is some movement toward consensus. SAFER (State Alliance for Error Reporting), a workgroup of states, is considering whether the National Quality Forum’s list of Serious Reportable Events can be developed into a core set of reportable events that each state could adopt (National Quality Forum, 2002).

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Patient Safety: Achieving a New Standard for Care more than one factor precipitated the adverse event, and be incorporated into SNOMED CT. The standardized report format should include the following: A standardized minimum set of data elements. Data necessary to calculate a risk assessment index for determining prospectively the probability of an event and its severity. A free-text narrative of the event. Data necessary to support use of the Eindhoven Classification Model—Medical Version for classifying root causes, including expansions for (1) recovery factors associated with near-miss events, (2) corrective actions taken to recover from adverse events, and (3) patient outcome/functional status as a result of those corrective actions. A free-text section for lessons learned as a result of the event. Clinical documentation of the patient context. The taxonomy and report format should be used by the federal reporting system integration project in the areas for basic domain, event type, risk assessment, and causal analysis but should provide for more extensive support for patient safety research and analysis (Department of Health and Human Services, 2002). REFERENCES Department of Health and Human Services. 2002. HHS Moves Forward to Establish New System for Collecting Patient Safety Data. Online. Available: http://www.hhs.gov/news/press/2002pres/20021125.html [accessed August 18, 2003]. National Quality Forum. 2002. Serious Reportable Events in Patient Safety: A National Quality Forum Consensus Report. Washington, DC: National Quality Forum.