Narrow Results Clear All
- Study 5
- Book/Report 25
- Legislation/Regulation 2
- Newspaper/Magazine Article 4
- Special or Theme Issue 1
- Toolkit 1
- Web Resource 16
- Award 1
- Press Release/Announcement 1
- Communication Improvement 2
- Culture of Safety 4
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 2
Legal and Policy Approaches
- Regulation 12
- Quality Improvement Strategies 13
- Teamwork 1
- Technologic Approaches 5
- Transparency and Accountability 2
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 2
- Medical Complications 9
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 3
- Australia and New Zealand 1
- Europe 3
- Canada 2
Search results for "Governmental Reporting"
- Governmental Reporting
- Policy Makers
Journal Article > Study
Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.
Moore TJ, Furberg CD, Mattison DR, Cohen MR. Pharmacoepidemiol Drug Saf. 2016;25:713-718.
According to this study, many adverse drug event reports submitted by drug manufacturers to the Food and Drug Administration were incomplete. The authors advocate for the FDA to update their reporting requirements and compliance policies.
Pino R, Furniss WH, Mueller L, Olson JC. Hartford, CT: Connecticut Department of Public Health; October 2016.
This annual publication provides data on adverse events reported to the Connecticut Department of Public Health. The most recent report discusses an analysis of the 456 incidents submitted in 2015, which represents a slight decrease. The most common adverse events reported were pressure ulcers and fall-related injuries or deaths. Past reports are also available.
Jefferson City, MO: Center for Patient Safety; April 12, 2016.
Patient Safety Organizations (PSOs) provide local evidence to inform learning at the state level. This annual report describes a Missouri PSO's activities in 2015 broken down by environments: long-term care; emergency medical services; home health and hospice; and hospitals, ambulatory surgical centers, and medical offices. The publication also summarizes breakdowns of data collected over 5 years.
Web Resource > Government Resource
National Patient Safety Agency.
This Web site provides data on safety incidents from the United Kingdom in the form of workbooks sorted by either organization or region.
Wright S. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2012. Report No. OEI-06-09-00092.
This report built on earlier research to examine rates of adverse events reported to state-level reporting systems compared with hospital data. It found that, even in states with required hospital reporting of adverse events, only about one in nine events is reported to the state. Because few of the events were found in each hospital's incident reporting system, the investigators concluded that the low rate of reporting was likely due to hospital failure to identify events rather than hospitals failing to report known events.
Lucado J, Paez K, Elixhauser A. HCUP Statistical Brief #109. Rockville, MD: Agency for Healthcare Research and Quality; April 2011.
Tools/Toolkit > Multi-use Website
Portland, ME: National Academy for State Health Policy.
This online toolkit provides sample documents, policies, and Web site links related to the 27 states that have implemented adverse event reporting initiatives.
The Quality Improvement Committee. Wellington, New Zealand.
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics on serious and sentinel events in New Zealand's 21 District Health Boards. The reports aim to encourage transparency in New Zealand medical practice and bolster knowledge to prevent future errors.
The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.
Thompson WC Jr. New York, NY: Office of the New York City Comptroller, Office of Policy Management; 2009.
This report assesses the New York State Department of Health's New York Patient Occurrence and Tracking System (NYPORTS). It observes trends of adverse event reporting, finds that New York City hospitals report dramatically fewer events per discharge, explores reasons for underreporting, and discusses the impact on safety improvement efforts.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471.
The Tax Relief and Health Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress a series of analyses with the first related to understanding the issues around hospital-based adverse events. This related and simultaneously released report identifies and describes state reporting systems and how they utilize the captured information. The report concludes that as of January 2008, 26 states had reporting systems in place, 23 states used the data to hold individual hospitals accountable, and 18 states reported using the data to promote learning and develop prevention strategies. A past AHRQ WebM&M perspective discusses the role of state reporting systems in advancing patient safety.
St. Paul, MN: Minnesota Department of Health; January 2009.
Through a qualitative evaluation of the Minnesota statewide reporting initiative, this report suggests ways to improve the reporting system to facilitate continued learning and transparency.
Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-808.
This report describes state reporting programs for health care–associated infection (HAI), hospital initiatives to reduce MRSA (methicillin-resistant Staphylococcus aureus), and challenges encountered in HAI reduction.
Rojas-Burke J. Oregonian. January 30, 2007:B01.
This article reports on results from the first round of error data reported to the Oregon Patient Safety Commission voluntary reporting program.
Award > Award Recipient
Rabinowitz ABK, Clarke JR, Marella W, et al. Jt Comm J Qual Patient Saf. 2006;32:676-681.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; September 2006. Report No. OEI-09-04-00350.
This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.
Web Resource > Government Resource
New Jersey Department of Health and Senior Services.
This Web site supports the data collection and educational initiatives associated with New Jersey's incident reporting program. The site includes reporting forms, instructions, and a patient safety newsletter.
Rosenthal J, Booth M. Portland, ME: National Academy for State Health Policy; 2005.
This report, generated by the National Academy for State Health Policy, provides practical guidance and tools for states with existing reporting systems. The expert group that came together included data collectors, analysts, and users who aimed to develop strategies for improved collection, analysis, and feedback. The authors present key findings and emphasize that the quality improvement aspect of reporting systems is critical to success. Although the authors encourage greater use of reporting systems, a need exists for states to produce better-quality reports from their data to promote patient safety interventions. Additional initiatives from the report include development of a central Web-based repository of tools and resources that they plan to make available at their Web site.
Journal Article > Study
Al Mohajer M, Joiner KA, Nix DE. Acad Med. 2018;93:1827-1832.
The Hospital-Acquired Condition Reduction Program (HACRP) was established by the Centers for Medicare and Medicaid Services (CMS) and withholds payment to hospitals for several hospital-acquired conditions deemed to be preventable sources of patient harm. Prior research has shown that teaching hospitals, hospitals caring for more complicated and high-risk patients, and safety-net hospitals may be more likely to experience financial penalties under HACRP compared to nonteaching hospitals caring for less sick patients. These findings raised concerns regarding the possible unintended consequences related to pay-for-performance. Researchers sought to identify factors associated with HACRP performance and penalties. They found that teaching institutions and hospitals with higher case-mix index, length of stay, and those located in the Northeast or Western United States were more likely to receive penalties under the CMS program. A previous WebM&M commentary discussed the unintended consequences associated with publicly reported health care quality measures.
Preventable tragedies: superbugs and how ineffective monitoring of medical device safety fails patients.
US Senate Health, Education, Labor, and Pensions Committee. January 13, 2016.
Insufficient sterilization of duodenoscopes and other medical equipment has been linked to health care–associated infection outbreaks. This report summarizes findings from a government investigation into existing methods for monitoring and reporting device problems and provides recommendations for Congress, hospitals, and the Food and Drug Administration to augment identification and prevention of safety issues associated with medical devices.
Fourth Report of Session 2014–15. House of Commons Health Committee. London, England: The Stationery Office; January 13, 2015. Publication HC 350.
Complaints are a proactive way to monitor and address recurring problems that may result in adverse events and system failures. This report discusses progress achieved through complaint response efforts in the United Kingdom and provides recommendations to augment how complaints are managed to develop further improvements.