Differences in the reporting of care-related patient injuries to existing reporting systems

This study compared the number of care-related injuries reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) with the number reported to 15 mandatory-reporting states.

The primary outcome measure was the number of patient injuries reported to each in 1999.

In all categories examined, the number of reports submitted by accredited hospitals to states equaled or exceeded the number reported to JCAHO.

State-reporting systems identified a greater number of care-related injuries than did the JCAHO system. Although JCAHO received fewer reports from accredited hospitals, its process requires an analysis of the event and a prevention plan, and it disseminates the lessons learned from reported events. For adverse event reporting to improve patient safety, there must be assurances that lessons are learned from these events, preventive measures are taken, and information is shared so others may benefit without having to experience the same adverse event.

This study represents an early attempt to understand the system characteristics that influence hospital reporting of care-related patient injuries. As reporting systems become more prevalent and standardized, the influence of factors such as legal protections, confidentiality, and technology on reporting should be better understood.