Designing Consumer Reporting Systems for Patient Safety Events

Allow reporting in real time and after the event, including after an extended period of time. Allow access to system at multiple points so that reporters can update their account of the event.

Facilitate access for diverse reporters (e.g., lower literacy, non-English speakers) and allow patient, family members, caregivers, and others who witness an event to report.

Mixed opinions about allowing anonymous reporting. Anonymity allows reporter to feel safer but precludes follow-up and investigation.

System should protect the identity of users and assure them of confidentiality.

System should be voluntary.

Most stakeholders favor a multilevel system in which reports "roll up" from the local level to State, regional, or national levels.

Opinions about levels of operation linked to goals of system. Local-level reporting important to provide immediate feedback to health care facility and institute rapid change. Higher-level reporting important for accountability and system-wide learning.

Consumer advocates favored a reporting system outside the health care institutions, where consumers feel safe.

Some stakeholders suggested the reporting system be implemented in stages or tested in pilot programs.

Many stakeholders favored Federal government agencies and private/independent/nonprofit organizations. Advantages of government are neutrality and authority; disadvantages are potential to become politicized and government inefficiency.

Mixed views about hospitals and health care institutions; have experience collecting patient safety data and will be more readily accepted by providers; consumer advocates opposed because not a safe place for consumers to report, and institutions can skew data.

Little support for consumer advocacy organizations because would be challenging to get buy-in from health care professionals.

Primary factors to consider: independence/neutrality/transparency, consumer involvement, authority, and ability to investigate.

Staff needed to serve as patient advocates, aid in reporting, triage reports, and conduct investigations; skilled analytic staff also needed.

Divided opinions about whether system should be federally funded or funded by health care organizations.

Some stakeholders suggested implementing the reporting system in stages or testing it in pilot programs.

Offer multiple reporting modalities and allow both structured and unstructured reports.

Provide meaningful and timely feedback to reporters.

Primary goals are organizational-level and system-wide learning and improving quality of care/patient safety (closely linked); also support for consumer empowerment.

Less support for accountability as goal, which would duplicate existing organizations and mechanisms; also focus on punishment could undermine trust and partnership needed for effective system.

Stakeholders generally supported linking to existing efforts to improve quality and patient safety. They did not suggest linking to programs that offer financial incentives for quality (pay-for-performance models) or providing feedback to health care facilities or providers.

Communication efforts needed in health care institutions (e.g., at intake) and public information campaigns; also work through trusted community organizations and employers.

Communication about system should convey importance of consumer reporting to improve patient safety.