Only 21% of hospitals that have adverse-event reporting systems are using them to fully consider and distribute error reports throughout their organizations, according to a new report by the Agency for Healthcare Research and Quality.
Stronger processes and systems are required to combat current variations in the systems hospitals have developed, the AHRQ said in its report, published in the Dec. 8 issue of Quality and Safety in Health Care
. The AHRQ said it will use the results to form baseline data on the characteristics of hospital reporting systems as it continues to assess their effectiveness for improving healthcare.
While about 96% of hospitals surveyed by the AHRQ said that they have centralized adverse-event reporting systems, only small percentages of respondents had established systems with effective components, according to the study. The AHRQ, working in conjunction with researchers from RAND Corp. and the Joint Commission, determined that effective reporting systems need four pieces: a supportive environment to protect staff, broad reporting from a range of staff, timely distribution of summary reports, and senior-level review and discussion of summary reports.
The AHRQ surveyed risk managers at 2,050 nonfederal hospitals from September 2005 to January 2006, with 1,652 hospitals, or 81%, responding. Of the respondents, 72% were accredited by the Joint Commission. Only 47% of respondents allowed staff to report errors anonymously, and 96% of respondents said their nursing staff conducted most of the reporting. Attending physicians rarely reported errors to the system, according to 86% of respondents in the survey. -- by Jean DerGurahian
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