Hospitals started implementing event reporting policies earlier than the 1990s, but the main focus on medical errors in the American healthcare system during the ’90s led to a surge in mandatory reporting systems. Namely, in 1991, a landmark study documented medical errors in 30,000 hospital discharges in New York.[i]
Renewed interest surged again in 2000 when the Institute of Medicine published the report, To Err Is Human: Building a Safer Health System.[ii] This resulted in a task force being assembled to recommend improved patient safety measures, and eventually led to a mandatory reporting system being put in place across the US.[iii] Since then, many healthcare studies have suggested that mandatory AND voluntary systems work together to improve patient safety in the healthcare system.
Other notable movements in event reporting and patient safety were the 100,000 Lives Campaign and a study in Minnesota which asked respondents to rate the priority level of patient safety before and after the passage of a state-wide event reporting law.[iv]
The Minnesota study showed that physicians need to be “engaged in and supportive of newly-implemented policies and practices” to create a “culture in which all team members feel comfortable speaking up about safety risks.”[v]
Where Are We Now?
Both mandatory and voluntary reporting systems currently operate through the United States with varying level of success. Although organizations throughout the United States have seen improvements in patient safety based on event reporting practices, many are still trying to implement better event reporting processes and best practices. So where do we see event reporting going?
The Future of Event Reporting
Updating event reporting systems and policies can lead to many benefits. Here are some ideal characteristics we will see as event reporting continues to improve:
- Improved understanding from/with patients: Organizations should be listening to their patients. New voluntary event reporting systems which are easily available and easy to use will allow for maximum use and maximum benefit.
- Improved education and accountability: Consumer reporting systems should serve two purposes for healthcare organizations: education, so organizations can learn from the consumer perspective and improve future outcomes; and accountability, in order to hold the system responsible for past events.
- Increased accessibility: Allowing systems to report at any time is key to maximizing use and function.
- Enhanced approachability: Alongside accessibility, systems must also allow both structured and unstructured reporting. Anonymity and confidentiality are key here. If organizations encourage confidentiality, then anonymity is less needed, but the option should still be available.
- Broadened reach of reporting: Event reporting systems should collect information on a wide range of events including near-miss and no-harm events as well as adverse events. They should capture both objective and subjective information.
- Increased action-orientated decision making: Organizations need decisive rules on what kind of events receive what type of analysis, to better lead to action and feedback.
- Advanced Communication: This includes not just within a healthcare organization but between healthcare organizations as well. Information sharing allows organizations to learn from each other, improve faster, and hold event reporting and patient safety at a higher standard.
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[i] Brennan TA, Leape LL, Laird NM. et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. NEJM. 1991 Feb 7;324(6):370–6.
[ii] Kohn LT, Corrigan JM, Donaldson, MS, editors. To err is human: building a safer health system. A report of the Committee on Quality of Healthcare in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
[iii] Flink E, Chevalier CL, Ruperto A. et al. Lessons learned from the evolution of mandatory adverse event reporting systems. Advances in Patient Safety: From Research to Implementation. 3;2005. http://www.ncbi.nlm.nih.gov/books/NBK20547/
[iv] Adverse healthcare events reporting system: What have we learned? 5-year review. Minnesota Department of Health. 2009 Jan. http://www.health.state.mn.us/patientsafety/publications/09aheeval.pdf