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.
Select to download print version (PDF File,
100 KB; PDF Help).
Project Overview
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.
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 involves 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 will undergo 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 is to outline the specifications for
the future development of consumer reporting systems for patient safety events.
This project is expected to be completed in September 2010.
Questions To Be Addressed
This project will strive to answer the following questions:
- What type 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?
For Additional Information
To obtain more information on this project, contact:
Linda Greenberg, Ph.D.
Center for Quality Improvement and Patient Safety
AHRQ
540 Gaither Road
Rockville, MD 20850
Phone: (301) 427-1621
E-mail: Linda.Greenberg@ahrq.hhs.gov
AHRQ Publication No. 09-M023
Current as of May 2009
Internet Citation:
Designing Consumer Reporting Systems for Patient Safety Events. AHRQ Publication
No. 09-M023, May 2009. Agency for Healthcare Research and Quality, Rockville,
MD. http://www.ahrq.gov/qual/consrepflyer.htm
540 Gaither Road Rockville, MD 20850