Adverse Event Reporting Practices by U.S. Hospitals

Survey Results from 2005 and 2009

by Donna O. Farley, Amelia Haviland, Ann C. Haas, Chau Pham

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In 2000, the U.S. Congress mandated the Agency for Healthcare Research and Quality (AHRQ) to take a leadership role in helping health care providers reduce medical errors and improve patient safety. In September 2002, AHRQ contracted with RAND to serve as the patient safety evaluation center for this initiative. The evaluation center was responsible for performing a four-year formative evaluation of AHRQ's patient safety activities, and providing regular feedback to support the continuing improvement of the initiative over the evaluation period. As part of this contract, RAND administered the Adverse Event Reporting System Survey (AERS) that was developed by AHRQ in 2003 through a contract with Westat. This report presents the results of the administrations of the AERS survey in 2005 and 2009. These two sets of survey data provide measurable information that documents need and highlights priorities for improvements in the internal adverse event reporting systems and practices of U.S. hospitals. These survey results also establish baseline data for use in future monitoring of improvement progress, as AHRQ implements the Patient Safety Organization program established by the Patient Safety and Quality Improvement Act of 2005 (S. 544) enacted by the U.S. Congress.

Table of Contents

  • Chapter One

    Introduction and Background

  • Chapter Two

    Data Collection and Analysis Methods

  • Chapter Three

    Cross-Sectional Comparisons for 2005 and 2009

  • Chapter Four

    Longitudinal Changes for 2005/2009 Hospital Cohort

  • Chapter Five

    Use of the AHRQ Patient Safety Tools by U.S. Hospitals, 2009

This work was supported by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services and was conducted in RAND Health, a division of the RAND Corporation.

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