Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems

Abstract

New York State has had a mandatory incident reporting system in place since 1985. The current system, the New York Patient Occurrence Reporting and Tracking System (NYPORTS), was implemented in 1998 pursuant to New York State Public Health Law Section 2805-1, Incident Reporting. NYPORTS is a secure Web-based system that simplifies reporting, coordinates with other reporting systems, and allows hospitals to obtain feedback on their own reporting patterns. The authors review the evolution and implementation of NYPORTS and its predecessors, the Hospital Incident Reporting System and the Patient Event Tracking System. Discussion and data comparisons are made between the Joint Commission on Accreditation of Healthcare Organizations voluntary sentinel event reporting system and NYPORTS. Critical elements for success of a mandatory incident reporting system include collaborative system design; basing the system on statute, with clear definitions and objective reporting criteria; providing meaningful data that can be analyzed and disseminated for improving patient safety; and adequate resources to maintain the system. Innovative program features may be of interest to other States implementing reporting systems.

Open PDF

Document Details

Document Type
Technical Report
Publication Date
May 01, 2005
Accession Number
ADA434291

Entities

People

  • Angelo Ruperto
  • C. L. Chevalier
  • Ellen Flink
  • Frederick J. Heigel
  • Janet Mannion
  • Peg Dameron
  • Robert J. Panzer
  • Ruth Leslie

Organizations

  • United States Agency for Healthcare Research and Quality

Tags

Communities of Interest

  • Biomedical

DTIC Thesaurus Topics

  • Data Analysis
  • Department Of Veterans Affairs
  • Diseases And Disorders
  • Drug Therapy
  • Education
  • Health
  • Health Care
  • Health Services
  • Information Systems
  • Law
  • Lessons Learned
  • Management Personnel
  • Medical Personnel
  • New York
  • Public Health
  • Surgery
  • Training

Fields of Study

  • Medicine

Readers

  • Defense Financial Management and Audit.
  • Military Training and Readiness Simulation
  • Systems Analysis and Design