Data Management System for Applied Strategies for Improving Patient Safety

Presenter: Wilson D. Pace, MD

Institution: University of Colorado

Introduction: Applied Strategies for Improving Patient Safety (ASIPS) is a three-year demonstration project that collects and analyzes medical errors from primary care practices within two PBRNs. The project involves three major investigations: analysis of reports from a patient safety reporting system (PSRS), analysis of malpractice insurance company reports, and analysis of Medicaid Claims data. This report will focus on the PSRS.

The ASIPS PSRS collects patient safety events from all members of participating practices as either anonymous or confidential reports. Reports may be submitted on-line, via a telephony system or by paper. All events are reported voluntarily. All reports are entered into a single database and managed through an Intranet interface. Confidential reports are completed within 10 days of receipt and then all contact information is destroyed. Given this short window for data collection, a system that managed data collection in an efficient manner was critical.

Database security features exclude the use of all serial numbers and date/time stamps in our permanent database. Thus, the movement of patient safety events from submission to analysis is orchestrated through database flags. Confidential follow up forms are all on-line as is coding and any secondary reviews, if required. All work assignments are tracked via this system. Confidential reports may move through as many as 9 steps before they are available for analysis. Coding is performed in small groups in a near real time format. In this presentation we will discuss the systems for capturing practice information without linking a specific event to a practice. We will also demonstrate the data management system.

If time permits, we will discuss analysis of the data to date. Our reports show a prominence of errors associated with diagnostic tests (labs, imaging, cytologic tests, etc.); approximately 50% of events. Events involving medication account for about 20%. Approximately half of the events involve clinical procedures and half involve some problem with communication. Although harm is often difficult to assess, reports indicate that about 20% of events result in some form of harm or increased risk to the patient(s) involved.