Network of Patient Safety Databases Chartbook, 2021


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Network of Patient Safety Databases Chartbook, 2021

This document is in the public domain and may be used and reprinted without permission. Citation of the source is appreciated. Suggested citation: Network of Patient Safety Databases Chartbook, 2021. Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Pub. No. 21-0050.

NETWORK OF PATIENT SAFETY DATABASES CHARTBOOK, 2021
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857 https://www.ahrq.gov/
AHRQ Publication No. 21-0050 August 2021 https://www.ahrq.gov/npsd/data/chartbook/index.html

ACKNOWLEDGMENTS
The Network of Patient Safety Databases Chartbook, 2021 and accompanying online dashboards are the product of voluntary participation in the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Organization (PSO) program by providers and PSOs nationwide. Many individual providers, hospital facilities, and PSOs collaborated to collect and submit the data used in this report. Without the efforts of these dedicated individuals and organizations, the AHRQ and Network of Patient Safety Databases (NPSD) team would not have been able to produce this report.
Specifically, we thank:
Authors: ActioNet, Inc. (ActioNet) and Health Services Advisory Group, Inc. (HSAG).
Primary AHRQ Staff: Jeff Brady, Paula DiStabile, Erin Grace, Hamid Jalal, Tselote Tilahun, and Andrea Timashenka.
Data Support Contractors: ActioNet and HSAG.

DATA LIMITATIONS:
• The Network of Patient Safety Databases (NPSD) does not contain a representative sample of patient safety concerns and cannot be used to calculate the actual incidence or prevalence of patient safety events. The reporting of patient safety concerns to the NPSD is voluntary as is the reporting to PSOs by providers.
• The NPSD is a summary of the elements in Hospital Common Formats Event Reports for specific types of patient safety concerns, that have been submitted voluntarily by a portion of Agency for Healthcare Research and Quality (AHRQ)-listed Patient Safety Organizations (PSOs).
• As only data submitted in the Common Formats for Event Reporting-Hospitals (CFER-H) are included in the NPSD dashboards, the dashboards are characterized as reflecting data from the hospital setting. While it is believed that the CFER-H are primarily used as intended to capture patient safety events in hospital settings, providers may have used the CFER-H to report data from other settings.

Patient Safety
INTRODUCTION TO THE NPSD
The Network of Patient Safety Databases (NPSD) provides an interactive, evidence-based management resource for healthcare providers, Patient Safety Organizations (PSOs), and others. The U.S. Department of Health & Human Services was authorized to create the NPSD by the Patient Safety and Quality Improvement Act of 2005 (PSQIA), and it is implemented by the Agency for Healthcare Research and Quality (AHRQ), the lead federal agency for patient safety. The goal of the legislation is to create a national learning system that promotes using nonidentifiable data about patient safety concerns to prevent patient harm and improve patient safety. Because the NPSD contains a large volume of standardized, non-identifiable patient safety data from across the country, it serves as a unique and valuable resource for research and learning.
AHRQ developed the Common Formats, a standardized reporting format using common language and definitions, to collect information about patient safety events and concerns from across the nation. PSOs collect voluntary reports from healthcare providers and submit data to the PSO Privacy Protection Center (PSOPPC). The PSOPPC ensures the Common Formats data are nonidentifiable before transmittal to the NPSD for aggregation and analysis. Because the NPSD contains a large volume of standardized, non-identifiable patient safety data from multiple sources across the country, it is a unique and valuable resource for research and learning about how to improve patient safety and prevent patient harm. This data can then be used to identify trends and patterns in patient safety concerns, and to provide insight in how to mitigate patient safety risks and reduce harm across healthcare settings nationally. Each provider and PSO that participates by contributing data advances knowledge about patient safety.
This Network of Patient Safety Databases Chartbook, 2021 (NPSD Chartbook), and accompanying online Dashboards, represent a comprehensive look at patient safety data submitted to the PSOPPC through December 31, 2020.
Data and Analysis Available at the NPSD
Submission of patient safety event data by providers to PSOs and PSOs to the NPSD is completely voluntary. The NPSD data are not statistically comparable to clinical quality measures. For example, the data from clinical quality measures reported by agencies such as the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC), which may focus on all eligible members of a population, can establish denominators and calculate rates of occurrence. Voluntary patient safety reporting systems are, however, marked by variability in the rate and consistency of reporting, and denominators are typically unavailable. Hence, the event report data submitted to the NPSD cannot be used to calculate the actual incidence or prevalence of patient safety events.
The NPSD Chartbook and Dashboards comprise three sections covering different types of NPSD analyses:
Data Submission Summary
The Data Submission section provides a high-level overview of the frequency of patient safety concerns reported by AHRQ-listed PSOs. Examples include number of reports submitted by calendar year (CY), by version, and by completeness (of Common Formats elements). It also illustrates the adoption, implementation, and spread of the Common Formats over time. The total number of reports submitted between July 26, 2012 and December 31, 2020 was 270,098 for CFER-H V1.1 and 1,806,910 for CFER-H V1.2 for a combined total of 2,077,008 reports.
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Patient Safety
Generic Patient Safety Concerns
The Generic Patient Safety Concerns section pertains to all patient safety concerns – incidents, near misses, and unsafe conditions – and includes basic information about all types of events. In the Common Formats for Event Reporting – Hospital Version 1.2 (CFER-H V1.2), the Healthcare Event Reporting Form (HERF), Patient Information Form (PIF), and Summary of Initial Report (SIR) Form are collectively referred to as the Generic Patient Safety Concerns module. Examples of generic information include type of event, location, contributing factors, and level of harm. This section displays the distributions of the types of events and unsafe conditions reported by the AHRQ-listed PSOs.
Event-specific Modules
The Common Formats include event-specific modules pertaining to nine patient safety event types that represent the majority of reported preventable injuries that happen in hospitals. Event-specific modules capture information that goes beyond generic data and is related to relevant patient outcomes or processes of care in hospitals. Event-specific modules are employed in addition to, not in place of, the Generic Patient Safety Concerns module. An example of additional detail from the Fall module would be the type of injury sustained in a fall.
The Event-specific section of the NPSD Chartbook displays more detailed information for the six types of safety events reported by PSOs: Blood or Blood Products, Device or Medical/Surgical Supply, Fall, Medication or Other Substance, Perinatal, and Pressure Ulcers. These six event-specific sections were developed for inclusion in the NPSD Chartbook because they were the most frequently reported events by PSOs, the data elements presented included at least 30 responses for reliable reporting, and data elements did not require extensive data suppression to meet non-identification requirements. There were insufficient data submitted to the PSOPPC to include results from the remaining three event-specific modules: Healthcare-Associated Infection, Surgery or Anesthesia, and Venous Thromboembolism. The NPSD Chartbook 2021 represents an update to the existing data displays. The intention is for future NPSD Chartbooks to expand upon these results as data become available and are analyzed for inclusion in the national learning system.
NPSD Chartbook Text Formatting
The text of the NPSD Chartbook has been formatted to assist readers in recognizing when the discussion relates to a Common Formats Event Type, Data Element, and Answer Value. Event Types represent the distinct modules of the CFER-H (e.g., Blood or Blood Product, Device or Medical/Surgical Supply, Fall, Healthcare-Associated Infection, Medication or Other Substance, Perinatal, Pressure Ulcer, Surgery or Anesthesia, and Venous Thromboembolism). Data Elements refer to the concepts reported in the CFER-H and captured through individual questions asked of reporters for each patient safety concern (e.g., “What is being reported?” Incident, Near miss, or Unsafe condition). Answer Values represent the unique response options for each Data Element. Following the previous example, the Data Element “What is being reported?” has three Answer Values: Incident, Near miss, and Unsafe condition.
Each of these types of information contained in the CFER-H is formatted differently in the text to clarify the context of the information for readers. The following formatting is used throughout the remainder of this document:
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Patient Safety
■ Event Types: All key words have first-letter capitalization, and are italicized (e.g., Blood or Blood Product)
■ Data Elements: All letters are capitalized, and bold-faced (e.g., CATEGORY ASSOCIATED WITH EVENT OR UNSAFE CONDITION)
■ Answer Values: First letter of the first word is capitalized, and all letters are italicized (e.g., Unsafe condition or Moderate harm)
Of the nine EVENT-SPECIFIC CATEGORIES (EVENT TYPES) collected for CFER-H, six are explored in more detail in event type-specific sections: Blood or Blood Product, Device or Medical/Surgical Supply, Fall, Medication or Other Substance, Perinatal, and Pressure Ulcer. There are no detailed sections for the Surgery or Anesthesia EVENT TYPE because too few of the submitted reports were sufficiently complete for meaningful analysis. No structured data were collected for Other reports, precluding detailed analysis. Subsequent to the development of the CFER-H, reporting Healthcare-Associated Infection through the CDC NHSN has been mandated in many states and by CMS. Given the small number (15,215) of CFER-H V1.2 HealthcareAssociated Infection reports submitted through December 31, 2020, and the high quality of the data collected through NHSN, AHRQ has elected not to report any CFER-H Healthcare-Associated Infection data beyond the number of reports submitted. Finally, while there is a recognized need to collect data on Venous Thromboembolism Incidents, the small number (232) of CFER-H V1.2 Venous Thromboembolism reports received was deemed insufficient for any analysis and, as with Healthcare-Associated Infection, AHRQ has chosen to report only the number of reports submitted.
The data in the NPSD Chartbook for the Generic Patient Safety Concerns module and six types of safety events (i.e., Blood or Blood Products, Device or Medical/Surgical Supply, Fall, Medication or Other Substance, Perinatal, and Pressure Ulcer) were submitted in CFER-H V1.2. Data submitted in CFER-H V1.1 is omitted from the analysis for these figures.
DATA SUBMISSION SUMMARY
The Data Submission Summary section illustrates the adoption and use of the CFER-H V1.1 and CFER-H V1.2 for reporting patient safety concerns, examining the frequency and types of reports submitted to the PSOPPC. Individual figures provide the distributions of the types of events and unsafe conditions reported by the AHRQ-listed PSOs in these two versions, as well as descriptive statistics about the number of reports submitted for each patient safety category or event type.
CFER-H V1.1 was released on March 31, 2010 and retired on July 7, 2017. CFER-H V1.2 was released on April 3, 2012 and remains in use. CFER-H V2.0a was released on August 3, 2018, but no data have been included using this version of the specifications since not enough reports have been submitted using this format to meet the requirements for the non-identification of the data.
Cumulative Number of Reports Submitted by Common Formats Version by Year
This figure displays a running total of all reports submitted to the PSOPPC by calendar year (CY) from July 26, 2012 through December 31, 2020 in CFER-H V1.1 and CFER-H V1.2.
The total number of reports submitted was 270,098 for CFER-H V1.1 and 1,806,910 for CFER-H V1.2 for a combined total of 2,077,008 reports.
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Important information is provided in the Technical Notes below.
Cumulative Number of Reports Submitted by Common Formats Version by Year
2500K

2000K

2,077,008 1,806,910

1500K

Cumulative Number of Reports

1000K

500K

270,098

0 2012

2013

2014

2015

2016 Year

2017

2018

2019

2020

CFER-H V1.1

CFER-H V1.2

Combined

Note: The data presented indicate a running total of the number of reports submitted to the PSOPPC via CFER-H V1.1 and CFER-H V1.2. Counts shown in the figure are cumulative, therefore it is not appropriate to sum the counts shown across years.

Technical Notes

■ The year displayed indicates the calendar year (CY) a report was submitted by a PSO to the PSOPPC. Note that this is neither the date the patient safety concern occurred nor the date the concern was reported by the health care provider or facility. While not reported here, the INITIAL REPORT DATE is the CFER-H data element representing the date the report was initially entered into the system at the provider facility and is often different from the date the report was submitted to the PSOPPC. An examination of the lag time between report dates and submission dates indicated that submission dates ranged between July 26, 2012 and December 29, 2020, and the median number of days between initial report date and submission to the PSOPPC was 587 (1.6 years), with an interquartile range (25th-75th percentiles) from 281 days (0.8 years) to 1,128 days (3.1 years). The full range of differences between initial report date and submission date was 0 days to 3,577 days (9.8 years). Importantly, the initial submissions from many PSOs contained historical data, resulting in the appearance of a longer lag time between initial report date and submission date.

■ Some reports that were counted in the Data Submission Summary module may not be

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Patient Safety
counted in one of the specified modules of the CFER-H: the Generic Patient Safety Concerns module; Blood or Blood Product; Device or Medical/Surgical Supply; Fall; Medication or Other Substance; Perinatal; and Pressure Ulcer patient safety event-specific modules. The excluded reports contained information that is not within the intended scope of CFER-H. For example, Medication or Other Substance events that were reported as Adverse reaction in patient to the administered substance without any apparent incorrect action are considered outside the scope of CFER-H. Thus, these were excluded from report counts in the Generic Patient Safety Concerns module and in the Medication or Other Substance module. It should also be noted that reports involving an Adverse reaction in patient to the administered substance without any apparent incorrect action have no further information associated with them. For this reason, frequencies and percentages displayed in the Data Submission Summary module differ from those shown in other modules. Criteria for exclusion may be found in the CFER-H Event Descriptions. A complete list of exclusion criteria for CFER-H V1.2 is located in Appendix A.
Completeness of Reports Submitted by Common Formats Version
Although the CFER-H were developed to collect a large number of detailed data elements related to patient safety concerns, many PSOs were only able to capture a portion of all possible data elements. There are numerous reasons for this partial reporting, such as the providers’ use of risk management data systems that do not include the same data elements and the expense required to convert existing data to meet CFER-H specifications. The difference between partial reporting and full reporting was revealed when the data were submitted to the PSOPPC.
This figure displays the number of reports by completeness of fields (minimum, partial, or full) as submitted for CFER-H V1.1 and CFER-H V1.2.
The percentage of reports that met the standard for full reporting in CFER-H V1.1 was higher than CFER-H V1.2: 47.6% (128,493 / 270,098) for V1.1 compared to 27.2% for V1.2 (491,597 / 1,806,910). The vast majority of reports submitted in CFER-H V1.2 were partial reports (1,270,606 / 1,806,910; 70.3%), or only met the minimum Validation Data Set requirement for reports to be accepted by the PSOPPC import process (44,707 / 1,806,910; 2.5%).
Although a larger percentage of reports were considered full among CFER-H V1.1 submissions when compared to CFER-H V1.2, most of the difference was not more detailed data, but the result of selecting Other as the CATEGORY ASSOCIATED WITH EVENT OR UNSAFE CONDITION (EVENT TYPE). When a patient safety concern is reported as an Other EVENT TYPE, only a limited number of generic informational data elements are collected, in contrast to each specific EVENT TYPE for which detailed event-specific data elements are collected. This means that Other EVENT TYPE records are more likely to be classified as full than records from the remaining EVENT TYPES. Additionally, a smaller number of PSOs reported a larger proportion of full Other records in V1.1, than occurred in V1.2, causing the portion of full records for Other events to decline in V1.2. The frequent selection of Other appeared to be predominantly the result of mapping data from various systems into CFER-H data elements.
Important information is provided in the Technical Notes below.
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