A Review of Current State-Level Adverse Medical Event Reporting Practices
Toward National Standards
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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
Introduction
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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