Adverse event reporting.pdf

A major issue for all reporting systems, public or private, mandatory or voluntary,
is confidentiality. There is broad agreement across many systems that patients’ and
caregivers’ names should not be disclosed, and these are protected by almost all
systems. However there is much less agreement on whether the public should have
access to hospital-level information.
Governmental health-care systems have a fiduciary responsibility to the public
to ensure reasonable levels of safe care in health-care organizations, and reporting
systems are one mechanism for discharging that responsibility.
Although accountability does not require release of all information, some form
of public disclosure of adverse incidents seems indicated. Some systems make the
events themselves available to the public; others disclose results of investigations
or summary reports. Another option is to provide public notice of the occurrence
of a serious event and of the actions taken in response by the institution and the
government. Some agencies issue annual reports that summarize events and actions
taken.
Types of patient safety reporting systems
The following information has been provided by representatives of reporting systems
from across the world as a result of a survey undertaken for these guidelines.
Czech Republic
Type of reporting system: The Czech Republic has a mandatory reporting system.
Voluntary reporting has also been in place for two years in 50 hospitals, and a
national pilot project has been launched for voluntary reporting.
What is reported: Reportable events include nosocomial infections, adverse drug
reactions, transfusion reactions, and medical equipment failures.
Who reports: Health care professionals.
How they report: Reports yield simple statistics of adverse events.
Analysis: Information is aggregated at different levels, including by hospital, medical
specialization, region, and the republic. Analysis of sentinel event reporting in the
field of acute hospital care launched in 2004; a similar project has been launched
in long term care.
Response, dissemination and application of results: Reports are not accessible to
the public.