The Near Miss
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Now in version 1.2, the Common Formats tool, under development for six years by AHRQ, is also geared to enable hospitals to report problematic systems or conditions in the same way—whether they caused harm or just had the potential to—so that hospitals everywhere can learn from the experience.
"The drafters of the act said that PSOs should use common definitions for reporting. 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 Munier.
To date, only about 26 states have requirements for adverse event reporting systems, and different states want different types of events reported. That makes it difficult to understand the scope of the problem and whether providers are improving, especially when for each hospital a serious reportable event is extremely rare.
Some use a full or modified version of the National Quality Forum's list of 28 Serious Reportable Events. Only Pennsylvania, through its Patient Safety Authority, collects information on near misses.
A July report from the Office of Inspector General, one in a series, detailed the wide variation in the way hospitals report. Investigators reviewed a sample of patient records and discovered that 60% of the adverse and temporary harm events it found occurred in states that had reporting systems, "yet only an estimated 12% of events nationally met state requirements for reporting ... [and] that hospitals reported only 1% of events."
Compounding the problem, the OIG report said, most of the unreported events were not identified by hospitals' internal incident reporting systems.
In May, the 1,491-bed Montefiore Medical Center in New York began using Common Formats to count near misses and is already seeking ways to change processes to avert patient harm, says Jennifer Lapponese, BSHA, systems administrator for Montefiore's Common Formats program.
For example, the hospital has realized that some patients who typically use a walker at home are at increased risk of in-hospital falls after their walkers are stored for safekeeping during their stay. "It's like their right arm is missing," she says. The hospital now asks patients on admission if they're accustomed to using a walker at home. If so, the hospital may issue them a walker to help them get around and use the bathroom without falling.
As part of the push to identify near misses, Montefiore's pharmacy department is examining all of its processes, such as how its decentralized medication supply dispensers are managed, Lapponese says.
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