The Patient Safety Toolbox for States

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As of September 2005, 25 states had passed legislation or regulations requiring hospitals to report to the state the occurrence of adverse events. Experience has shown, however, that chronic underreporting and inadequate feedback are limiting the potential of state reporting systems to improve the safety of care. This online toolbox—containing background information, policies, sample reporting forms, and more—is designed to help state officials improve the collection, analysis, and feedback of data obtained through state adverse event reporting systems.

The Organization: National Academy for State Health Policy

Target Populations: State health officials, policymakers, reporting system administrators; hospital officials, patient safety officers, patient safety researchers

The Issue: The Institute of Medicine estimates that 44,000 to 98,000 hospitalized patients die each year in the United States as a result of medical errors, which is a subset of all adverse events that occur. As of September 2005, 25 states had passed legislation or regulations requiring hospitals to report to the state the occurrence of adverse events. Experience has shown, however, that chronic underreporting and inadequate feedback are limiting the potential of state reporting systems to improve the safety of care. While these state mandates are intended to hold health care facilities accountable for errors, they also offer the potential to improve patient safety through event report analysis and by dissemination of best practices and lessons learned.

The Intervention: The National Academy for State Health Policy has developed a Patient Safety Toolbox for States, intended to help policymakers improve the collection, analysis, and feedback of data obtained through state adverse event reporting systems. The toolbox explores the policies and practices that 25 states use in their reporting systems and offers ways to continue to develop and improve them. In particular, the toolbox aims to:

  • Help states ensure the consistency of data collection. The toolbox includes examples of reportable event forms, clarifications of what constitutes a reportable event, and examples of users' guides for health care facilities in use in various states, such as Colorado's reporting manual and Tennessee's interpretive guidelines for reporting unusual events.
  • Address challenges of data analysis. The toolbox provides resources for evaluating adverse event reports, determining root causes and contributing factors, conducting onsite investigations, and more.
  • Use feedback from reported data to foster change. The toolbox includes examples of mechanisms used by certain states, such as public or legislative reports, patient newsletters, and alerts/advisories that can help to disseminate best safety practices and generate consumer demand for improvement.
The toolbox includes a U.S. map interface that enables users to browse the adverse event reporting systems by state and access state-specific resources.

For Further Information: To use the toolbox, visit www.pstoolbox.org. You can also download a related report from NASHP, Maximizing the Use of State Adverse Event Data to Improve Patient Safety, or contact Jill Rosenthal, M.P.H., project manager, National Academy for State Health Policy, at jrosenthal@NASHP.org.

January 2006


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