BMJ Qual Saf doi:10.1136/bmjqs-2011-000114
  • Original research

How event reporting by US hospitals has changed from 2005 to 2009

  1. James B Battles2
  1. 1RAND Corporation, Pittsburgh, Pennsylvania, USA
  2. 2Agency for Healthcare Research & Quality (AHRQ), Rockville, Maryland, USA
  1. Correspondence to Dr D O Farley, RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213, USA; donna_farley{at}
  1. Contributors Scott Ashwood performed the data management and programming support for the analyses of the survey data.

  • Accepted 22 August 2011
  • Published Online First 22 September 2011


Context Information is needed on the performance of hospitals' adverse-event reporting systems and the effects of national patient-safety initiatives, including the Patient Safety and Quality Improvement Act (PSQIA) of 2005. Results are presented of a 2009 survey of a sample of non-federal US hospitals and changes between 2005 and 2009 are examined.

Methods The Adverse Event Reporting System survey was fielded in 2005 and 2009 using a mixed-mode design with stratified random samples of non-federal US hospitals; risk managers were respondents. Response rates were 81% in 2005 and 79% in 2009.

Results Virtually all hospitals reported they had centralised adverse-event-reporting systems. However, scores on four performance indexes suggested that hospitals have not effectively implemented key components of reporting systems. Average index scores improved somewhat between 2005 and 2009 for supportive environment (0.7 increase; p<0.05) and types of staff reporting (0.08 increase; p<0.001). Average scores did not change for timely distribution of event reports or discussion with key departments and committees. Some within-hospital inconsistencies in responses between 2005 and 2009 were found. These self-reported responses may be optimistic assessments of hospital performance.

Conclusions The 2009 survey confirmed improvement needs identified by the 2005 survey for hospitals' event reporting processes, while finding signs of progress. Optimising the use of surveys to assess the effects of national patient-safety initiatives such as PSQIA will require decreasing within-hospital variations in reporting rates.


  • Funding This study was conducted with support from the Agency for Healthcare Research and Quality, US Department of Health and Human Services. Grant Number 290-02-0010 (contract).

  • Competing interests None.

  • Patient consent This study did not involve patients. It was a survey of risk managers at US hospitals.

  • Ethics approval RAND Human Subjects Protection Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Articles citing this article

Free sample

This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of BMJ Quality & Safety.
View free sample issue >>

Email alerts

Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published.


Navigate This Article