NPSD Dashboards display data that follow the Common Formats for Event Reporting – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event Descriptions. There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific modules for specific types of adverse events that are common. The Generic module allows classification of all events as Incident, Near miss, or Unsafe condition as well as provides other information relevant to all events (e.g., harm). The event-specific modules provide additional and more detailed information about the following nine event categories: Blood or Blood Product; Device or Medical/Surgical Supply, Including Health Information Technology (HIT); Fall; Healthcare-Associated Infection; Medication or Other Substance; Perinatal; Pressure Ulcer; Surgery or Anesthesia; and Venous Thromboembolism. The text of the NPSD Dashboards has been formatted to assist readers to better understand event types and reporting categories, including the specific Data Elements and associated Answer Values that operationalize the Common Formats. Data Elements refer to the concepts reported in the CFER-H and captured through individual questions asked of reporters for each patient safety concern (e.g., “What is being reported?” Incident, Near miss, or Unsafe condition). Answer Values represent the unique response options for each Data Element. Following the previous example, the Data Element “What is being reported?” has three Answer Values:
- Incident: A patient safety event that reached a patient and either resulted in no harm (no harm incident) or harm (harm incident). The concept “reached a patient” encompasses any action by a healthcare practitioner or worker or healthcare circumstance that exposes a patient to harm. For example, if a nurse gives a patient an incorrect medication to take and the patient recognizes it as such and refuses to take it, an incident has occurred.
- Near miss: An event that did not reach a patient. For example: discovery of a dispensing error by a nurse as part of the process of administering the medication to a patient (which if not discovered would have become an incident); discovery of a mislabeled specimen in a laboratory (which if not discovered might subsequently have resulted in an incident).
- Unsafe condition: Any circumstance that increases the probability of a patient safety event; includes a defective or deficient input to or environment of a care process that increases the risk of an unsafe act, care process failure or error, or patient safety event. An unsafe condition does not involve an identifiable patient. For example, an out-of-date medicine on a shelf represents an unsafe condition. It might be given to a patient, but the identity of the patient is unknown at the time of discovery. The attempt to administer the out-of-date medicine to a patient would either represent a near miss (if not administered) or an incident (if administered).
Each of these types of information contained in the CFER-H are highlighted in the text to clarify the context of the information for readers. The following pedagogy is used throughout the document:
- Event Types: All key words have first-letter capitalization, and are italicized (e.g., Blood or Blood Product)
- Data Elements: All letters are capitalized, and bold-faced (e.g., CATEGORY ASSOCIATED WITH EVENT OR UNSAFE CONDITION)
- Answer Values: First letter of first the word is capitalized, and all letters are italicized (e.g., Unsafe condition; Moderate harm)