Nearly all U.S. hospitals have adverse event reporting systems

Dec 10 2008

More than ninety-four percent of U.S. hospitals have centralized systems for collecting reports of adverse events, but only 21 percent fully distribute and consider adverse event summary reports, according to a study funded by HHS' Agency for Healthcare Research and Quality.

The new study published in the December 8 issue of Quality and Safety in Health Care is based on a national survey of more than 1,600 hospitals. Hospitals participating in the random, voluntary survey described how their adverse event reporting systems work, the status of reporting practices, and how they use reporting to improve care.

Adverse events are unintended injuries that occur due to flaws in patient care rather than disease progression. In its seminal 1999 report, To Err is Human: Building a Better Health System, the Institute of Medicine estimated that 44,000 to 98,000 people die each year as a result of preventable medical errors. The AHRQ-funded report highlighted the importance of adverse event reporting as a necessary foundation for improving patient safety. The report said fragmented reporting systems were a barrier to patient safety improvements.

According to the new AHRQ-funded study, successful reporting systems share common elements, including provisions that protect the privacy of staff who report adverse events; encourage reporting by a range of hospital staff; and distribute timely summary reports that are reviewed by senior-level staff and used to develop event reduction strategies.

The survey found only 32 percent of hospitals have established "supportive environments" that allow anonymous reporting. Only 13 percent have broad staff involvement in reporting adverse events (96 percent of adverse events are submitted by nursing staff members). Authors said study results provide a baseline for future evaluations of how hospitals report adverse events.

The study, "Adverse Event Reporting Practices by U. S. Hospitals: Results of a National Survey," was conducted jointly by AHRQ researchers James Battles, Ph.D., and William Munier, M.D., and researchers from the RAND Corporation and The Joint Commission.

The study comes at a time when patient safety initiatives are gaining momentum. On November 21, the Department of Health and Human Services published the final rule for the establishment of Patient Safety Organizations. The rule's effective date is January 19, 2009. The creation of PSOs, authorized by the Patient Safety and Quality Improvement Act of 2005, helps remove barriers - the fear of legal liability or sanctions - that clinicians and health care organizations currently face related to patient safety event reporting. Information reported to PSOs from providers is held confidential and privileged. This will allow PSOs to provide feedback to providers for improvements in quality and safety.