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Hospitals' Adverse Event Reporting Systems Inadequate

Cheryl Clark, for HealthLeaders Media, July 26, 2012

A Call for Standardization
The only realistic and practical way to start that process is to have a national system, Classen adds. "We have to move from measuring only those most serious events to measuring all-cause harm, and that will probably represent a paradigm shift from voluntary reporting to some sort of surveillance system."

If it's left up to individual state public health departments to design their own, he says, "you'll have 50 different solutions."

A major issue complicating the development of a reporting standard is the question of what makes an error a reportable adverse event. These four scenarios illustrate the confusion.

1. An expired, potentially harmful medication erroneously remains stored in the pharmacy and ready to be filled with a doctor's order. The expiration date is noticed before the drug leaves storage.

2. The expired medication is drawn for a patient and taken to the patient's bedside but is caught before it is administered.

3.  The expired medication is administered to the patient but does not cause harm, or provokes a very minor symptom that is promptly mitigated.

4. The expired medication is administered, prompting a severe reaction that exacerbates illness, prolongs hospitalization, and perhaps even leads to a patient death.

One method to standardize harm reporting, called "Common Formats," is under development by the federal Agency for Healthcare Research and Quality, mainly for use by Patient Safety Organizations (PSOs) working with hospitals. Programmed hospital event reporting systems would capture "anything that goes wrong with the patient as the result of the care process," explains William Munier, MD, Director of AHRQ's Center for Quality Improvement and Patient Safety. 

While that's a long way off from being widely implemented, what may evolve could achieve the same ends as the voluntary Centers for Disease Control and Prevention's National Healthcare Safety Network reporting system now in use for reporting certain types of hospital-acquired infections.

Common Formats is already in use by a number of PSOs, and I hope to write about it in the next few weeks.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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1 comments on "Hospitals' Adverse Event Reporting Systems Inadequate"


Cynthia Jones, COHQ (7/26/2012 at 2:47 PM)
Regardless of a national standard and nomenclature - hospitals have the responsibility to First-do no harm. With that, humans make errors, and we are human. Health systems must facilitate a culture of safety to first - idenitfy, report and address actual harm with prevenatative strategies and system improvements. That is still a huge gap even in the "best centers". From that- organizations begin to learn to identify weaknesses in processes and do proactive strategies based on Near Misses... It's every healthcare members responsibility... It's about building and establishing fundamentals of safe care: Communication, Validation, and thorough assessment that utilze the bedside experts in care-who know processes and their variables - to build better care. It's not the Board, or The CEO, or The Managers, or The Staff. It's AND -all working for the same cause. It's culture. It's fundamental. It can be done.