PSOs are required to collect and analyze data in a standardized manner. AHRQ created the Common Formats (common definitions and reporting Formats) to help uniformly report patient safety events and to improve health care providers' efforts to minimize and potentially eliminate harm. The Formats are broadly divided into two categories: generic ones that apply to all patient safety events and event-specific ones that relate to certain high-frequency event types.
Patient Safety Events—What Gets Reported?
- Incidents: patient safety events that reached the patient, whether or not there was harm involved.
- Near misses (or close calls): patient safety events that did not reach the patient.
- Unsafe conditions: circumstances that increase the probability of a patient safety event occurring.
The AHRQ Common Formats include:
- Precise definitions of patient safety events that comprise all-cause harm
- Examples of patient safety population reports
- Paper forms to guide development of data collection instruments
- A Users Guide which describes how to use the Formats
- A metadata registry with data element attributes and technical specifications for use by developers.
Currently, the Common Formats allow for event reporting within three settings of care: hospitals, nursing homes, and community pharmacies. Common Formats for Surveillance—Hospital version 0.2 Beta is now also available for public commenting on the National Quality Forum (NQF) website.
Quality Safety Review System (QSRS)
AHRQ's most recent development is Common Formats for Surveillance—Hospital, which is designed to provide, through retrospective review of medical records, information that is complementary to that derived from event reporting systems. These Formats will facilitate improved detection of events and calculation of adverse event rates in populations reviewed. Previously, Common Formats have been designed to support only traditional event reporting.
The AHRQ Common Formats for Surveillance are being used to develop the Quality Safety Review System (QSRS). This system, when available for use by the general public, could meet the needs of a variety of users, including hospital providers served by PSOs. PSOs may choose to offer services to hospitals that use QSRS, such as abstracting information from medical records for entry into the QSRS, analyzing the results, and generating useful information.
Automation of Data Abstraction for QSRS Report
The report below, "Feasibility of the Partial Automation of Data Abstraction for the Quality and Safety Review System (QSRS)," assesses the feasibility of decreasing and potentially eliminating the need for human abstraction of medical records, which is currently required when using the QSRS. The study found that 58% of QSRS questions were relatively easy to automate and 77% of QSRS questions were feasible for automation using available capabilities in the market. This report was completed in 2016. However, there are currently efforts underway to update the report based on new knowledge and available technology.
Department of Health and Human Services Office of Inspector General (OIG) Studies Related to Adverse Events in Rehabilitation and Long-Term-Care Hospitals
The OIG has published a series of reports regarding adverse events experienced by Medicare beneficiaries in health care settings.
OIG Report on Adverse Events in Rehabilitation Hospitals
The OIG's study of the incidence of adverse events among Medicare beneficiaries in rehabilitation hospitals found that an estimated 29 percent of Medicare beneficiaries experienced preventable and non-preventable adverse or temporary harm events during their rehabilitation hospital stays resulting in temporary harm; prolonged stays or transfers to other hospitals; permanent harm; life-sustaining intervention; or death.
Link to the OIG Report: U.S. Department of Health and Human Services, Office of Inspector General (OIG). Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Report No. OEI-06-14-00110, July 2016.
OIG Report on Adverse Events in Long-Term-Care Hospitals
The OIG’s study of adverse events in long-term-care hospitals (LTCHs) found that 46 percent of patients in LTCHs experienced preventable and non-preventable adverse or temporary harm events. However, the OIG noted that there are more opportunities for harm with longer hospital stays, and that the number of harm events per patient day was similar between LTCHs and other post-acute-care settings and lower than in non-LTCH acute-care hospitals.
Link to the OIG Report: U.S. Department of Health and Human Services, Office of Inspector General (OIG). Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries. Report No. OEI-06-14-00530, November, 2018.
Lists of Potentially Preventable Adverse Events
Using the adverse events identified by the OIG as potentially preventable, the lists posted below were developed to raise awareness and encourage reporting for the purpose of learning and reducing patient harm.
Link to the List Developed for Rehabilitation Hospitals: Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in Office of Inspector General Report as Clearly Preventable or Likely Preventable, by Clinical Category (PDF, 218 KB) NOTE: AHRQ has determined that the majority of these events could be captured using either version of the current Common Formats for Event Reporting – Hospital.
Link to the List Developed for Long-Term-Care Hospitals: Adverse and Temporary Harm Events in Long-Term-Care Hospitals Designated in Office of Inspector General Report as Clearly Preventable or Likely Preventable, by Clinical Category (PDF, 253 KB)