Learn more about this State-Based Reporting in Healthcare project:
The Opportunity
While many states are making important strides toward establishing effective public reporting systems for medical errors, the need for broader establishment of adverse event reporting systems is ongoing. When done well, these reporting systems can facilitate substantive reporting and the information derived can then be evaluated and acted upon to improve care and reduce errors.
To date, 26 states and the District of Columbia have enacted reporting systems to help practitioners identify and learn from serious reportable events. The majority of those states incorporate at least some portion of the National Quality Forum’s (NQF) list of 28 Serious Reportable Events (SREs) to help establish a more uniform set of criteria by which to report and act. Despite the existence of these standardized SREs, there remains some incongruity among states in the use, implementation approaches, and perspectives toward reporting a variety of patient safety events, and in turn, efforts for improving adverse outcomes from these events.
While some states have established systems for reporting patient safety events (including SREs), the path toward effective nationwide reporting of these events, as recommended by the Institute of Medicine, is very much in its infancy.i Sixteen of the 27 states with reporting requirements enacted or significantly revised their systems between 2005 and 2007.ii Compliance is also a significant issue; for example in the state of Washington—where the reporting requirement for adverse events was enacted in 1999—a bill has recently been introduced to allow its state Department of Health to fine medical facilities up to $1,000 per violation per day against the medical facility for each day the medical facility is not in compliance with these notification or reporting requirements.iii
Resource:
Overview of State Reporting of Adverse Events, NQF June 2010 Issue Brief
About the Initiative
NQF has developed an ongoing effort to engage representatives of states with reporting systems in order to facilitate communication and inform NQF about successes, barriers, and unintended consequences within adverse event reporting at the state level, including use of NQF's Serious Reportable Events in Healthcare. This initiative began in October 2009, when NQF convened government agency officials representing more than 20 state patient safety reporting systems.
This first meeting provided opportunity to:
- Increase understanding by states of NQF’s list of Serious Reportable Events (SREs), and their potential basis for public reporting nationwide;
- Highlight the key issues faced by state safety reporting systems and how state-level experiences can help develop a framework to guide the collective work of NQF, the states, and the entire healthcare community;
- Facilitate communication among managers of state reporting systems, many of whom are in the early stages of developing their systems;
- Enhance the state perspective in NQF’s safety work, particularly SREs, as input from state officials garnered during the meeting has informed the SRE steering committee’s work.
Convening leaders of state safety reporting systems was a first step in reducing incongruity in state-based event reporting by sharing lessons learned and challenges. Through meetings, issue briefs, and an ongoing working group of state representatives, we aim to create an ongoing dialogue about healthcare reporting as a means for continuous quality improvement.
Process
Based on the interest and input from the 2009 meeting, NQF will continue to convene representatives from the 27 states (including the District of Columbia) with adverse event reporting via periodic teleconferences. States are welcome to opt into this series of teleconferences by contacting NQF with their interest. This includes those states that have not yet formalized patient safety event reporting systems.
Funding
The inaugural meeting and subsequent conference calls are funded under NQF's contract with the Department of Health and Human Services. Additional partial support from the Agency for Healthcare Research and Quality has been provided.
Related NQF Work
Contact Information
For information about the project, contact NQF at 202-783-1300 or via e-mail at patientsafety@qualityforum.org.
i Committee on Quality of Health Care in America, Institute of Medicine, To Err is Human: Building a Safer Healthcare System. Washington, DC: National Academies Press; 2000.
iiRosenthal, J. and Takach, M. 2007 Guide to State Adverse Event Reporting Systems. http://www.nashp.org/sites/default/files/shpsurveyreport_adverse2007.pdf. Last accessed January 5, 2010
iii“An Act Relating to penalties for violating requirements concerning reporting adverse health events; amending RCW 70.56.020; adding a new section to chapter 70.56 RCW; and prescribing penalties.” http://apps.leg.wa.gov/documents/billdocs/2009-10/Pdf/Bills/Senate%20Bills/6247.pdf. Last accessed January 12, 2010.
NQF has begun an initiative to review results and discuss successes, barriers, and unintended consequences within adverse event reporting at the state level, including use of NQF's Serious Reportable Events. This effort will be guided by a working group of representatives from the 27 states (including the District of Columbia) with medical error reporting.
NQF has convened a working group of representatives from 27 states (including the District of Columbia) to create an ongoing dialogue about healthcare reporting as a means for continuous quality improvement.
Working Group Roster
The initial in-person meeting of this group, a one-day session entitled, "Creating a Vision for Patient Safety Event Reporting," was held on October 28, 2009, at the Westin Grand Hotel in Washington, DC.
Agenda (PDF)
Meeting Minutes (PDF)
The next in-person meeting of this group, entitled, "Creating a Vision for Patient Safety Event Reporting II: A Focus on the State Level," was supported by the Agency for Healthcare Research and Quality, and was held on June 15, 2010, at the Westat Conference Center in Rockville, MD.
Agenda (PDF)
Overview of National Reporting Programs (PDF)
Conference Call on the Relationship Between Providers and State Reporting Agencies
The working group met via conference call on June 28, 2010 to discuss expanding the relationship between state reporting agencies and provider organizations. Dr. Kathy Jenkins, Chief Patient Safety and Quality Officer, Childrens Hospital Boston, joined the group as a guest speaker.
Conference Call on Auditing and Data Validation in Adverse Event Reporting
The working group met via conference call on September 13, 2010.
Conference Call on Data Quality and the Potential Under-reporting of Adverse Events
The working group met via conference call on November 29, 2010.
Conference Call Reviewing the Role and Responsibility of a Patient Safety Organization
The working group met via conference call on January 24, 2011. Please continue to monitor this project page for information about future calls.
Agenda (PDF)
Meeting Minutes (PDF)
Meeting Recording (MP3)
