Improved Patient Safety Goal of New Standardized Reporting Forms

Published in the Journal of Biomedical Informatics, the study notes that most Medicare and Medicaid hospitals are required to be part of a Patient Safety Organization (PSO).

Those organizations, in turn, must report adverse patient events in a uniform way, using standard forms called the Common Formats for Patient Safety data collection and reporting.

As many as a third of patients admitted to the United States’ best hospitals have experienced harm as part of their care. That 2005 statistic is often cited to underscore the need for improvement in health care.

The Patient Safety and Quality Improvement Act was signed into law in 2005, providing legal protections around reporting and analysis of patient safety events when reported to designated PSOs.

Tracking patient-safety trends, as well as adverse events, is extremely difficult when data collection methods and definitions vary from organization to organization.

Based on clinical guidelines and expert opinion from the Agency for Healthcare Research and Quality (AHRQ) and the National Quality Forum’s expert panel, the Common Formats require that organizations now use the same definitions to report patient-safety problems and events.

Similar kinds of requirements have been successfully applied to the aviation and nuclear power industries, the paper reports.

These steps are critical to making health care safer and will require additional data entry by patient-safety officers at hospitals, according to the paper. Such measures also can provide hospitals with better legal protection in the event that a liability issue arises.

“We believe this is worth the effort as data collection of outcomes and root cause analysis — the factors that make errors more likely — are the best way for us to determine the important interventions needed to improve patient safety,” Elkin says.

The standardization of such tools has another advantage, he notes, since they are easily incorporated into electronic systems, such as electronic health records.

“These tools can be deployed at the point of care and can assist us in finding systematic error in the clinical practice and in resolving incongruities toward a safer patient care environment for our patients,” Elkin says.

The expectation is that the Common Formats will help improve the health care system as a whole by creating what the paper terms “a patient safety life cycle of standardization,” so that problems are detected, analyzed, studied and ultimately used to improve the entire system.

The standardized reporting requirements are an excellent example of translational medicine because they take research results from disciplines like biomedical informatics and apply them to the real-world health care system, Elkin says.

“The Common Formats are helping to systematize the practice of medicine by providing the tools, workflow and knowledge at the point of care to assist clinicians,” he says. “This helps decrease both errors of commission and of omission.”

Elkin is a member of the expert panel of the National Quality Forum (NQF), which is charged with helping the health care system become better and more affordable through the development of ways to measure and assess different health care variables. The Common Formats were created by the AHRQ, and approved by the NQF’s expert panel. 

Elkin’s co-authors are Henry C. Johnson, MD, of Henry Johnson Healthcare Consulting, LLC; Michael R. Callahan, JD, of KattenMuchinRosenman, LLP; and David C. Classen, MD, of the University of Utah School of Medicine and Pascal Metrics PSO.