Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Quality Presented to the ONC HIT Policy Committee – Safety Task Force 13 June 2014 Common Formats and the Network of Patient Safety Databases

2 Reducing Patient Safety Events Creating a culture of safety – the Patient Safety Organization (PSO) Program Creating a culture of safety – the Patient Safety Organization (PSO) Program Providing standard definitions & reporting formats to harmonize reporting – the Common Formats Providing standard definitions & reporting formats to harmonize reporting – the Common Formats Providing specific information on HIT-related adverse events – the Formats device module Providing specific information on HIT-related adverse events – the Formats device module Aggregating nationwide safety information at the Network of Patient Safety Databases Aggregating nationwide safety information at the Network of Patient Safety Databases

3 Common Formats Common language for patient safety event reporting Common language for patient safety event reporting – Common language & definitions – Standardized rules for data collection Standardized patient safety reports (“apples to apples”) Standardized patient safety reports (“apples to apples”) Authorized by statute; developed through a formal, collaborative process Authorized by statute; developed through a formal, collaborative process

4 Common Formats Only national patient safety reporting scheme designed to meet all of the following four goals: Only national patient safety reporting scheme designed to meet all of the following four goals: 1. Support local quality/safety improvement 2. Provide information on harm from all causes 3. Allow comparisons over time & among different providers 4. Allow the end user to collect information once & supply it to whoever needs it (harmonization) – a long-term goal Designed to decrease data collection burden! Designed to decrease data collection burden!

5 Network of Patient Safety Databases Patient Safety Act authorized creation of PSOs, which in turn report aggregate patient safety data to a Network of Patient Safety Databases Patient Safety Act authorized creation of PSOs, which in turn report aggregate patient safety data to a Network of Patient Safety Databases The NPSD is designed to provide an interactive evidence-based management resource for providers, patient safety organizations, & other entities – a national resource for quality improvement & research The NPSD is designed to provide an interactive evidence-based management resource for providers, patient safety organizations, & other entities – a national resource for quality improvement & research There are certain rules governing confidentiality of data that must be followed There are certain rules governing confidentiality of data that must be followed

6 HIT-Related Adverse Events In 2010, AHRQ, FDA, & ONC collaborated to develop a special, enhanced module to the Common Formats to address HIT-related adverse events In 2010, AHRQ, FDA, & ONC collaborated to develop a special, enhanced module to the Common Formats to address HIT-related adverse events Experience with PSOs & others suggests that: Experience with PSOs & others suggests that: – Many HIT-related adverse events present as other types of patient safety events, e.g., medication errors – HIT usually plays an indirect role, as a contributing factor

7 Collaborating to Learn It is important to view HIT’s contribution to patient risk in the context of “all cause harm” It is important to view HIT’s contribution to patient risk in the context of “all cause harm” It is also valuable to have available a focus of professional knowledge regarding the special, complex nature of HIT risk It is also valuable to have available a focus of professional knowledge regarding the special, complex nature of HIT risk For these reasons, ONC – with its Patient Safety Center – AHRQ – with its PSOs & NPSD – make an ideal partnership for expanding understanding of HIT risk & how to reduce it across the nation For these reasons, ONC – with its Patient Safety Center – AHRQ – with its PSOs & NPSD – make an ideal partnership for expanding understanding of HIT risk & how to reduce it across the nation

8 Common Formats on the Web