States Develop Strategies to Reduce Medical Errors and Improve Patient Safety Through Hospital Reporting Systems

From 2000 to 2003, staff at the National Academy for State Health Policy assisted state officials in developing strategies to reduce medical errors and improve patient safety through mandatory hospital reporting systems.

Project staff documented, analyzed and communicated information on the state's role in patient safety, state policies and reporting standards.

Part of the nonprofit Center for Health Policy Development, the academy is a nonprofit, nonpartisan organization that works on state health policy and practice.

Key Results

  • Eleven states adopted or improved mandatory reporting systems to collect standardized information about adverse events (injuries resulting from medical management).

  • The academy published one workbook, one guidebook, nine reports and seven news briefs, and developed a website section on Quality and Patient Safety.

Key Findings

  • A set of standardized reporting requirements that could be easily adopted might be useful at the state and national levels. (Defining Reportable Adverse Events: A Guide for States Tracking Medical Errors, March 2003)

  • States need resources to improve their systems in order to meet public expectations of a patient safety system. (How States Report Medical Errors to the Public: Issues and Barriers, October 2003)

  • Underreporting by facilities—due to concerns about medical malpractice, dislike of regulation, bad publicity, loss of market share, etc.—is a problem. (Medical Malpractice and Medical Disclosure: Balancing Facts and Fears, December 2003)

  • The project identified no relationship between mandatory reporting and an increase in malpractice claims. (Medical Malpractice and Medical Disclosure: Balancing Facts and Fears, December 2003)