The Agency for Healthcare Research and Quality (AHRQ) presents the dashboards of patient safety data received for analysis and publication in the Network of Patient Safety Databases (NPSD). The 2020 NPSD dashboards were initially based on more than 1.7 million records reported by healthcare providers to approximately 15 percent of AHRQ-listed Patient Safety Organizations (PSOs). Data reflecting an additional 318,773 records submitted to the PSO Privacy Protection Center between January 1, 2020 and December 31, 2020 are now also available in the NPSD dashboards.
Two sets of interactive hospital safety incident dashboards are presented: the Data Submission Summary Dashboard, which provides a high-level overview of the frequency of patient safety events reported, and the Patient Safety Event Dashboards, which include a generic section that provides an overview of the numbers and categories of various patient safety event reports, and dashboards that describe in greater depth the patient harm experienced due to specific safety events. Through the interactive functions, a user can choose to view the dashboards reflecting the more than 2 million cumulative records submitted through 2020, the more than 1.7 million records submitted through 2019, or the 1.1 million records submitted through March 31, 2018.
Eight hospital safety incident dashboards are presented:
Examines all reports on patient safety concerns submitted to the PSOPPC. The dashboard charts detail reports submitted by Common Formats version by year, completeness of reports submitted by version, percentage of reports by version, percentage of reports by report type, and percentage of events by event type and version.
Is based on general information gathered from reports of patient safety concerns associated with at least one of ten specific event types. The dashboard charts detail event type, report type by event type, extent of harm by event type, event type by extent of harm, and extent of harm.
Details the extent of harm due to blood or blood products, type of blood product involved, type of blood product by patient harm, stage of process where event originated, and stage of process where event originated by patient harm.
Details the extent of harm due to devices; type of device; type of device by patient harm; device defect, failure, or user error; device defect, failure, or user error by patient harm; type of health information technology (HIT) device in HIT-related report, and type of HIT device in HIT-related report by patient harm.
Details the extent of harm due to falls, the presence of fall assistance, presence of fall assistance by patient harm, type of fall injury, and fall location.
Details the extent of harm due to medication incidents, incorrect action taken, incorrect action by patient harm, type of incorrect dose, type of incorrect dose by patient harm, stage of process where event originated, and stage of process where event originated by patient harm.
Details the extent of harm to a mother, fetus(es), and/or neonates(s) as a result of perinatal incidents, and whether originated during either the birthing process or an intrauterine procedure.
Details the extent of harm due to a newly-developed or worsening pressure ulcer, including suspected deep tissue injury (sDTI); the documentation of increased risk for pressure ulcer following a risk assessment; and the timing of the first risk assessment for reported pressure ulcers or sDTIs.
Learn more about how the individual dashboards are set up.
- As only data submitted in the Common Formats for Event Reporting – Hospitals (CFER-H) are included in the NPSD dashboards, the dashboards are characterized as reflecting data from the hospital setting. While it is believed that the CFER-H are primarily used as intended to capture patient safety events in hospital settings, providers may have used the CFER-H to report data from other settings.
- Each individual dashboard presents the responses to particular data elements. The primary dashboard is a figure depicting the relative response rates, which is paired with a data table presenting the specific data points. Details on the frequency and percentage of responses can be seen by hovering the mouse over points of interest. Captions provide details about the eligible population and other information necessary to interpret the figure.
- Drop-down menus are provided where there is sufficient data to allow the user to filter and select the data along specific parameters. Each dashboard contains a brief text summary of the main findings of the data.
- Technical notes follow each dashboard to provide additional details such as the text of the specific Common Formats question on which the dashboard is based, any constraints on the eligible population of reports for the data element (such as whether the question is limited to certain report types), and the data element response rate and population size.