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Patient Safety Tool Helps ID Hospital Errors

Cheryl Clark, for HealthLeaders Media, January 10, 2013

The voluntary information collected by the PSOs is protected from discovery, litigation, or punitive action under the Patient Safety and Quality Act of 2005. The data is also stripped of details that would link these incidents to specific hospitals or individual patients.

"Such Common Formats provide the opportunity to define patient safety events in a way that's scientifically sound and consistent from place to place to allow people to report events in the same way," says William B. Munier, MD, AHRQ's director of the center for quality improvement and patient safety.

Today around the country, "what's defined as an adverse event in one hospital might not be defined as one in another. With the Common Formats, we can standardize reporting, improve the value of information collected, and, through feedback, constantly improve the formats themselves," he says.

Nonidentifiable information from the PSOs will be rolled up into a Network of Patient Safety Databases clearinghouse starting in 2013, which will enable reviewers to see how an event that almost happened once in one hospital, or actually did happen, may be much more common than anyone knew.

About 20 of the nation's 78 PSOs in 30 states and the District of Columbia are now collecting data from hundreds of hospitals, and many vendors are now incorporating the Common Formats into their electronic software, Munier says.

The tool provides a decision pathway that allows the person reporting to detail specifics about where and how the mistake was made—for example, why an expired drug wasn't removed from a pharmacy refrigerator according to protocol, or the realization that half of patient falls that did not result in harm occurred next to the toilet.

Julie Cerese, RN, MSN, is vice president of performance improvement for UHC, a Chicago-based PSO alliance with 116 academic medical center members and more than 250 of their affiliate hospitals, 50 of which have elected UHC as their performance improvement PSO. She notes that a severe adverse event happens rarely at a hospital, and once the investigation and evaluation is concluded, it may be viewed as an isolated event when, in fact, other organizations are experiencing similar problems.

But as UHC collected reports from its member hospitals, "we discovered that retained guidewires—a very obscure event—happened 26 separate times" over the course of a few years. Each organization may have identified the cause of its own incident, not realizing that other organizations had other root causes.

"We were able to understand the breadth of potential or latent errors that led to this problem and share that information," Cerese says.

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