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State-Based Patient Safety Reporting Systems. Institute of Medicine Committee on Patient Safety Data Standards Jill Rosenthal May 6, 2002. Pre-IOM Reporting Systems. 15 States report having programs NASHP studies programs and finds: State specific approaches; definitions not compatible

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State based patient safety reporting systems

State-Based Patient Safety Reporting Systems

Institute of MedicineCommittee on Patient Safety Data Standards

Jill Rosenthal

May 6, 2002


Pre-IOM Reporting Systems

  • 15 States report having programs

  • NASHP studies programs and finds:

    • State specific approaches; definitions not compatible

    • No baseline but states perceive under-reporting, regardless of confidentiality

    • Validation efforts

vNational Academy for State Health Policy v © May 2002v


Pre iom reporting systems
Pre-IOM Reporting Systems

  • Findings continued:

    • More data analysis and focus on improvement needed

    • Resource shortage

    • States lack a single entity responsible for patient safety

    • States value reporting as tool for oversight

vNational Academy for State Health Policy v © May 2002v


Reportable events and definitions
Reportable Events and Definitions

  • Terminology

    • occurrence (CO), reportable incident (KS), serious injury (MA), sentinel event (ME)

  • Categories

    • unexpected deaths, wrong site surgery, serious unanticipated injury

  • Descriptions

    • interpretive guidelines, includes/excludes, Q &A

vNational Academy for State Health Policy v © May 2002v


Information reported

Facility name

Type of incident

Date

Description of incident

Person reporting

Action taken

Patient outcome

Provider identification

Patient identification

Root cause analysis

Information Reported

vNational Academy for State Health Policy v © May 2002v


Use of data
Use of Data

  • Accountability

    • Identification of system weaknesses and assurance of corrective actions

  • Facility education

    • Patient safety alerts

    • Newsletters identifying trends and highlighting best practices

    • Web-based facility comparisons

vNational Academy for State Health Policy v © May 2002v


Continued State Interest

  • 2001: 12 bills on reporting introduced in 7 states

  • 2001: Studies, commissions, and data collection (including reporting) in 11 states

  • 2001: UT reporting regulation

  • 2002: Reporting statutes in ME, PA, TN

vNational Academy for State Health Policy v © May 2002v


Patient safety centers
Patient Safety Centers

  • MA, NY, PA

  • System-wide data analysis

  • Near miss data

  • Root causes and best practices

vNational Academy for State Health Policy v © May 2002v


State considerations
State Considerations

  • Standardization of data within and across states

  • State flexibility

  • Resources and support

  • Political opposition-- get what you can

vNational Academy for State Health Policy v © May 2002v


Future work
Future Work

  • Operationalizing NQF List of Serious Reportable Events

  • Disclosure and confidentiality

  • Legislative tracking

  • Technical assistance

vNational Academy for State Health Policy v © May 2002v


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