Implementation and Evaluation of a Prototype Consumer Reporting System for Patient Safety Events

Objective

No methodologically robust system exists for capturing consumer-generated patient safety reports. To address this challenge, we developed and pilot-tested a prototype consumer reporting system for patient safety, the Health Care Safety Hotline.

Design

Mixed methods evaluation.

Setting

The Hotline was implemented in two US healthcare systems from 1 February 2014 through 30 June 2015.

Participants

Patients, family members and caregivers associated with two US healthcare systems.

Intervention

A consumer-oriented incident reporting system for telephone or web-based administration was developed to elicit medical mistakes and care-related injuries.

Main Outcomes Measures

Key informant interviews, measurement of website traffic and analysis of completed reports.

Results

Key informants indicated that Hotline participation was motivated by senior leaders' support and alignment with existing quality and safety initiatives. During the measurement period from 1 October 2014 through 30 June 2015, the home page had 1530 visitors with a unique IP address. During its 17 months of operation, the Hotline received 37 completed reports including 20 mistakes without harm and 15 mistakes with injury. The largest category of mistake concerned problems with diagnosis or advice from a health practitioner. Hotline reports prompted quality reviews, an education intervention, and patient follow-ups.

Conclusion

While generating fewer reports than its capacity to manage, the Health Care Safety Hotline demonstrated the feasibility of consumer-oriented patient safety reporting. Further research is needed to understand how to increase consumers' use of these systems.