1/26/09 - 

Collecting Consumer Reports May Lead to the Prevention and/or Reduction of Patient Harm and Unnecessary Costs Associated with Healthcare Delivery

CHICAGO, January 27, 2009 – The Agency for Healthcare Research and Quality (AHRQ) has awarded $618,000 for a contract to develop recommendations for the possible design, development, and implementation of a patient safety event reporting system for consumers.  RTI International and Consumers Advancing Patient Safety (CAPS) have been selected to conduct this 2 year project. 

The project is designed to (1) develop recommendations for consumer reporting systems for patient safety events; (2) identify the types of information that would be collected from consumers; and (3) determine the different types of mechanisms in which consumer reporting can best be captured.  This research project uses the IDEALS conceptual framework to serve as a guide for developing recommendations for consumer reporting systems for patient safety events; Creative thinking and brainstorming about ideal systems allows for ideas to flow about possible solutions of what can be done now, as well as what can be done in the future for continuing work toward an ideal system.
 
In 1999, the Institute of Medicine raised national awareness of the prevalence and severity of medical errors, highlighting the finding that between 44,000 and 98,000 deaths in US hospitals each year result from preventable medical errors.  Since then, more than 25 states have passed legislation or created regulations related to hospital reporting of adverse events.  However, current reporting systems for patient safety events often do not accommodate patients and their families to provide input based on their experiences with care. 

“Consumers are an untapped resource to learn about vulnerabilities in the health care system and often the only source of information on the continuum of care for themselves or a family member,” said CAPS president Susan E. Sheridan, MIM, MBA. Understanding patients’ perceptions of their experience of care is necessary to improve the safety of care.” 

In 2004, one in three people said they or a family member experienced a medical error.  Yet, nearly all patient safety event reporting systems are designed for health care providers, not consumers.  One study has shown that incident reports of undesirable events may be effectively used with hospital patients to identify problems with the quality of their care.  Only a few systems allow patients to report adverse events directly to health care agencies.

“Patients are a critical part of the health care team and have an important role to play in ensuring the quality and safety of the care they receive,” said William B. Munier, M.D., director of AHRQ’s Center for Quality Improvement and Patient Safety. “We look forward to the results of this important initiative and to finding ways to use patient reports of adverse events to complement the information that is being collected by Patient Safety Organizations.”
 
Currently, consumer input on the safety of care has been through consumer satisfaction surveys, which tend to focus on interpersonal aspects of care, communication, and access to care issues.  One of the limitations with satisfaction surveys is that they do not provide consumers with an opportunity to comment on patient safety events or provide narrative information on their experiences with care. 

“AHRQ recognizes that consumers can be an important source of information about patient safety,” said Martin J. Hatlie, JD, CAPS program chair.  “Consumers’ narratives will very likely highlight system flaws that may be amenable to analysis and change. This project will help CAPS make significant progress towards one of our top organizational goals.” 

Patient input can reveal information that is not necessarily observed or reported by providers.  Systems that include patients’ reports will complement the information that is collected through other reporting mechanisms.  Such systems may improve our understanding of the nature and causes of medical errors and enhance the development of effective methods for improving quality and preventing patient harm.

This project is funded through AHRQ's Accelerating Change and Transformation in Organizations and Networks (ACTION) initiative, an implementation model of field-based research designed to promote innovation in health care delivery by accelerating the diffusion of research into practice.

About Consumers Advancing Patient Safety (CAPS)
Consumers Advancing Patient Safety (CAPS) is a consumer-led non-profit organization formed to be a collective voice for individuals, families and healers who wish to prevent harm in healthcare encounters through partnership and collaboration. CAPS envisions a partnership between consumers and providers to create global healthcare systems that are safe, compassionate and just.




Contact:
Mitchell Dvorak
Consumers Advancing Patient Safety
(312) 274-1301
mdvorak@patientsafety.org

Asta Sorensen
Project Director, Health Care Quality Program
Division for Health Services and Social Policy Research
RTI International
(919) 541-1238
asorensen@rti.org

Karen Migdail
Director of Media Relations
AHRQ
(301) 427-1855
Karen.Migdail@ahrq.hhs.gov



ENDNOTES:

ⁱ Patient safety events encompass a spectrum of no-harm events, near misses, and adverse/harm events. A near-miss event is defined as an event for which unwanted consequences were prevented because some recovery action was taken that identified and corrected the failure.

ⁱⁱ The Ideal Design of Effective and Logical Systems (IDEALS) design concept was developed by G. Nadler in 1967. Nadler G. Work Systems Design: The IDEALS Concept. Homewood, IL: Richard D. Irwin; 1967.

ⁱⁱⁱ National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004. The Kaiser Family Foundation, Agency for Healthcare Research and Quality, and Harvard School of Public Health.

^iv Agoritsas, T., P.A. Bovier, T.V. Perneger. Patient Reports of Undesirable Events During Hospitalization. J. Gen. Intern. Med., 2005; 20: 922-928.