Improving the Value of Patient Safety Reporting Systems

Use of patient safety reporting systems (PSRS) to identify and mitigate risks to patients who are harmed by medical care has been a national priority for nearly a decade. Yet, most reporting systems are still new and focus on reporting events. To improve the value of PSRS, we must use the data to identify safety hazards, prioritize where to focus resources, develop interventions to mitigate these hazards, and evaluate whether the interventions reduced harm. We developed and implemented a Web-based PSRS and discuss in this paper the benefits, limitations, and challenges we encountered. First, we discuss the benefits of PSRS as part of a patient safety learning community. The remainder of the paper focuses on the challenges we faced that still need to be resolved to improve the value of reporting systems. We address these challenges as follows: what to report, how to minimize reporting burden and costs, how to conduct expert reviews and prioritize safety efforts, how to place incidents into taxonomies, how to know that the reporting system actually improved patient safety, and who should be responsible for attempting risk mitigation.