Generic & Event-Specific Formats

General Scope of the Common Formats:

Common Formats Version 1.2 are intended for use in acute care hospitals in the United States. They are designed to support the first stage in the improvement cycle—reporting. They consist of two general types of formats:

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 to:

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

The types of information being collected in the generic Common Formats include the following:

Type of Event

  1. Class of patient safety concern being reported
    1. Incident
      1. Harm
      2. No harm
    2. Near miss (close call)
    3. Unsafe condition
  2. Category of patient safety concern (one of the nine defined, Event-specific Formats or “other” type of event)

NOTE: AHRQ provides the opportunity to classify events as an NQF serious reportable event, if applicable.

Circumstances of the Event

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

Patient Information

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

Reporting, Reporter, and Report Information

  1. Unique ID assigned to the event/condition
  2. Report date
  3. Reporter information

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

  1. Brief narration of the name of the event category, with specifications of the event
  2. Processes of Care—delineation of process error(s) that caused/are the (defined) event; these can include near misses.
  3. 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. Furthermore, 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

Event-specific Common Formats list assessments, preventive actions, or other measures that should have been performed or in place prior to the event, to prevent or mitigate its occurrence. This includes the precise circumstances in which such actions should have been taken. The Event-Specific Common Formats do not include routine protocols that apply to all patients, such as the Universal Protocol (used in the operating room).

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

  1. Identifying or descriptive information pertaining to the category of patient safety concern (e.g., product name, drug name, ICD-9/ICD-10, etc.)
  2. Risk factors specific to the event. (Risk factors increase the probability of an event and are known in advance of its occurrence).
  3. Contributing factors specific to the event. (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.

To access the most current versions of the Common Formats, go to the Patient Safety Organization Privacy Protection Center (PPC) Web site. There, you will find the full list of event-specific formats for both acute care hospital settings and skilled nursing facility settings. Future versions of the Common Formats will be developed for ambulatory settings to include ambulatory surgery centers and physicians’ and practitioners’ offices.

Common Formats for Surveillance—Hospital

Most recently, AHRQ and the interagency Federal Patient Safety Workgroup released Common Formats for Surveillance—Hospital. Until now, Common Formats have been designed to support only traditional event reporting. Common Formats for Surveillance—Hospital are 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. To view the Federal Register notice announcing Common Formats for Surveillance—Hospital, go to: http://www.gpo.gov/fdsys/pkg/FR-2014-02-18/html/2014-03492.htm. To access and comment on Common Formats for Surveillance—Hospital, go to the Patient Safety Organization Privacy Protection Center (PPC) Web site.