In this chapter,
the QuIC responds to recommendations from the IOM report and describes
how the Federal Government can act on the issues of medical error
and patient safety. This includes responses by the QuIC, as an interagency
coordinating organization, as well as responses by individual agencies
of the QuIC.
Focus and Leadership
create a Center for Patient Safety within the Agency for Health
Care Policy and Research. This Center should:
- Set the national
goals for patient safety, track progress in meeting these goals,
and issue an annual report to the President and Congress on patient
- Develop knowledge
and understanding of errors in health care by developing a research
agenda, funding Centers of Excellence, evaluating methods for
identifying and preventing errors, and funding dissemination and
communication activities to improve patient safety (IOM;
1999, page 6).
The IOM’s recommendations
build upon AHRQ’s focus on health care quality, its expertise, and
its track record in funding research, training, and dissemination
activities. AHRQ will take immediate action to expand the mission
of the Center for Quality Measurement and Improvement, creating
the Center for Quality Improvement and Patient Safety (CQuIPS),
which will provide leadership in reducing medical error and improving
patient safety. Integration of the patient safety agenda within
AHRQ’s existing quality improvement efforts reflects an approach
similar to that used by the IOM, in which its work on patient safety
was included within a broader "Quality in America" framework.
of CQuIPS explicitly recognizes that patient safety and quality
improvement are complementary activities with great potential for
synergy. Furthermore, establishing the Center takes advantage of
AHRQ’s current infrastructure, which includes a center focusing
on quality improvement and a task force that advises the Director
on matters related to patient safety and medical errors. The Center
will develop initiatives in these areas and facilitate communication
between the Agency and external organizations. In the Center’s first
year, the President has proposed a budget of an additional $20 million
to be spent on research.
The Center will:
- Conduct and
provide grants and contracts for extramural research on patient
safety and the causes of medical errors, and on the effectiveness
of programs to reduce them.
- Include patient
safety within the broader focus of quality measurement and improvement.
- Bring together
individuals and groups from the public and private sectors with
an interest in patient safety.
Center’s role will not include regulatory, payer, or provider functions,
it is well positioned to share information from both the private
and public sectors (e.g., pooling and analyzing results of State
mandatory error reporting systems). Additionally, patient safety
will be integrated into the activities of other organizational units
functions will be coordinated with and complementary to other private-sector
and Federal initiatives focused on error reduction and improved
patient safety. For example, VA, CDC, HCFA, FDA, DoD, the National
Patient Safety Foundation (NPSF), the National Patient Safety Partnership
(NPSP), and professional societies all have expertise relevant to
identifying and reducing medical errors and improving patient safety.
Their collaboration via the QuIC will enhance the Center’s functions.
One example of such collaboration will be the Center's development
of a curriculum for QuIC participants on reducing medical errors
that can be used as a model and expanded by other public- and private-sector
- AHRQ will
take immediate action to establish the Center for Quality Improvement
and Patient Safety (CQuIPS), which will replace and broaden the
mission of AHRQ’s Center for Quality Measurement and Improvement.
- CQuIPS will
coordinate with and complement other public- and private-sector
initiatives to improve patient safety.
- QuIC will
coordinate Federal activities on patient safety, as it does on
the broader quality agenda. This will include both regular meetings
of the QuIC and use of its current structure to redirect QuIC
working group efforts towards enhancing patient safety.
- AHRQ will
sponsor a program to educate personnel of QuIC member agencies
about patient safety, bringing them together with leading researchers
on human factors analysis, systems design, error reporting, and
quality improvement. This curriculum will serve as a model and
be expanded for future educational activities with private-sector
- QuIC agencies
such as OPM, HCFA, DoD, and VA will demonstrate their national
leadership as purchasers and providers of care, developing model
programs that use information on errors to improve patient safety.
- Federal agencies
and other bodies, including AHRQ, FDA, CDC, and HCFA, will collaborate
to provide national leadership in developing and testing systems
of mandatory reporting for public accountability.
Develop a research
agenda, conduct and fund intramural and extramural research to assess
the magnitude of errors and the role of human factors, and test
and evaluate approaches for preventing errors.
research program is central to the overall effort to improve patient
safety and reduce medical errors. Without the evidence base that
research provides, efforts to reduce errors and improve safety are
unlikely to be fully productive, and may even be harmful. An example
of an event with potential for harm is the automation of health
care processes without due consideration of system design and human–technology
interfaces. Automating a flawed system may invite errors and further
mask their occurrence.
is needed on the role of patients in helping to reduce errors. While
much is known about the power of patient participation in helping
to improve overall patient outcomes and satisfaction, research is
sparse regarding the patient’s role in error reduction (e.g., wrong-site
surgery, medication errors). In general, further research is needed
on how best to measure medical errors, explore options for reporting
them, understand why they occur, and test the success and cost-effectiveness
of various approaches to improving safety, including the patient’s
role in helping to prevent errors.
A number of
research activities are currently underway in Federal agencies and
departments. In December 1999, AHRQ released a request for grant
applications to research the effectiveness of the transfer and application
of "best practices" to reduce medical errors that are
frequent, serious, and preventable. AHRQ also is supporting a project
conducted by the NPSF that identifies and gathers information on
public- and private-sector agencies and organizations funding research
on medical errors and patient safety. This is effort helps to coordinate
research initiatives, prevent overlaps, and identify research gaps.
and departments also have research projects underway. VA is evaluating
grant applications focused on mitigating adverse drug events and
has established four Patient Safety Centers of Inquiry to develop
innovative solutions to critical challenges in patient safety. HCFA
is funding the Study of Clinically Relevant Indicators for Pharmacologic
Therapy (SCRIPT) to develop and test a core set of measures that
can be used to evaluate and improve medication use associated with
significant morbidity, mortality, and unnecessary cost. The FDA
is strengthening its understanding of the impact of pre- and postmarket
risk management decisions, which includes exploring the association
between errors and medical products, human factors and pharmaceutical
name confusion, patient communication, exposure to risk, and improved
methods for extracting information from both large reporting databases
and patient medical records.
collaborative efforts also are underway. For example, in 1999 AHRQ
funded four Centers for Education and Research on Therapeutics (CERTs).
Established as part of the FDA Modernization Act of 1997 and administered
by AHRQ in collaboration with the FDA, the CERTs examine the benefits
and risks of new drugs, biologics, and medical devices. Under the
aegis of the QuIC, several agencies and departments will implement
a project in 2000 focused on identifying and reducing medical errors
in high-hazard health care environments.
and timely, however, these initiatives fall short of meeting the
ambitious research agenda described in the IOM report.
The QuIC proposes
a broad research initiative aimed at developing evidence-based approaches
to reducing medical error and improving patient safety, but it will
require substantial additional funding. With coordination, direction,
and input through AHRQ’s new CQuIPS, this initiative will include
setting a coordinated research agenda, supporting research and demonstrations,
evaluating programs, developing tools and training initiatives,
and disseminating findings. Potential components of this initiative
are outlined below.
- Hold national
summits on medical error and patient safety research: AHRQ will
lead the convening of conferences and expert meetings to review
the information needs of those who wish to improve safety, assess
the current state of patient safety research, set coordinated
research agendas, and develop adequate reporting mechanisms. VA
will lead a summit on lessons learned from its experiences in
improving patient safety, and the FDA will lead a summit on drug
errors. These summits will take place within 1 year.
joint research solicitations (including partnerships between AHRQ,
CDC, FDA, and VA) for:
Research on Errors: Investigate root causes analysis, informatics,
the role(s) of human factors, and legal/judicial issues.
Research on Reporting Systems: Identify critical
components of successful reporting systems used for learning,
examine options for voluntary and mandatory reporting systems,
implement and evaluate demonstration programs for reporting, evaluate
existing State mandatory reporting systems, and investigate techniques
and methods for analyzing and disseminating patient safety data
(including integration into a National Quality Report being prepared
by DHHS under the leadership of AHRQ and CDC).
Applied Research on Patient Safety: Test the application
of human factors knowledge to the design of health care products,
processes, and systems; identify best practices in reducing errors;
fund patient safety "Centers of Research Excellence";
and support research and demonstrations on-site, as well as level-of-care
and cross-cutting research, such as in diagnostic accuracy, informatics
applications, and systems re-engineering.
- Develop tools
for the public and private sector to support efforts to enhance
patient safety, including:
Identify tools and approaches from other industries that could
be applied to the health care sector and develop community-based
settings that can serve as laboratories for error reduction through
medical specialty societies, primary care networks, and integrated
service delivery networks.
Measures: Develop and evaluate data specifications
for reporting on patient safety and work with the Quality Forum
and other private- and public-sector efforts on developing consensus
around a core set of measures for patient safety.
a QuIC Research Agenda on Working Conditions and Patient Safety.
The QuIC will finalize a research agenda to explore the relationship
between health care workers’ working conditions and the quality
of patient care, including patient safety. CDC and AHRQ will coordinate
this activity with VA and other agencies.
and Learning From Errors
mandatory reporting system should be established that provides for
the collection of standardized information by State governments
about adverse events that result in death or serious harm. Reporting
should initially be required of hospitals and eventually be required
of other institutional and ambulatory care delivery settings. Congress
the Forum for Health Care Quality Measurement and Reporting as the
entity responsible for promulgating and maintaining a core set of
reporting standards to be used by States. Reporting standards should
include a nomenclature and taxonomy.
Require all health care organizations to report standardized
information on a defined list of adverse events.
Provide funds and technical expertise for State governments
to establish or adapt their current error reporting systems to collect
the standardized information, analyze it, and conduct followup action
as needed with health care organizations. Should a State choose
not to implement the mandatory reporting system, the Department
of Health and Human Services should act as the body responsible
for data collection and analysis. Further, the Center for Patient
Safety should be designated to:
States to share information and expertise, and evaluate alternative
approaches taken for implementing reporting programs, identify
best practices for implementation, and assess the impact of
and analyze aggregate reports from States to identify persistent
safety issues that require more intensive analysis and/or a
broader based response (e.g., designing prototype systems or
requesting a response by agencies, manufacturers or others).
of voluntary reporting efforts should be encouraged. The Center
for Patient Safety should:
and disseminate information on external voluntary reporting programs
to encourage greater participation in them and track the development
of new reporting systems as they form.
- Convene sponsors
and users of external reporting systems to evaluate what works
and what does not work in the programs and ways to make them more
assess whether additional efforts are needed to address gaps in
information to improve patient safety and to encourage health
care organizations to participate in voluntary reporting programs
- Fund and
evaluate pilot projects for reporting systems, both within individual
health care organizations and within collaborative efforts among
health care organizations.
The IOM report
states that to decrease the incidence of errors in the health care
system, it is necessary to have and use information. The IOM’s recommendations
reflect two important information needs that are vital to efforts
to improve safety. First, the public expects and has a right to
information that will demonstrate that the health care delivery
system is as safe as possible. Second, there is the need for data
and information in support of efforts to learn why errors occur
and what changes are effective in preventing errors or minimizing
their effects. Both needs can be met only through the development
of effective data collection systems. Additionally, accountability
and learning will only be achieved if the data are analyzed and
information is fed back to the users.
The kind of
information that is produced from these systems needs to be useful
to those who can act on it. Learning systems must be designed to
produce information for providers, drug and device manufacturers
and others. Accountability systems must meet the information needs
of the public, public policymakers, and purchasers. The data needs
for accountability and those for learning are complementary but
The QuIC believes
that the IOM is correct in identifying these information needs,
and will take steps—in collaboration with a variety of other organizations—to
begin to meet them. As appropriate, the QuIC supports the extension
of peer review protections to encourage reporting. Details of these
extensions are given in "Peer Review Protections," below.
agencies are committed to providing the public with information
about the safety of the health care delivery system, in general,
and about the providers from which they can choose. To that end,
the QuIC proposes that the Quality Forum identify those patient
safety practices that health care organizations have adopted and
that have been proven through research to be effective in reducing
errors. The QuIC anticipates that the Quality Forum will encourage
health care organizations to adopt these practices and inform the
public of their use.
As a start,
OPM will require that the provider organizations with which it does
business have patient safety programs in place and provide public
information on what those programs do. This information will be
disseminated broadly on OPM’s Web site and through other mechanisms
available to it. Methods for insuring this reporting are further
described in "Raising the Standards
for Health Care Organizations" and "Raising
the Standards for Health Care Professionals."
on what programs are in place will be useful, it may not be sufficient
to ensure the public is able to make the decisions it wants to make
about its health care. Therefore, the QuIC proposes to look at how
to provide useful information on errors to the public. This examination
will consist of two separate parts.
will lead a QuIC effort to examine the existing State reporting
systems that have been designed for public accountability, to learn
what their common characteristics are, how effective they have been
in providing information to the public, and what have been the most
successful elements of those programs. This information will be
shared with the States that currently operate error reporting systems
and others that are considering developing such systems, as a means
of encouraging improvement and expansion of State reporting. The
goal would be for all States to have a reporting system for errors
within 3 years. If, at the end of 3 years, all States have not implemented
reporting systems, the QuIC will recommend options to the President
so that all health care institutions are reporting serious errors.
will experiment with creating its own program for collecting and
reporting publicly on medical errors that result in significant
harm to patients and are preventable, given the current state of
knowledge. Examples of such events are: surgery on the wrong body
part, surgery on the wrong patient, and suicide while the patient
is being watched to prevent a suicide. HCFA proposes to conduct
a pilot study of such a mandatory reporting system for these events
in collaboration with a State. It will work with the Quality Forum
or similar entity to develop a finite list of events to be reported,
and will ensure they have unambiguous definitions. In addition,
HCFA will ask the Quality Forum or other entity to advise it on
how best to report the information to the public to ensure it is
understandable and useful.
HCFA will work
with the chosen State to require that such events are reported by
all hospitals in the State and published on a hospital-by-hospital
basis. The published data will be stripped of all information that
might jeopardize patient confidentiality. In the course of the pilot
study, HCFA will refine any definitions and work out the operational
issues of enforcement and reporting mechanics with the State Survey
and Certification agency. HCFA and its QuIC partners will evaluate
whether consumers found this information valuable and what they
understood about it, and how they used it. Finally, HCFA and its
QuIC partners will evaluate the impact of such a system on confidential
reporting for learning from errors.
based on the results and evaluation of the pilot study by HCFA and
its QuIC partners, HCFA will move towards a national mandatory reporting
system for all hospitals participating in the Medicare program,
with the intent of making the data publicly available.
and accidents also occur during the collection, testing, and administration
of human blood. On January 27, 2000, the DHHS Advisory Committee
on Blood Safety and Availability recommended, among other things,
facilitating development of technology to prevent misidentification
of blood products and/or recipients. By the end of the year, FDA
will release regulations to improve the safety of blood transfusions
by requiring the over 3,000 blood banks and establishments dealing
with blood products to report errors and accidents, such as mistyping
blood products and adverse events affecting donors, that affect
patient safety. Currently, only 400 blood banks are required to
report such errors.
to broad public accountability, the IOM asserted that providers
have the responsibility to provide information to affected individuals
and their families about mistakes that cause serious injury or death.
The QuIC agrees with this recommendation. However, subsequent investigations
by the health care organization into the causes of error need not
- The QuIC
will ask the Quality Forum to define unambiguously, within 12
months, a set of egregious errors that are preventable and should
never occur. These measures will serve as criteria for a HCFA-sponsored
mandatory reporting demonstration project with a State that already
has an existing mandatory reporting requirement. HCFA will publish
the hospital rates for these events without patient identifiers.
- HCFA and
its QuIC partners will evaluate whether consumers found this information
valuable and what they understood about it. Based on these results,
HCFA will move towards a national mandatory reporting system,
with publication of findings, for all hospitals participating
- Federal agencies,
in partnership with other organizations, will develop options
for mandatory reporting systems that provide the public and purchasers
with publicly available information about programs and procedures
in place to reduce errors. This work will require the development
of evidence-based, systems-level measures in collaboration with
the Quality Forum.
- OPM will
require that health plans have error reduction plans, and will
report on its Web site whether the health plans have reliable
patient safety initiatives in place.
- QuIC will
ask the Quality Forum to identify, within 12 months, patient safety
practices that institutions should undertake and urges that information
about whether the measures are in place be made available to the
- FDA will
report to the public on the safety of drugs, devices, and biologic
- QuIC proposes
that State and Federal mandatory reporting systems, as well as
those of private accrediting and other oversight groups, be evaluated
to determine the ways in which they are helpful in assuring public
accountability for patient safety, and that these results be used
to develop future reporting systems.
- AHRQ will
include information on patient safety in the National Quality
Report it is developing in collaboration with other agencies,
in particular, the National Center for Health Statistics.
- OPM will
require that health plans describe their patient safety initiatives,
will make patient safety information available in both print and
electronic formats for the open enrollment period in Fall, 2000,
and will expand its web site to include information about programs
designed to reduce errors and enhance patient safety.
- OPM will
encourage health plans to annotate Preferred Provider Organization
(PPO) directories to indicate which hospitals and physicians’
offices use automated information systems.
- FDA will
improve the safety of transfusions by expanding mandatory reporting
requirements for blood bank errors and accidents, so that they
apply to all registered blood establishments.
To learn from
errors, the aviation industry experimented with different models,
but found it most useful to have a large national database of information
that can be analyzed for patterns of underlying causes of mistakes.
This ensures that data from events that rarely occur, but which
have dire consequences, can be more readily identified. At the moment,
no comprehensive system of data collection exists that will drive
the Nation’s efforts to learn from medical errors.
To inform its
thinking about how such a system should be constructed, the QuIC
reviewed data collection systems that have been designed to support
learning systems in other industries. Successful reporting programs
possess the following common characteristics.
of an Ideal Reporting System for Learning
- The intent
and goal of the reporting system are clear to all interested parties.
- Active leadership
support is ensured at all levels.
- Reports are
accepted from all interested parties.
- Reports are
confidential and identifying information has been removed.
- Reports are
used for prevention, not punishment.
- Reports are
analyzed by technically expert peers, from multiple perspectives.
is easy to do and captures rich detail.
and larger interested communities receive timely feedback.
- Pilot testing
and prototyping of the system takes place before large scale roll-out
databases exist that collect information on specific types or errors,
such as CDC’s hospital acquired infections reporting systems, FDA’s
adverse drug and device event reporting systems, and the JCAHO’s
sentinel event system. Others exist that collect information on
errors that occur in a particular health care system, such as VA’s
error reporting system. As previously mentioned, some States have
data collection systems for the facilities within their boundaries.
The QuIC believes
that the fastest way to create a useful and analyzable data set
would be to integrate the data from these existing databases and
from any others that exist. AHRQ has experience in creating such
harmony from disparate data collections. Within its Healthcare
Cost and Utilization Project (HCUP), AHRQ currently employs
cooperative agreements with 22 States to ensure the collection of
a core set of administrative data from hospital discharges that
are then aggregated. These data are then made available for research
and analysis, in a way that protects patient and provider identities.
The QuIC proposes that a similar method should be used to create
an errors database that can be used to provide important insights
into the causes and effective methods for prevention of errors.
AHRQ will lead an effort to gather information from those who run
the existing error data-collection systems, including the Federal,
State and private-sector systems. This evaluation of existing systems
will be used to determine whether they can be aggregated into a
reporting system, which the IOM and others have suggested as a model
that health care should emulate, depends on the collection of as
much information as possible about close calls (which are sometimes
called near misses) as well as errors that actually resulted in
harm. To encourage people to report errors and speed the availability
of information, the aviation system protects the identity of those
who report and those who are involved in the incident. The QuIC
will encourage States and others to include sufficient protections
on the information to ensure that providers will report errors.
This issue is discussed more fully in the section on Peer
A common set
of core measures is necessary to integrate a broad array of data
collected through different reporting systems. The Quality Forum
can ably undertake the creation of a common set of core measures
for a national errors database. The QuIC agencies would support
such an effort by the Quality Forum or other appropriate private-sector
reveal information about their care experiences, including errors
that occurred during their care, that are not otherwise available.
Systems will also be created that will enable patients to report
errors and adverse events, using a standard reporting format that
will complement the error reporting and collection activities of
health care professionals and facilities. To collect such data,
the QuIC will design a Web-based error reporting mechanism.
Within six months,
HCFA, working with a Peer Review Organization (PRO) program, will
develop a pilot study of a confidential, penalty-free learning system
with several hospitals on a voluntary basis.
First, the PRO
will assemble routine hospital error reports to create a highly
confidential database of documented errors occurring in the participating
hospitals. This database would include both near misses and actual
patient harm. The PRO will use the standard taxonomy of medical
errors adopted by the Quality Forum, and use the collected data
for education and technical assistance, not for punitive actions.
This is consistent with the educational strategy that PROs have
adopted over the past decade.
PRO will provide support for provider and practitioner error reduction
programs through participating in local root cause analysis of near
misses as well as the episodic serious adverse events, to identify
patterns of medical errors. The PRO will feed back and interpret
information from the database, convene workgroups of interested
and expert parties, and facilitate the exchange of best practices
that could be shared between participating hospitals. The PRO will
also provide the data, with all identifiers removed, to AHRQ, HCFA,
and other partners and investigators. With this information, the
PRO will work with hospitals and practitioners on systems interventions
to reduce medical errors.
spring, the Department of Defense will implement a new reporting
system in its 500 hospitals and clinics, which serve approximately
8 million patients. This reporting system will be modeled on the
system in operation at the Department of Veterans Affairs and will
be used to provide health care professionals and facilities with
the information necessary to protect patient safety. This system
will begin to be pilot tested in August of 2000, will collect information
on adverse events, medication errors, close calls, and other patient
safety issues. Under this system, patients or their families are
notified when a serious medical mistake has been made.
The VA currently
operates a mandatory reporting system. By the end of the year, the
VA will implement a voluntary reporting system for both adverse
events and close calls nationwide. Information will be collected
by an independent external entity, analyzed, and disseminated to
all VA health care networks to help prevent medical errors before
they occur. Implementing this system is likely to lead to a richer
database of information, as incidents are reported on a de-identified
basis, and will allow researchers to compare the effectiveness of
identified systems to de-identified ones.
While the aggregate
database is being created, Federal agencies, such as the VA, CDC,
and FDA will continue to examine their own data for critical information
on why errors occur and how to avoid them. This information will
continue to be communicated to appropriate health care organizations,
manufacturers, and others who need to act on it. Once the database
has been created, AHRQ will lead Federal efforts to expand both
the knowledge of errors and communication with providers and others
who can act on this information. Both information about methods
shown to be effective in reducing errors and particular hazards
will be communicated to providers.
about what methods have been shown to be effective in reducing errors
will also be shared with organizations that have health care oversight
or purchasing responsibilities, so that they can choose to incorporate
them into their efforts to ensure accountability as appropriate.
This forms a natural link between the learning systems and the accountability
systems for error reduction. Health care provider organizations
can be held responsible for adopting methods shown to be effective
in reducing errors, and the public should be given information that
demonstrates such initiatives are in place and are effective.
- The new Center
for Quality Improvement and Patient Safety (CQuIPS) at AHRQ will
identify existing State and Federal reporting systems (both mandatory
and voluntary), evaluate their suitability in helping to build
a national system of errors reporting, and evaluate how their
data collection or enforcement efforts can be enhanced to improve
the value of those systems.
- QuIC will
work with the Quality Forum to develop reporting criteria that
assure that information can be pooled and shared as needed across
- CQuIPS, working
with the QuIC, will describe and disseminate information on characteristics
of existing voluntary reporting programs associated with successful
error reduction and patient safety improvement efforts. FDA, CDC,
and NASA will provide expertise in the development of these nonpunitive
- Within six
months, HCFA, working with a Peer Review Organization (PRO) program,
will develop a pilot of a confidential, penalty-free learning
system with several hospitals on a voluntary basis.
- Federal agencies,
including the FDA, VA, DoD, CDC, HCFA, and AHRQ, will integrate
data from different sources and conduct and support analysis to
identify error prone procedures, products, and systems.
- By August
2000, the DoD will complete development of a patient safety improvement
program based on a reporting system modeled on that of the VA.
- VA will establish
a voluntary reporting system to supplement its existing mandatory
- AHRQ, in
collaboration with other Federal agencies, will investigate, develop
and test strategies to provide effective feedback to clinicians
and institutions on methods for improving patient safety.
- Federal agencies
will assist health care providers to develop the skills necessary
for analyzing adverse events and near misses (e.g., root cause
analysis, trending, search tools). Federal agencies providing
health care will develop internal systems to 1) identify and report
errors to clinicians and other decision makers, and 2) learn from
those errors and near misses to prevent future events.
to Stakeholders: QuIC will develop programs to foster the dissemination
of research findings to end users through activities such as AHRQ’s
User Liaison Program; provide support to the Quality Forum to
increase the national discussion on errors, their reduction, and
standardized measures of errors; and fund collaborative agreements
with health care professional organizations that foster education,
track patient safety initiatives, provide input to the new patient
safety research centers, and translate, disseminate, and promote
adoption of research findings.
- Patient Safety
Clearinghouse: AHRQ will develop a clearinghouse in partnership
with other Federal agencies and private-sector organizations to
provide an objective source of state-of-the art information on
- AHRQ will
initiate a "National Morbidity & Mortality Conference"
posting selected cases (stripped of identifying information) in
a public forum via Internet technology, and establish a Web site
where patients can report incidents that will be analyzed to identify
On pages 85
and 86, the IOM report summarizes two important points: 1) caution
must be exercised when calculating rates from any type of adverse
event reporting system; and 2) the goal of reporting systems is
not to count the number of reports.
reporting systems are analysis and feedback systems. The key to
their success starts with a highly visible ability to properly analyze
cases and recommend changes to those who are empowered to implement
them. Experts in the field of patient safety report that understanding
the "root" of the problem and the "contributing"
factors are winning strategies; counting errors and comparing performance
key decision makers and those who report is the second part of all
successful error reporting systems. The CDC and FDA have found that
lack of feedback was one of two main reasons for failed "mandatory"
systems. Other activities contributing to success include: 1) training
for those with reporting responsibilities; and 2) free software
and generic data to aid internal analysis.
other reporting systems for improving safety demonstrates the importance
of closing the feedback loop. Timely and usable feedback is crucial
in making the system useful to those who report. Therefore, reporting
formats should include both free-text narrative and standardized
information as well as indicate how those who report can use the
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