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Comparative Summary of States' Adverse Event
Reporting and Performance Experiences

Comparative Summary of States' Adverse Event
Reporting and Performance Experiences
  • •  13 states publish Adverse Events / Medical Error Data

    Reporting by States of adverse event data on the Internet did not begin until 1999-2000. Aggregate data of reportable event performance are available for hospitals in 13 states in 2006. However, in Colorado and Washington, these aggregate data are only available to the Public upon request, and this raw facility-identified data must be collated and analyzed to make it interpretable.

    Among these 13 States, facility-identifed data is available in three States. Only Minnesota provides a partial facility-level analysis on the Internet. Colorado publishes redacted adverse event data by occurrence and by facility on the Internet but does not collate or compare facilities. Washington data prior to June 7, 2006 is available for facility-level and aggregate data analysis.1 Although not reporting in 2006, nascent programs in Illinois and Indiana indicate an intent to report facility-identified data on the Internet by 2008.

    Ten (10) States (CT, FL, MA, MD, ME, NY, PA, TN, TX, UT) have published only aggregate State data for reportable events in variable depth. These States provide no facility-identified information. Wyoming's new program will publish only aggregate facility data beginning December 31, 2006, and Washington's revised program will begin reporting aggregate data on January 1, 2008.

  • •  Numbers of Specified Events and Definition Origins

    States collect data with different measures and/or different definition origins, including:

    • ◊  NQF's 27 ‘Never’ Events Definitions: 2 states - (Connecticut and Minnesota) use NQF definitions; Connecticut also reports 6 state-specific adverse events. Illinois and Indiana anticipate reporting facility-identified NQF data beginnning in 2007.
    • ◊  ICD-9CM Occurrence Codes Definitions: 2 States, New York and Tennessee, utilize Occurrence Codes based on International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) taxonomy of administrative data. New York uses 54 discrete measures, whereas Tennessee includes 48 measures.
    • ◊  Unique State-specific Definitions: 5 states (Colorado, Connecticut, Florida, Maryland, Massachusetts) employ unique state reportable event definitions; (Connecticut has 6 state-specific measures, in addition to 27 NQF measures).
    • ◊  JCAHO Definitions: 5 states (Maine, Pennsylvania, Utah, Texas, Washington1) utilize varying numbers and versions of JCAHO's ‘voluntary reportable sentinel events.’

1   Washington facility-identified data are no longer available to the public after mid-2006 due to changes in the reporting program. Washington will provide only aggregate state data after the switch to NQF definitions on June 7, 2006.


– Figure 1.  Specified Reportable Events –
Numbers and Definition Origins in
13 States that Publish Aggregate State Data

 
STATE DEFINITION ORIGINS NUMBER LISTED EVENTS
 
ICD-9 Occurrence Codes
54
ICD-9 Occurrence Codes
48
NQF + Unique
33
Unique
33
NQF
27
NQF
27
JCAHO + Unique
21
JCAHO
19
Unique
17
Unique
14
JCAHO + Unique
13
JCAHO + Unique
12
JCAHO
11
JCAHO
10
Unique
5
 
 
*   JCAHO definitions based on JCAHO's ‘voluntary reportable sentinel events’ and other examples of sentinel events published on JCAHO's website.
**   Maryland has released partially analyzed aggregate data for Level 1 Adverse Events only [PDF]. As defined by statute, each hospital is required to "list and describe examples of adverse events that shall be reported," thereby developing a unique hospital-specific list of Level 1 adverse events [COMAR 10.07.04B(2)]. As such there are no standard definitions for reportable events across hospitals in the state.
  • •  Literature Documenting Medical Errors / Adverse Events Problem

    The two key publications supporting the IOM's To Err is Human are the Harvard Medical Practice Study (HMPS) published in 1991 that utilized 1984 New York discharge data[1] and a study published in 2000 that used 1992 Colorado and Utah discharge data.[2]

    [1] [Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH, "Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I." N Engl J Med 1991; 324:370-6.] (Reprint available at Qual Saf Health Care 2004;13:145-151)
    [2] Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA, "Incidence and types of adverse events and negligent care in Utah and Colorado." Med Care 2000; 38:261-71

    The HMPS is useful in developing a scheme for standards and/or expectations for interpreting reported adverse events across States. The table below reveals the categories of incident adverse events (AEs) and negligent adverse events (NAEs) by % that were uncovered in the HMPS. A similar categorization was not created in the Utah/Colorado study.

Table 1.  
HMPS Categories of incidence of
Adverse Events (AE) and Negligent Adverse Events (NAE)

Category AE Timing relative to Index Hospitalization AE (%) Negligent
AE (%)
Time of Occurrence Time of Discovery
1
During
During
50.6 % 51.0 %
2
During
After – OutPatient
6.1 % 2.3 %
3
During
After – Later Hospital Stay
5.2 % 6.2 %
4
During or Before
During
13.1 % 19.3 %
5
Before
During
25.0 % 21.2 %

The data published by both New York and Colorado/Utah studies provided incident values for AEs and NAEs for events that were discovered during the index hospitalization and which occurred either during or prior to the index hospitalization. HMPS categories 1, 4, and 5 satisfy this criterion, leaving out categories 2 and 3, and these are the incident categories that make up the data that is used as the foundation for reported incidence of medical errors in the IOM study, To Err is Human.

However, State reporting programs for adverse events and medical errors do not follow this temporal methodology. State programs provide instructions for TEMPORAL monitoring of only HMPS category 1 events that occur during and are discovered during the index hospitalization. In the table below, the temporal category of State reporting (category 1 only) is compared to all event categories identified in the HMPS (categories 1+2+3+4+5), and to the events reported in the HMPS and by the IOM (categories 1+4+5). These category 1 adverse events make up a little over half of all adverse events and negligent adverse events noted in the 1984 New York dataset and slightly more than less than 60% of the AEs and NAEs reported in the IOM study.

Table 2.  
HMPS Adverse Event Incidence Summary by
Category of New York 1984 Discharge Data

Category Category Timing
Relative to Index
Hospitalization
SAMPLE DATA POPULATION DATA*
Total
AEs
Total
NAEs
Total
AEs
Total
NAEs
Events per
100,000 DCs
Occurrence Discovery AEs NAEs
Sum
(1,2,3,4,5)
During or Before During or After 1,278 306 111,461 29,812 4,172 1,116
Sum
(1,4,5)
During or Before During 1,133 280 98,608 27,179 3,691 1,017
1 During During 647 156 55,046 15,257 2,060 571
 
* Population numbers based on 1984 New York Discharge volume of 2,671,863

Based upon this data from the HMPS, the interpretation of this table is that State adverse event reporting programs that predominantly measure events that both occur and are discovered during an index hospitalization will yield

2,060 Adverse events per 100,000 hospital discharges AND

571 Negligent Adverse Events per 100,000 hospital discharges.

These numbers assume that all categories and types of adverse events that were measured in the HMPS are measured and properly recorded. Since most State programs report a subset of all recognized adverse events, it is unlikely that most States' reporting programs would ever satisfy these criteria, even under an assumption of full reporting compliance.

  • •  Comparison of State Reported Medical Errors / Adverse Events

Table 3.  
Adverse Events and Hospital Discharges
with Indexed Incidence Values

State /
Entity
Reporting
Year(s) and
Reportable
Events
Population Totals Events per
100,000 Discharges
Hospital
AEs
Hospitals
Discharges
Aggregate
Number
Indexed to
MN (NQF)*
HMPS-NY1 1984 All 55,046 2,671,863 2,060 141
New York 2001 54 28,689 2,473,930 1,160 80
Pennsylvania 2004-2005 21 28,689 1,702,971 407 28
Tennessee 2004 48 1,313 773,598 170 12
Massachusetts 2001-2004 33 2,010 3,305,147 60.8 4.2
Colorado 2000-2004 14 1,404 2,314,649 60.7 4.2
Connecticut2 2004-2005 33 206 500,169 41.2 2.8
Florida 2000-2004 17 4,287 11,838,434 36.2 2.5
Maryland 2004-2005 5 237 1,340,508 17.7 1.2
Minnesota3 2004-2005 27 202 1,384,892 14.6 1.0
Connecticut3 2004-2005 27 72 500,169 14.4 1.0
Maine 2004-2005 10 50 315,624 15.8 1.1
Utah 2002-2004 13 108 780,780 13.8 0.9
Washington 2000-2004 12 269 2,775,574 9.7 0.7
Texas4 2004-2005 11 184 2,565,007 7.2 0.5
* Events per 100,000 discharges are indexed to Minnesota's NQF-based event definitions
1 Harvard Medical Practice Study Events numbers based solely upon events that occurred and were discovered during index hospitalization
2 NQF + 6 Connecticut-specific Events
3 NQF Events only
4 Texas collects data with each facility's annual license renewal, so that first year of data represents composite of 12 different monthly collection periods.
Negligent Adverse Events
NY (1984) – HMPS
TX
All Adverse Events
Occurring and Discovered during Hospitalization
NY (1984) – HMPS

Figure 2.  
Index Of Hospital Reportable Events
per 100,000 Discharges by State

STATE & YEAR INDEX RELATIVE TO MN
New York - HMPS (1984)
Discharges - Adverse Events
Discharges - Negligent AEs

141
39

Based upon projections from the Harvard Medical Practice Study, these adverse events represent the same proportion of adverse events that occurred during and were discovered during the index hospitalization. The HMPS did not measure adverse events per patient-day.
New York (2001)
Discharges
Patient-days

80
60

Pennsylvania (2004)
Discharges
Patient-days

28
26

Tennessee (2004)
Discharges
Patient-days

12
11

Massachusetts (2002-04)
Discharges
Patient-days

8.3
7.7

Colorado (2000-04)
Discharges
Patient-days

4.2
4.8

Florida (2000-04)
Discharges
Patient-days

2.5
2.3

Connecticut ALL (2004-05)
Discharges
Patient-days

2.8
2.6

Connecticut NQF (2004-05)
Discharges
Patient-days

1.0
0.9

Maryland (2004-05)
Discharges
Patient-days

1.2
1.1

Maine (2004)
Discharges
Patient-days

1.1
1.0

Minnesota (2004-05)
Discharges
Patient-days

1.0
1.0

Utah (2002-04)
Discharges
Patient-days

0.9
1.1

Washington (2004)
Discharges
Patient-days

0.7
0.8

Texas (2004-05)
Discharges
Patient-days

0.5
0.4

 
†   Minnesota used as Referent Group (MN = 1.0)
Design support from Skysoft Consulting
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