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


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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