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Adverse-event-reporting practices by US hospitals: results of a national survey
  1. D O Farley1,
  2. A Haviland1,
  3. S Champagne2,
  4. A K Jain3,
  5. J B Battles4,
  6. W B Munier4,
  7. J M Loeb2
  1. 1
    RAND Corporation, Pittsburgh, Pennsylvania, USA
  2. 2
    The Joint Commission, Oakbrook Terrace, Illinois, USA
  3. 3
    RAND Corporation, Arlington, Virginia, USA
  4. 4
    Agency for Healthcare Research & Quality (AHRQ), Rockville, Maryland, USA
  1. Dr D O Farley, RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA 15213, USA; donna_farley{at}


Context: Little is known about hospitals’ adverse-event-reporting systems, or how they use reported data to improve practices. This information is needed to assess effects of national patient-safety initiatives, including implementation of the Patient Safety and Quality Improvement Act of 2005 (PSQIA). This survey generated baseline information on the characteristics of hospital adverse-event-reporting systems and processes, for use in assessing progress in improvements to reporting.

Methods: The Adverse Event Reporting Survey, developed by Westat, was administered in September 2005 through January 2006, using a mixed-mode (mail/telephone) survey with a stratified random sample of 2050 non-federal US hospitals. Risk managers were the respondents. An 81% response rate was obtained, for a sample of 1652 completed surveys.

Results: Virtually all hospitals reported they have centralised adverse-event-reporting systems, although characteristics varied. Scores on four performance indexes suggest that only 32% of hospitals have established environments that support reporting, only 13% have broad staff involvement in reporting adverse events, and 20–21% fully distribute and consider summary reports on identified events. Because survey responses are self-reported by risk managers, these may be optimistic assessments of hospital performance.

Conclusions: Survey findings document the current status of hospital adverse-event-reporting systems and point to needed improvements in reporting processes. PSQIA liability protections for hospitals reporting data to patient-safety organisations should also help stimulate improvements in hospitals’ internal reporting processes. Other mechanisms that encourage hospitals to strengthen their reporting systems, for example, strong patient-safety programmes, also would be useful.

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  • Competing interests: None.

  • Ethics approval: Ethics approval was provided by the Human Subjects Protection Committee of the RAND Corporation.

  • See Commentary, p 400

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