Ease of use important for medical event reporting
The report To Err is Human: Building a Safer Health System, which was issued in 2000 by the Institute of Medicine in the Washington, DC, indicated a lack of information on medical event reporting within ambulatory health care settings, including same-day surgery programs.1
This lack of information implies that the number of ambulatory health care settings that have medical event reporting systems is low, says Naomi Kuznets, PhD, director of the Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement (IQI) in Wilmette, IL. A more recent survey by IQI of 539 ambulatory health care facilities that included freestanding surgery centers shows that 33% of participants have reporting systems in place, she adds.
"The Institute of Medicine report included only 1½ pages of information on outpatient care that did not necessarily reflect all ambulatory care," Kuznets says. The lack of information collected in the study implied that the state of medical event reporting within ambulatory care organizations is rudimentary, she adds. After a literature search showed that there is little information regarding medical event reporting within ambulatory care facilities, IQI staff recognized a need to find out what is being done, she explains. The result is the IQI Medical Event Reporting Special Report.
Of the 539 respondents to the study designed by IQI, a total of 180 or 33% reported participation in a system that collects information on illnesses or injuries related to medical treatment and/or instances in which illness or injury related to medical treatment is likely to occur, Kuznets says.
Respondents described three types of reporting systems, Kuznets says. Fifty-three percent of respondents participate in voluntary programs in which the medical event reporting system is imposed internally or through a professional association; 43% participate in involuntary programs that are imposed by state, federal, regulatory, or network organizations; and 3% participate in both types of programs, she explains.
Responses show the voluntary programs offer more appropriate information, more feedback, and more opportunity to use the data in a positive, actionable manner, Kuznets says. The problem with mandatory systems imposed by other organizations is the lack of feedback that does not enable the reporting ambulatory organization a chance to use data to improve quality, she adds.
Attributes of a medical event reporting system that are being used by study respondents include:
- ease of reporting (more than 86%);
- frequent reports (more than 58%);
- actionable feedback (more than 54%);
- information important to the participating program’s unique situation (more than 50%).
- reports from several sites (more than 40%);
"Unique information that applies specifically to a participant’s specialty makes the medical event reporting system more useful," Kuznets says. For example, a same-day surgery program that specializes in ophthalmology will not want the same information about anesthesia incidents that a multispecialty program that performs a high percentage of laparoscopic procedures will want, she explains.
The types of systems used by study participants ranged from voluntary participation in medical society or professional organization systems, vendor systems, or internal systems to involuntary participation in federal, state, insurer, and surgery center network systems, she says.
When asked how much they would be willing to spend to participate in a reporting system, 102 respondents suggested costs that ranged from $5 to $180,000 per year. The median cost was $200, and the average cost was $2,235, Kuznets says.
While the report spells out the features that are most likely to increase participation in medical event reporting, Kuznets points out that none of the systems in use by the participants measure "near-miss" events. "This is one area in which ambulatory care programs could really increase their opportunities to learn in situations in which they aren’t liable for any injuries but could identify potential problems proactively," she says.
[Editor’s note: Copies of the IQI Medical Event Reporting Special Report can be ordered by contacting: The Institute for Quality Improvement, Accreditation Association for Ambulatory Health Care, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091. Telephone: (847) 853-6060. Fax: (847) 853-9028. Web: www.aaahciqi.org. The cost is $25 plus $5 for shipping.]
Reference
1. Kohn LT, Corrigan JM, Donaldson MS, eds.; Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
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