Developing a comprehensive electronic adverse event reporting system in an academic health center | JoVE Visualize

Developing a comprehensive electronic adverse event reporting system in an academic health center

Coleen Kivlahan¹, William Sangster, Kathryn Nelson

¹Office of Clinical Effectiveness (OCE), University of Missouri Health Care, Columbia, Missouri, USA.

The Joint Commission Journal on Quality Improvement|November 12, 2002

View abstract on PubMed

Summary

University of Missouri Health Care implemented a new Patient Safety Network System (PSN) to streamline adverse event reporting. This system significantly reduced resolution times and improved reporting willingness among healthcare professionals.

Area of Science:

Healthcare Informatics
Patient Safety
Quality Improvement

Background:

University of Missouri Health Care (MUHC) identified fragmented patient safety reporting systems in 2000.
Multiple disparate data systems hindered systemic prevention of adverse events.
An interdisciplinary team was formed in 2001 to develop a unified reporting approach.

Purpose of the Study:

To create a comprehensive system for patient safety reporting and resolution.
To improve the efficiency and effectiveness of adverse event management.
To enhance patient safety through integrated data and streamlined processes.

Main Methods:

Developed and implemented a secure, Web-based Patient Safety Network System (PSN).
Enabled reporting of comments, adverse events, and near-miss events via the internet.
Facilitated immediate report availability to managers and alerted them via email.

Main Results:

Pilot study in intensive care units showed dramatic reductions in adverse event resolution time.
Demonstrated increased willingness to report among physicians and respiratory therapists.
Successful hospital-wide implementation of the PSN by January 1, 2002.

Conclusions:

The PSN has been extended to all ambulatory care settings.
Future development includes a component for physician reporting of complications.
The system aims to further enhance patient safety through continuous improvement and broader data capture.