Background, Data analysis, collection and feedback tools

Background Information

This section of the toolbox includes information from the 26 states and the District of Columbia with legislation or regulation related to hospital reporting of adverse events to a state agency. It includes background information on the reporting systems to provide context. It includes authorizing statutes or regulations, advisory groups, websites, and other useful information.

Data Collection Tools

Consistency in reporting is essential to analysis. States need consistent, reliable data in reporting systems in order to extract useful information. This section of the toolbox contains information and tools that may help states increase the number of reports and ensure that the reports they do receive are complete and accurate so that the resulting information is as useful as possible.

Data Analysis Tools

Event report analysis can be conducted at various levels using a number of different approaches. States may analyze individual event reports to hold facilities accountable for serious errors and to better understand and share contributing factors (i.e., communication, safety culture, etc.) so that events can be avoided in the future. States may also aggregate data over time and/or across facilities to assess the patient safety performance of a facility, region, or state. State-level aggregated data can be used to identify institutional factors that may contribute to adverse events, which cannot be identified by an individual facility. Aggregated data can also enable a state to build a larger database with a greater number of events to enhance analysis of rare events. This section of the toolbox contains tools that may help states with both kinds of analysis. The challenges of analysis Statistical analyses of event reporting can be problematic. The small number of events reported in most states limits the type of statistical analyses that can be conducted. The number of reported events is not a valid indicator of the incidence of events as the number of opportunities for the event to occur is usually unknown. For instance, the number of morphine overdoses may be captured accurately, but the number of morphine injections given in all the hospitals in the state over a certain time period will probably be elusive. Nonetheless, there are ways to use reported data that, while not yielding epidemiological trends, can enhance our understanding of what causes these events and how they can be reduced.

Data Feedback Tools

Feedback from reported data can help foster needed change within an institution. It can offer providers information on best practices and help prioritize critical issues in need of attention. It can also help purchasers and consumers exert external pressure for change and improvement by providing information about health care facility safety. Finally, it can assure the public that the issue is being addressed, improving the public trust. Challenges associated with feedback Providers have indicated that lack of data feedback from reporting systems is a disincentive to report. They view reporting systems that do not provide feedback as data graveyards, a burden that provides no benefits. Reporting systems can dispel this notion by disseminating useful information that can be used to spur change and offer helpful and effective "lessons learned." Providing users with an easy and efficient way to access meaningful data can be challenging for states. These challenges include determining what data sets are appropriate and useful to disseminate, creating user-friendly formats for disseminating information, targeting the appropriate audience, and determining the most useful mechanisms for disseminating the information in order to reach the intended audience.