OIG says adverse event reporting systems vary by state, many are limited

The Office of Inspector General released a memorandum last week saying that there is no standardized method of collecting adverse event information nationally, and that state systems vary on how they define and manage this information. The memorandum, mandated by the Tax Relief and Health Care Act of 2006, outlined the results of an examination of adverse event reporting systems in 17 states, as well as eight Patient Safety Organizations, and CMS’ “never events.”

Of the states it looked at, seven states made more information public than others. These were Maryland, Massachusetts (which has two systems), Minnesota, New Jersey, Oregon, and Pennsylvania. There were three states that disclosed less than the first seven, including Colorado, Maine, and Rhode Island, and seven other states had no public disclosure included with their adverse event reporting systems. These were Utah, Florida, Nevada, New York, South Carolina, South Dakota, and Vermont.

Overall, even with the inclusion of Patient Safety Organizations (which were launched a year ago as the byproduct of the Patient Safety Act of 2005), there is a lack of one central database to which all hospitals can submit adverse event data. PSOs have created the Network of Patient Safety Databases, as well as a list of common formats for which adverse event data can be in, but that is just for PSOs and not for the state adverse event reporting systems. Additionally, the data coming from the NPSD will not be available for analysis until early 2011.

Do you live in a state that collects adverse event reporting data and if so, is that data made available to the public? Do you think the government needs to take on a larger role in creating a standardized set of adverse events around which data should be collected at each hospital?

You can read more analysis about the memorandum in this HealthLeaders Media article.