IT Example
To date, the only comparable data-collection system is MedMarx, which compiles information on medication errors. The Joint Commission requires providers to supply a root-cause analysis on every Level 1 incident, “but that’s just scratching the surface of what occurs,” Dr. Nagamine says. “There are far many more Level 2 and Level 3 events with the same precursors, and that information would be very valuable.”
By collecting nationwide data on patient safety events, PSOs will be able to bridge the gaps in the reporting system and provide crucial patient safety information to the healthcare industry. “In general, the concept of aggregate information that allows us to compare events is incredibly important,” Dr. Nagamine says. “A hospitalist working in one hospital has only the information about events in that hospital, but 5,000 hospitals can provide more specific and actionable information. We just haven’t seen this operationalized yet.”
Dr. Nagamine uses a technology example to show the value PSOs could have in identifying patterns or problems that threaten patient safety: “Every hospital has a horror story of implementing a new information technology (IT) system, and we’re getting some very interesting feedback from hospitals about unintended consequences,” she says. “We’re hearing that patients are being hurt because of mistakes in systems—the use of dropdown menus (on computer screens) that don’t drop down far enough to reveal all options, or a screen where it’s easy to click the wrong item.”
Current systems might not allow problems like these to be highlighted. Even if staff knows of a problem, their hospital’s coding system might not allow them to detail it. “It may fall under ‘communications’ or ‘physician computerized order entry’ or something vague, so the data won’t show the specifics of what happened,” Dr. Nagamine points out. “If we had aggregate data on issues like this, we could address it. Right now, we just have word of mouth.”
An isolated event at a hospital is one thing, but similar data from around the nation is significant. “Drug companies or IT vendors confronted with (patterns) might make some changes,” she says. “That kind of data is powerful.”
Hospital Medicine on Board
When hospitals start reporting data to PSOs, where will hospitalists fit into the process? Hospitalists likely will be interviewed to answer some of the PSO’s questions, but they will not be the ones filling out the forms, Dr. Nagamine says. Hospitalists also will be among the ranks of healthcare professionals eagerly awaiting the release of the data. “The way that PSOs approach patient safety and quality—what’s near and dear to our hearts—is it gives us more data,” Dr. Nagamine says. This is crucial for hospitalists leading quality-improvement projects and similar tasks. “Without that data, it’s hard to get traction and movement. That data will help convince someone to invest more time and money in a particular problem area.”
Phase One: Participation
AHRQ has established a comprehensive Web site (www.pso.ahrq.gov) that includes information on the first draft of common formats for use with hospital inpatients. These are found on downloadable paper forms, available at the PSO Privacy Protection Center (PPC) Web site at www.psoppc.org/ web/patientsafety/paperforms.
“The forms are a first step,” Dr. Nagamine explains. “If we had these data points on every incident at every hospital, we’d know a lot more than we do now. We’d be able to harness that information.”
It will be a while before healthcare providers can search the data for patterns and possible solutions in patient safety, but the wait should be worth it. “You’ve got to start somewhere, and it’s not going to happen in one sweep,” Dr. Nagamine says. “This is simply a start. Hopefully, in a decade, we’ll have a lot more actionable information.” TH