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Developing a comprehensive electronic adverse event reporting system in an academic health center
Coleen Kivlahan1, William Sangster, Kathryn Nelson
1Office of Clinical Effectiveness (OCE), University of Missouri Health Care, Columbia, Missouri, USA.
The Joint Commission Journal on Quality Improvement
|November 12, 2002
Summary
University of Missouri Health Care implemented a Patient Safety Network System (PSN) to streamline adverse event reporting. This web-based system significantly reduced resolution times and increased reporting willingness.
Area of Science:
- Healthcare Management
- Patient Safety Informatics
- Quality Improvement
Background:
- Identified fragmented patient safety reporting systems at University of Missouri Health Care (MUHC) in 2000.
- Disparate data systems hindered systemic prevention of adverse events.
- An interdisciplinary team formed in 2001 to develop a unified reporting approach.
Purpose of the Study:
- To create and implement a comprehensive web-based system for patient safety reporting and resolution.
- To improve the efficiency and accessibility of adverse event and near-miss reporting.
Main Methods:
- Developed the secure, web-based MUHC Patient Safety Network System (PSN).
- Enabled reporting via the internet by staff, physicians, patients, families, and visitors.
- Integrated email alerts for managers and offered anonymous reporting for near-misses.
Main Results:
- Pilot study in intensive care units showed dramatic reductions in patient safety event resolution time.
- Demonstrated increased willingness to report among physicians and respiratory therapists.
- Successfully implemented the PSN hospital-wide by January 1, 2002.
Conclusions:
- PSN implementation expanded to all ambulatory care settings.
- Future development includes a component for physician-reported complications.
- The system aims to enhance overall patient safety through integrated reporting and resolution.