How event reporting by US hospitals has changed from 2005 to 2009

• Published in: BMJ quality & safety Vol. 21; no. 1; pp. 70 - 77
• Main Authors: Farley, Donna O, Haviland, Amelia, Haas, Ann, Pham, Chau, Munier, William B, Battles, James B
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd 01.01.2012; BMJ Publishing Group LTD
• Subjects: adverse effects; Case studies; communication; crew resource management; Cross-Sectional Studies; Data collection; failure modes and effects analysis (FMEA); Health administration; Health Care Surveys; health policy; health professions education; health services research; healthcare quality improvement; hospital reporting systems; Hospitals; Hospitals - standards; Hospitals - statistics & numerical data; Humans; Medical Errors - statistics & numerical data; Methods; Patient safety; Patient Safety - standards; Patient Safety - statistics & numerical data; Polls & surveys; Quality Indicators, Health Care - statistics & numerical data; Questionnaires; Risk management; Safety; safety culture; Safety management; Safety Management - methods; Safety Management - statistics & numerical data; surveys; United States - epidemiology; United States; United States > US
• ISSN: 2044-5415; 2044-5423
• DOI: 10.1136/bmjqs-2011-000114

ContextInformation is needed on the performance of hospitals' adverse-event reporting systems and the effects of national patient-safety initiatives, including the Patient Safety and Quality Improvement Act (PSQIA) of 2005. Results are presented of a 2009 survey of a sample of non-federal US hospitals and changes between 2005 and 2009 are examined.MethodsThe Adverse Event Reporting System survey was fielded in 2005 and 2009 using a mixed-mode design with stratified random samples of non-federal US hospitals; risk managers were respondents. Response rates were 81% in 2005 and 79% in 2009.ResultsVirtually all hospitals reported they had centralised adverse-event-reporting systems. However, scores on four performance indexes suggested that hospitals have not effectively implemented key components of reporting systems. Average index scores improved somewhat between 2005 and 2009 for supportive environment (0.7 increase; p<0.05) and types of staff reporting (0.08 increase; p<0.001). Average scores did not change for timely distribution of event reports or discussion with key departments and committees. Some within-hospital inconsistencies in responses between 2005 and 2009 were found. These self-reported responses may be optimistic assessments of hospital performance.ConclusionsThe 2009 survey confirmed improvement needs identified by the 2005 survey for hospitals' event reporting processes, while finding signs of progress. Optimising the use of surveys to assess the effects of national patient-safety initiatives such as PSQIA will require decreasing within-hospital variations in reporting rates.