Accession Number:

ADA434291

Title:

Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems

Descriptive Note:

Corporate Author:

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY ROCKVILLE MD

Personal Author(s):

• Flink, Ellen
• Chevalier, C. L.
• Ruperto, Angelo
• Dameron, Peg
• Heigel, Frederick J.
• Leslie, Ruth
• Mannion, Janet
• Panzer, Robert J.

Report Date:

2005-05-01

Pagination or Media Count:

19.0

Abstract:

New York State has had a mandatory incident reporting system in place since 1985. The current system, the New York Patient Occurrence Reporting and Tracking System NYPORTS, was implemented in 1998 pursuant to New York State Public Health Law Section 2805-1, Incident Reporting. NYPORTS is a secure Web-based system that simplifies reporting, coordinates with other reporting systems, and allows hospitals to obtain feedback on their own reporting patterns. The authors review the evolution and implementation of NYPORTS and its predecessors, the Hospital Incident Reporting System and the Patient Event Tracking System. Discussion and data comparisons are made between the Joint Commission on Accreditation of Healthcare Organizations voluntary sentinel event reporting system and NYPORTS. Critical elements for success of a mandatory incident reporting system include collaborative system design basing the system on statute, with clear definitions and objective reporting criteria providing meaningful data that can be analyzed and disseminated for improving patient safety and adequate resources to maintain the system. Innovative program features may be of interest to other States implementing reporting systems.

Descriptors:

• *LESSONS LEARNED
• *INFORMATION SYSTEMS
• *NEW YORK
• *ERRORS
• *HEALTH CARE FACILITIES
• SAFETY
• PATIENTS
• MEDICAL SERVICES
• INTERNET

Subject Categories:

• Information Science
• Medical Facilities, Equipment and Supplies

Distribution Statement:

APPROVED FOR PUBLIC RELEASE