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Project Overview: Designing Consumer Reporting Systems for Patient Safety Events

Current patient safety event reporting systems are aimed at obtaining information from health care providers. However, patients and their family members are in a unique position to identify gaps in care that may have contributed to adverse events. The Agency for Healthcare Research and Quality (AHRQ) recognizes that consumers can be an important source of information about patient safety, and consumer reporting systems may greatly improve our understanding of the nature and causes of medical errors.

To develop recommendations for ideal reporting systems that consumers would use to report their experiences with patient safety events, AHRQ awarded a 2-year, $618,000 contract in September 2008 to RTI International in Research Triangle Park, N.C., and Consumers Advancing Patient Safety, a consumer-led nonprofit organization based in Chicago. The following document gives additional information on this project. The project's final report is available by selecting Final Report.


Background

It's been nearly a decade since the Institute of Medicine raised national awareness of the prevalence and severity of medical errors, highlighting findings that between 44,000 and 98,000 deaths in U.S. hospitals each year are the result of preventable medical errors. Since 1999, more than 25 States have passed legislation or created regulations related to hospital reporting of adverse events. However, current reporting systems do not accommodate the desire of patients and their families to provide input on their experiences with care.

Current Reporting Systems

Current patient safety event reporting systems are aimed at obtaining information from health care providers. However, patients and their family members are in a unique position to view the continuum of care, which enables them to identify gaps in care that may have contributed to adverse events.

The Agency for Healthcare Research and Quality (AHRQ) recognizes that consumers can be an important source of information about patient safety, and systems that include patients' reports of patient safety events will complement information that is collected from health care providers through other reporting mechanisms. Consumer reporting systems may greatly improve our understanding of the nature and causes of medical errors and enhance the development of effective methods for improving quality and preventing patient harm. Specifically, the consumer perspective will likely contribute to an improved understanding of patient safety and assist in the detection of patterns associated with medical errors or health system failures.

Research to Create Patient Safety Event Reporting Systems for Consumers

To develop recommendations for ideal reporting systems that consumers would use to report their experiences with patient safety events, the Agency for Healthcare Research and Quality (AHRQ) awarded a 2-year, $618,000 contract in September 2008 to RTI International in Research Triangle Park, N.C., and Consumers Advancing Patient Safety, a consumer-led nonprofit organization based in Chicago.

The project involved an iterative consensus-building process with extensive support from a technical expert panel, consumer focus groups, interviews with key stakeholders, and an environment scan and literature review.

Recommendations from the technical expert panel underwent an external peer review process, and key findings will be disseminated broadly via peer-reviewed journals, professional conferences, Web sites of major health organizations, and other mechanisms.

The ultimate outcome of this project was to outline the specifications for the future development of consumer reporting systems for patient safety events. This project was completed in September 2010.

Questions That Were Addressed

This project's goal was to answer the following questions:

  • What types of information can consumers provide concerning their experience with patient safety events that may be useful in a patient safety reporting system?
  • What are the scope and range of options for consumer reporting mechanisms, and would these options differ at the national, regional, State, or local level?
  • What type of infrastructure is needed to enable effective consumer reporting of patient safety events that can lead to corrective action?
  • What is the most effective operational approach for consumers to report patient safety event information? Specifically, in what type of organization (public-private partnership, public, or private) should a consumer reporting system be housed, and how should the reporting system be financed?
  • How would consumer reporting of patient safety events be linked to quality and patient safety improvement efforts?
  • How can a reporting system maximize the willingness and ability of consumers to report on patient safety events?

Final Report

The conclusions reached by the contractors and the technical expert panel are available in the contract final report, Designing Consumer Reporting Systems for Patient Safety Events (AHRQ Pub. No. 11-0060-EF), which can be found on the AHRQ Web site. A link to the printable PDF file ( PDF file PDF version - 2.92 MB ) is located on that page. Printed copies will not be available through the AHRQ Publications Clearinghouse.

For Additional Information

To obtain more information on this project, contact:

James Battles, Ph.D.
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850
Phone: (301) 427-1332
E-mail: James.Battles@ahrq.hhs.gov

Current as of July 2011
Internet Citation: Project Overview: Designing Consumer Reporting Systems for Patient Safety Events. July 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/consumer-experience/systems/index.html