Designing Consumer Reporting Systems for Patient Safety Events

Contract Final Report

Based on a series of technical expert panel meetings, consumer focus groups, interviews with key stakeholders, and an environment scan and literature review, this project addressed a series of questions about the ideal characteristics of a consumer reporting system, and how such a system could be realistically implemented. (For a summary, select Project Overview.)

The technical expert panel was able to reach consensus on many aspects of consumer reporting systems. However, the panel suggested that there may be a number of types of organizational structures capable of supporting consumer reporting. The report ends with discussion of what is needed to make consumer reporting successful, and the limitations of the study.

This report was funded by the by the Agency for Healthcare Research and Quality (AHRQ) through Contract No. 290-06-00001-5.


Prepared for:

Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
5600 Fishers Lane
Rockville, MD 20857

Prepared by:

RTI International, Washington, DC and Research Triangle Park, NCa and
Consumers Advancing Patient Safety, Chicago, ILb


a Michael T. Halpern, M.D., Ph.D.
Senior Fellow, RTI International
a Amy Elizabeth Roussel, Ph.D.
Vice President, RTI International
a Katherine Treiman, Ph.D., M.P.H.
Senior Research Scientist, RTI International
a Patrick A. Nerz, B.A.
Health Services Analyst, RTI International
b Martin J. Hatlie, J.D.
CEO, Project Patient Care, and Co-founder and Program Director, Consumers Advancing Patient Safety
b Susan Sheridan, M.I.M., M.B.A.
Co-Founder, Consumers Advancing Patient Safety and Expert Lead, Patients for Patient Safety, World Health Organization

This document is in the public domain and may be used and reprinted without permission, except those copyrighted materials that are clearly noted in the document. Further reproduction of those copyrighted materials is prohibited without the specific permission of the copyright holders.

None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.

The opinions presented in this report are those of the authors, who are responsible for its content, and do not necessarily reflect the position of the U.S. Department of Health and Human Services or the Agency for Healthcare Research and Quality.

Peer reviewer's comments on a preliminary draft of this report were considered in preparation of this final report. Synthesis of the scientific literature presented here does not necessarily represent the views of individual reviewers.


The authors are pleased to acknowledge the assistance of the members of the project's Technical Expert Panel; the consumers who participated in focus groups and provided their insights regarding patient safety experience; stakeholders who participated in interviews; the external reviewers of this report; Asta Sorensen (RTI International); and Dr. James Battles (AHRQ) and Dr. Linda Greenberg (formerly, AHRQ).

Page last reviewed October 2014
Page originally created September 2012
Internet Citation: Designing Consumer Reporting Systems for Patient Safety Events. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.