How Does the NPSD Work?

Information known as Patient Safety Work Product (PSWP) is developed by providers and AHRQ-listed Patient Safety Organizations (PSOs). This information is submitted by PSOs to the Patient Safety Organization Privacy Protection Center (PSOPPC) using the AHRQ Common Formats for Event Reporting, which is a standardized reporting format using common language and definitions. The AHRQ Common Formats for Event Reporting can be used to report patient safety concerns, a term that includes patient safety incidents, near misses (close calls), and unsafe conditions. The PSOPPC ensures the Common Formats data are non-identifiable before transmittal to the NPSD for aggregation and analysis. The data are reflected in the NPSD Dashboards and Chartbooks. In addition, some of this information also appears in AHRQ's National Quality and Disparities Report.

Because the NPSD contains a large volume of standardized, non-identifiable patient safety data from multiple sources across the country, it is a unique and valuable resource for research and learning about how to improve patient safety and prevent patient harm.

Common Formats and Data Non-identification Are Keys to NPSD Data Reporting

Common Formats

Recognizing the importance of data standards for data analysis, the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) authorized the HHS Secretary to determine common formats and common and consistent definitions for the reporting of patient safety events. These data standards can enable analysis of national and regional statistics, including trends and patterns of healthcare errors. Presently, data must comply with AHRQ's Common Formats for Event Reporting (CFER) in order to be accepted by the PSOPPC import processor. While the CFER exist for three settings of care, the first and most active setting for data collection remains the Hospital (CFER-H). Only data for CFER-H have been reported to the PSOPPC/NPSD; therefore, they are the only source of data included in NPSD. While the CFER-H are intended to capture patient safety events in hospital settings, providers may use the CFER-H in other settings.

Select for the complete documentation on all current versions of AHRQ's Common Formats.

Additional information on AHRQ's development of the Common Formats is also available.

Data Non-identification

Common Formats data voluntarily submitted to the PSOPPC are rendered non-identifiable by a data non-identification protocol to protect the confidentiality of not only the patient, but also the involved providers and reporters. The data are then transmitted to the NPSD for aggregation and analysis and are reflected in the NPSD Dashboards and Chartbooks.

NPSD Data Are Unique

The data presented by the NPSD differ from clinical quality measures reported by agencies such as the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), because the eligible population used to calculate percentages by the NPSD includes only the voluntary sample of reports submitted for analysis and aggregation by participating PSOs. Clinical quality measures reported by other agencies typically focus on all eligible members of the population identified using administrative claims data and are therefore not directly comparable to the NPSD data.