Wednesday, May 30, 2012

The Patient Safety Organization Common Format

In a recent call with the HIT Policy Committee, I was asked to comment on the suggestion that EHRs include the technology necessary to submit reports to patient safety organizations about defects in the EHR or safety issues caused by the use of the software.

I commented that the standards to do this are still emerging.

You may not be familiar with the AHRQ and NQF efforts to standardize reporting to Patient Safety Organizations.

AHRQ recently released version 1.2 of the "Common Format"  .

Its objective is well described in the implementation guide:

"The Common Formats published by the Agency for Healthcare Research and Quality (AHRQ) of the U.S. Department of Health & Human Services were created as part of the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). AHRQ has coordinated the development of the Common Formats to facilitate the voluntary collection of patient safety event information. The Common Formats are available on the PPC Web Site ( For more information on the Common Formats, refer to the Common Formats Users Guide available on the PPC Web Site (

The Common Formats are intended to be used to gather information on a patient safety event in order to create a Common Formats Patient Safety Report (hereinafter referenced to as “report”). Reports may be submitted to the PPC for data nonidentification and transmission to the Network of Patient Safety Databases (NPSD)."

The Common Format is a CDA document customized to include 3 report types

*Incident: A patient safety event that reached the patient, whether or not the patient was harmed.
*Near Miss: A patient safety event that did not reach the patient.
*Unsafe Condition: Any circumstance that increases the probability of a patient safety event.

Each of these types includes an issue category for Device or Medical/Surgical Supply, including Health Information Technology (HIT).

The challenge is that the data elements required do not map to the information commonly available in EHRs today.

Although software vendors supporting Patient Safety Organizations have implemented the Common Format, no EHR vendors have yet included it.

At Harvard, we're working to map our own local codes, supporting our patient safety organization, to the Common Format, so that we have interoperable incident reporting among all our hospitals.

Thus, the PSO Common Format is emerging - low maturity, low adoption, but deserves watching.   I think it unlikely that PSO reporting will be included in the 2014 Meaningful Use final rule, but it's clear that PSO report is on the list of desirable future goals.


pjonwhite said...

Thanks for the discussion, John. Looking forward to future posts on this.

Susan M. Reese MBA, RN, CPHIMS said...

John, I am thrilled to have found this blog post!

I am in the midst of doing some research around PSO and reporting. There is one question that I need help with. Perhaps you could shed some light for me.

Since PSO reporting is strictly voluntary, what is the motivation for an organization to participate? (of course, benchmarking comes to mind, but are there other motivations? Incentives?)


Steve Earle, PMP, CPHIMS said...

Great article John - thanks.

Down the road here in Rhode Island, all of our 13 private hospitals have joined the same PSO, and are using the same Medical Event Reporting System to capture patient safety event data. The main reason for joining a PSO? If we can't share information and learn from our mistakes, we can't make things better. Under federal law, information sent to a PSO is protected information.

At our hospitals, we've noticed that event reporting has risen substantially, leading to a number of safety improvements, including at least two that had national repurcussions due to supplier/manufacturer issues that were discovered and corrected.

HIT-related safety events are already important, and will only become more so as we increasingly rely upon automated systems to drive improvements in healthcare.