Reporting Patient Safety Events

About the Challenge

Background:

Patient Safety Organizations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ) create a safe environment for health care providers to collect, aggregate, and analyze data without fear of legal discovery. This flow of information is designed to improve the quantity and quality of actionable information available and ultimately improves the safety of health care by identifying and reducing the risks associated with patient care.

The Institute of Medicine, in its 2011 report on Health IT and Patient Safety:  Building Safer Systems for Better Care, recommended voluntary adverse event reporting by health care providers and promoted PSOs using AHRQ’s Common Formats as the “best option” for advancing effective reporting. Because medical errors occur in a complex environment and are caused by multiple factors, adverse event reporting must capture a wide range of data, which may go beyond structured data required by Common Formats. Furthermore, providers may need to send the same or similar data to more than one PSO as well as to other public health or health oversight agencies. 

The Reality This Challenge Addresses: Hospitals and other health care organizations have multiple adverse event reporting relationships – with 1) the PSO of a national organization or a PSO recently formed through a trusted state hospital association, 2) one or more specialty PSOs (e.g., that concentrate on adverse events associated with lab, anesthesia or medication errors), 3) a state agency that receives reports mandated by the state, and 4) the Food and Drug Administration for reports on regulated medical devices. 

Hospitals struggle to increase internal incident reporting, especially by busy care providers, and to create effective systems for the quality and risk management staff to complete root cause analyses and follow-up which are required by both CMS and the Joint Commission. Hospitals enter relationships with PSOs because of Board commitments to quality patient care and a culture of safety. They do this while attesting to Stage 1 of Meaningful Use at a fierce pace. Many Boards intend to use EHRs to drive quality and safety, but they also hear reports about new patient safety hazards associated with the introduction of EHRs.   

Quality and risk management staff suffer from reporting fatigue in a paper-based reporting system, which affects reporting frequency and quality – all of their energy is spent on convincing physicians and nurses to report incidents (not just talk about them in the halls), doing enough of an investigation to fill out the appropriate forms, and faxing them to the appropriate agencies.

These reporting issues would be partially alleviated through the deployment of an effective software reporting solution. The solution needs to make it easier for any qualified individual to file a report electronically, using Common Formats but allowing for additional elements and narratives. It must allow the hospital quality and risk management staff to add information from follow-up investigation, submit reports as appropriate to PSOs, the state, or the FDA (which may differ, and need to be tracked separately), and track follow-up activities. 

In order to improve our understanding of patient safety issues, it is important to innovate beyond the existing tools so that a new system will:

1)     Collect and analyze information that characterizes patient safety events in a standardized, discrete, measurable way

2)     Increase the rate of reporting of patient safety events and improve the quality of the reported data

3)     Leverage existing health information technology (HIT) to eliminate duplicate data entry, as well as transcription and transposition errors

4)     Analyze patient safety event data to provide useful reports and actionable information to providers and PSOs

Challenge Description:

The “Reporting Patient Safety Events Challenge” asks multi-disciplinary teams to develop an application that facilitates the reporting of patient safety events, whether implemented in hospital or ambulatory settings. This application would:

• Increase the ease of reporting patient safety events to the provider or parent organization;
• Enable providers to import relevant EMR, PHR, and other electronic information, including screen shots,  to the patient safety report and, in turn, submit  an AHRQ Common Formats-compliant report to one or more PSOs;
• Capture useful demographic and other relevant information from each patient including age, gender, race, and relevant diagnoses;
• Capture information about the type of organization submitting the report using AHRQ’s PSO Information format;
• Reduce burden of reporting by enabling the provider or parent organization to have the option of submitting information in the patient safety report to non-PSO public health or health oversight organizations, including state or federal programs or accrediting or certifying bodies. 
• Be platform-agnostic; and
• Leverage and extend NwHIN standards and services including, but not limited to, transport (Direct, web services), content (Transitions of Care, CCD/CCR), and standardized vocabularies

Timeline:

• Submission Period Begins: April 12, 2012
• Submission Period for Entries Ends: August 31, 2012
• Evaluation Process for Entries Begins: September 6, 2012
• Evaluation Process for Entries Ends: September 18, 2012
• Winners notified: September 21, 2012
• Winners Announced: Health 2.0 Fall Conference, October 7-10, 2012

Prizes:

• Total: $70,000 in prizes
• First Place: $50,000 plus demo opportunity
• Second Place: $15,000
• Third Place: $5,000

Review Criteria:

The ONC review panel will make selections based upon the following criteria:

1. Effectiveness of the system in facilitating patient safety event reporting including its compliance with AHRQ’s Common Formats
2. Usability and design from the standpoint of all stakeholders
3. Ability to integrate with electronic health records and other HIT data sources
4. Creativity and innovation
5. Leverage NwHIN standards including transport, content, and vocabularies

Review Panel

• Diane Cousins, Agency for Healthcare Research and Quality
• Amy Helwig, Agency for Healthcare Research and Quality
• Kathy Kenyon, Office of the National Coordinator for Health Information Technology
• Terrie Reed, U.S. Food and Drug Administration
• David Hunt, Office of the National Coordinator for Health Information Technology