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Concepts Underlying Common Formats Event Descriptions

To obtain event descriptions for the generic and event-specific categories of Common Formats, go to the Patient Safety Organization (PSO) Privacy Protection Center (PPC) Web site

General Scope of the Common Formats

Common Formats Version 1.2 are intended for use in acute care hospitals in the United States and designed to support the first stage in the improvement cycle—reporting. They consist of two general types of formats, generic and event-specific. Generic Common Formats pertain to all patient safety concerns. Event-specific Common Formats pertain to frequently occurring and/or serious patient safety events, nine of which have been developed for Version 1.2. Event-specific Common Formats add specific, objective detail regarding these nine event categories. They are employed in addition to, not in place of, generic Common Formats.

Some types of information, such as facility characteristics (e.g., number of beds), that are common to all reports from a facility are not included as part of the generic or event-specific Common Formats data. This information will be specified separately for reporting to a PSO.

Subsequent versions of the Common Formats will address later stages in the improvement cycle, such as root-cause analysis, and other settings, such as ambulatory.

Generic Common Formats

Generic Common Formats specify information that is to be collected for all patient safety concerns—incidents, near misses, and unsafe conditions. They have been developed for three reasons:

To standardize “generic” information (e.g., reporter, location), no matter what kind of event/unsafe condition is being reported.
To allow changes to generic information that may be specified in subsequent versions of the Common Formats to be made easily and consistently, across all types/categories of patient safety concern.
To allow standardized collection of basic information for all types of events, including those outside the scope of the nine categories for which AHRQ has developed event-specific Common Formats.

The types of information in the generic Common Formats include the following.

Type of Event

Class of patient safety concern being reported
1. Incident
  1. Harm
  2. No harm
2. Near miss (close call)
3. Unsafe condition.
Category of patient safety concern, if one of the defined, event-specific Formats pertains.

Circumstances of the Event

Date and time that the event was discovered.
Where the event occurred or unsafe condition exists—defined field and free text.
Factors contributing to the event, known at the time of the initial report.
Association of the event with a handover (hand-off).
Preventability of the event, as noted at the time of the initial report.
Reason the near miss did not reach the patient.
Narrative descriptions (for facility and PSO use)
1. Narrative by the initial reporter.
2. Summary comments by the patient safety manager.

Patient Information

Identifying information about the patient affected.
Degree of harm—AHRQ's Harm Scale—including when the harm was assessed.
Rescue—interventions made within 24 hours after discovery of an incident to reduce or halt the progression of harm to the patient.
Increased length of stay attributed to an adverse outcome (hospital setting only).
Notification of the patient, patient's family, or guardian.

Reporting, Reporter, and Report Information

Unique ID assigned to the event/condition.
Report date
1. Initial report.
2. Summary of the initial report.
Reporter information—defined field and free text.

Event-Specific Common Formats

Event-specific Common Formats have been developed for frequently-occurring and/or serious events, to allow collection of structured information about these important patient safety concerns. The event categories addressed by the Common Formats are not conceptually homogeneous, but rather reflect categories widely used today in event reporting systems. These categories represent domains (anesthesia), clinical processes (medication), and patient outcomes (health care-associated infections). Despite this heterogeneity, there are common types of information that serve as a framework for all event-specific Common Formats.

Types of information in event-specific Common Formats include the following:

Definition of the Event

Brief narration of the name of the event category, with specifications of the event
1. Inclusions.
2. Exclusions.
Processes of Care—delineation of process error(s) that caused/are the (defined) event; these can include near misses and (rarely) unsafe conditions.
Patient Outcomes: delineation of outcomes that are associated with/are the (defined) event; includes no-harm events; by definition, unsafe conditions do not result in patient outcomes.

Scope of Reporting

Separate Common Formats are developed for each overall type of setting, such as a hospital or skilled nursing facility. Scope is used to delineate specific locations within a setting to which the Formats pertain, such as outpatient pharmacies physically located within a hospital. Further, scope delineates the applicability of specific event descriptions to incidents, near misses, and unsafe conditions. For instance, the description for Fall events pertains to incidents only (not near misses or unsafe conditions), whereas the description for Medication and Other Substance events pertains to incidents, near misses, and unsafe conditions.

Risk Assessments and Preventive Actions

Lists assessments, preventive actions, or other measures that should have been performed or in place prior to the (defined) event, to prevent or mitigate its occurrence; includes the precise circumstances in which such actions should have been taken. Does not include routine protocols that apply to all patients, such as the Universal Protocol.

Note: If precise specification is not possible, such actions cannot be delineated in an event-specific Common Format; this type of information/opinion can be entered into a narrative field to assist in the analysis of any individual event.

Circumstances of the Event

Identifying or descriptive information pertaining to the category of patient safety concern (e.g., product name, drug name, ICD-9/ICD-10, etc.)
Risk factors specific to the (defined) event that can be known at the time of the initial report. (Risk factors increase the probability of an event and are known in advance of its occurrence.)
Contributing factors specific to the (defined) event that can be known at the time of the initial report. (Contributing factors are only determined retrospectively, after the event has occurred.) These factors are different from those that could apply to any event and that are found in the generic event descriptions.