A Review of Current State-Level Adverse Medical Event Reporting Practices

Toward National Standards

by Megan K. Beckett, Donna Fossum, Connie S. Moreno, Jolene Galegher, Richard S. Marken


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Nearly half of states require or request the reporting of adverse medical events. In 2003, the Institute of Medicine (Patient Safety: Achieving a New Standard of Care) called for the use of consistent standards for medical error reporting. Standardization will facilitate the creation of a national patient safety repository that aggregates data from states and enable policymakers to track trends in adverse events nationally. The Agency for Healthcare Research and Quality (AHRQ) is leading the national Patient Safety Initiative to combat medical errors. This report summarizes the results of an AHRQ sponsored 50-state survey of adverse reporting systems in 2004. It documents the consistency of information that states are collecting as part of their reporting systems, identifies issues related to establishing a national patient safety repository, and presents an action plan to implement a standardized nationwide system elicited from an external advisory panel that was convened explicitly for this purpose.

Table of Contents

  • Chapter One


  • Chapter Two

    Data Collection and Analytic Methods

  • Chapter Three

    Administrative Characteristics of Adverse Event Reporting Systems

  • Chapter Four

    Defining Reportable Events

  • Chapter Five

    Data Elements: Information About Reportable Events Collected By States

  • Chapter Six

    Existing Medical Standards Applicable to Adverse Event Reporting

  • Chapter Seven

    Design and Implementation of an Adverse Medical Events Reporting System: The Views of Patient Safety Experts

  • Chapter Eight

    Summary and Conclusions

  • Appendix A

    Creating Analytic Files or Worksheets

  • Appendix B

    Summary of Information Collected About Each State System (including Maryland)

  • Appendix C

    Hierarchical Categorization of Reportable Adverse Events

The research described in this report was sponsored by the Agency for Healthcare Research and Quality (AHRQ). The research was conducted in RAND Health, a division of the RAND Corporation.

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