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State-Based Patient Safety Reporting Systems

State-Based Patient Safety Reporting Systems

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State-Based Patient Safety Reporting Systems

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  1. State-Based Patient Safety Reporting Systems Institute of MedicineCommittee on Patient Safety Data Standards Jill Rosenthal May 6, 2002

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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