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Two months ago, Naomi Kuznets, PhD, director of the Accreditation Association for Ambulatory Health Care’s (AAAHC) Institute for Quality Improvement (IQI) in Wilmette, IL, hinted to Healthcare Benchmarks about some of the interesting results from two upcoming studies: a special report on medical event reporting and one on diagnostic colonoscopy.
The published results don’t disappoint.
The former, Medical Event Reporting, offers both reasons for concern and some comforts. (For more information, see "Making colonoscopy patients comfortable," in this issue.) Only a third of those responding to the survey (543 respondents out of 1,240 surveyed) are involved in collecting information on adverse medical events and near misses. But more than half of those that do have such systems have implemented them voluntarily, and half looked at near misses as well as actual events.
With so much attention focused on medical errors after the 1999 Institute of Medicine (IOM) report, To Err Is Human, the AAAHC board decided in September 2000 to survey its accredited members and see what they were doing to address the issue. They sent out a survey about how respondents reported medical events — defined as illness and injury associated with medical care, or instances where health care providers realize that illness or injury is likely to occur and prevent it (near misses) — and elements of those reporting systems.
The institute said it was particularly important to look at event reporting in the ambulatory setting because so much patient care has shifted from inpatient to outpatient settings, says Kuznets. According to the report, it was estimated that as of 1996, more than three-quarters of medical procedures were done in the ambulatory care setting.
Key findings of the report include:
• Who has them? Ambulatory surgery centers (ASCs) are most likely to participate in medical event reporting programs, while student health centers were the least likely to do so. The average staff size for the former is 50, with 36 physicians and 11 nurses, while the latter has only an average of five each physicians and nurses, and 17 total staff. "We believe that size is the primary reason for this difference," Kuznets says. "It appears it’s a matter of clinical staff size. Whether it’s a factor of them being more easily identified or there is not enough staff we don’t know. Our guess is it’s the two things in combination."
• Who runs them? Most of the ASCs that participated did so through voluntary programs that are run by medical societies and professional organizations. Of the voluntary systems that 57% of the respondents participate in, 13% are run by medical societies or professional organizations, 45% are self-administered, and 21% are government run (either state or federal). The remainder is divided between consultant or commercial vendors, network, accreditation, and device or implant-maker groups. The involuntary systems are primarily run by state or federal governments (48%), networks (22%), or the organizations themselves (19%). Accreditation organizations, consultants, insurers, manufacturers, and medical schools run the remainder.
• What are the attributes? Only one organization didn’t have a system that required information on actual injuries or illnesses. The rest did. Two-thirds of those in voluntary systems looked at close calls, as did 55% of those in mandatory reporting systems and half of those respondents (3%) that used both voluntary and involuntary systems.
There are several characteristics that respondents indicate make for a better medical event reporting program.
1. Offering unique information. Well over half (107 of 180 reporting organizations) have systems that offer "unique information" that applies particularly to their specialties. The respondents like this because it provides data that they can act upon.
2. Multisite data. Respondents also like systems that report de-identified information from several sites. The report suggests they like this because since the frequency for medical events is usually low, it’s hard to discern patterns from only one site. Sharing information gives more "meaningful, contextual feedback," the report states.
3. Actionable feedback. Examining issues such as common factors associated with medical events and near misses helps organizations make changes that keep problems from occurring in the future. More than 80% of the organizations in voluntary systems or both mandatory and voluntary systems report that their systems offer actionable feedback. But only 54% of those in mandatory systems alone say so. The report suggests that these organizations may feel reporting is a futile activity.
4. Learning from others and sharing experiences. One hundred and six organizations reported that their programs provide information to learn from others errors, and 89 reported their programs offer the opportunity to share experiences so others can avoid potential pitfalls.
The survey also asked respondents what would motivate them to participate in a reporting program. They wanted a program that didn’t take too much time (they reported an average of 5.6 hours per month would be acceptable), didn’t cost too much (an average of $2,235 per year to collect the data), guaranteed confidentiality, provided opportunities for quality improvement and reduced liability insurance costs, and provided information at least once per year, and preferably quarterly.
Disappointingly, 11% of organizations said nothing would motivate them to become involved in a medical-event reporting system. Among the comments was that they had enough reporting requirements, didn’t think it was applicable to them, or that resources could be better used elsewhere. Some felt that their own internal systems were enough.
"One thing we heard from these organizations is that their liability attorneys tell them not to be involved in these kinds of programs or not to tell anyone they are," says Kuznets. "Now, that’s anecdotal information, but my guess is that the idea is that if you don’t say anything, it can’t be used against you."
Kuznets says she was happy to discover that medical error reporting is not as rudimentary as the IOM report indicated. "I figured there were a fair number of organizations doing this," she says. "Granted, AAAHC accredited organizations are unusual in that they seek out accreditation without having to. And the 45% who responded were self-selecting, so this probably overstates the reality. More organizations doing this is better, but this is a growing trend, and that’s great."