Toward an Optimal Patient Safety Information System

National concerns about the quality of care and patient safety have called increasing attention to the adoption and use of health information technology (health IT) for collecting and analyzing information pertaining to adverse events. Although efforts to incorporate technology to patient safety programs are underway, the link between applied technology and the integration of disparate reporting systems has not been widely studied. Applications to improve patient safety reporting, data analysis, and learning from errors in health care and their associated root causes must be better understood. This project was designed to critically examine and when appropriate demonstrate the added value these specific applications bring to patient safety reporting systems, particularly in the clinical, financial and organizational realms. In order to establish baseline data on the current penetration, characteristics, utility, and value of extant incident reporting systems, we first conducted a comprehensive assessment of current patient safety reporting among a large national sample of hospitals. This assessment utilized the federal Quality Interagency Coordination Taskforce (QuIC) Adverse Event Reporting Questionnaire and a Value Questionnaire developed specifically for this project. Then, a representative sub-sample of respondents from the initial assessment were provided with the opportunity to participate in one of two enhanced reporting applications for a one-year period. The first involved use of the Patient Safety Event Taxonomy (PSET), developed by the Joint Commission, which combines and classifies data from disparate reporting systems to facilitate comparisons across hospitals. The second application involved the Hospital Incident Reporting Ontology (HIRO), which examines the relationships among the variables collected and classified by the PSET, in order to facilitate data-mining and data sharing of patient safety information among hospitals. Both applications will continually provide participating hospitals with aggregate trends and interpretation of the data analyzed by the PSET and the HIRO. Following the implementation period, these hospitals were re-assessed for their perceived value of the 'improved' reporting systems. Throughout the project, the results and lessons learned were disseminated to the health care community. The primary theme of the project was to promote a national reporting system for adverse events through the use of a standardized patient safety taxonomy and ontology - both applications complement each other in the collection, classification and organization of near miss and adverse event data in a format suitable for use in disparate hospital settings. The Joint Commission, KEVRIC, and Joint Commission Resources were poised to undertake this project given their extensive experience in patient safety, health information technology, and educational research.