AHRQ 2009 Annual Conference Research to Reform: Achieving Health System Change Bethesda, MD • September 14, 2009. Learning From the Patient's Experience: Opportunities to Improve Patient Safety International Initiatives on Patient & Public Reporting of Adverse Events Martin J. Hatlie, JD
AHRQ 2009 Annual ConferenceResearch to Reform: Achieving Health System ChangeBethesda, MD • September 14, 2009
Learning From the Patient's Experience: Opportunities to Improve Patient Safety
International Initiatives on
Patient & Public Reporting of Adverse Events
Martin J. Hatlie, JD
President, Partnership for Patient Safety
Co-Founder, Consumers Advancing Patient Safety
CEO, Coalition for Quality & Patient Safety of Chicagoland
25% of things that go wrong are easy to understand
75% are infrequent and difficult to measure
Hence, reporting events and deconstructing what happened is essential to understanding risk
Patients and their lay carers see things across the continuum of care.
Perhaps in contrast to providers, patients appear to be very willing to report:
Consumers (including patients and carers) have a unique expertise in relation to their own health and their perspective on how care is actually provided. Consumer complaints are therefore a unique source of information for health care services on how or why adverse events occur and how to prevent them. As well as reducing harm to patients, better management of complaints should restore trust and reduce risk of litigation, through open communication and a commitment to learn from the problem and prevent its recurrence.
Better Practice Guidelines on Complaints
Management for Health Care Services (2004)
Australian Council on Safety & Quality of Health Care
Patient/Consumer reporting not well understood.
FAQ 2: Why can't the NPSA investigate my case?
We don't have official powers to investigate individual cases or deal with complaints about the NHS organisation that provides your care. But there are other organisations that can help if you have a complaint or would like to request an investigation. See Q3 below. We don't keep information identifying individuals because we want to help the NHS learn from its mistakes by looking at why things have gone wrong, rather than trying to blame or punish individuals. We don't keep the names of either patients or healthcare staff. We hope this anonymity will encourage everyone to tell us when things go wrong.
1.Evaluate public perception, satisfaction, and level of awareness of NPSA’s patient and public reporting system to date.
2.Understand who reports patient safety incidents and how and why patients want to report their incidents.
3.Determine patient expectations and needs when reporting patient safety incidents.
5.Provide recommendations on what the NPSA should do to increase reporting, reduce barriers for patients and the public to report, and manage expectations of patients and the public.
Recommendations will address:
ICPS framework will advance understanding of patient actions or omissions as:
ICPS classification framework will advance patient outcomes research:
Extent of disability
Consumer Reporting Research Questions:
“One reason that an incident reporting system worked in aviation...was that the entire aviation community -- essentially all of the stakeholders, including air passengers -- were involved in the process from the beginning and became advocates for the reporting system (as well as severe, but constructive, critics).”
…Charles E. Billings, MD, Developer of the Aviation Safety Reporting System, Editorial
Arch Pathol Lab Med 1998, 121:214-215
Patient Reporting of Adverse Events = an Issue at Every World Health Organization Patients for Patient Safety Workshop