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Track 6: Using Reporting Systems for Safety and Quality Improvement

Featured Sessions | Track 1 | Track 2 | Track 3 | Track 4 | Track 5 | Track 6 | Track 7 | Track 8 | Track 9

Track 6-I Improving the Accuracy and Utility of Reporting Systems

This session will describe efforts to optimize error reporting systems and enhance their utility for patient safety improvement. Covered topics will include: a discussion of the utilization of the AHRQ Patient Safety Indicators (PSI) report as a means to identify opportunities for improvement, a review of an automated vaccine adverse event surveillance and reporting system, and an assessment of the National Quality Forum (NQF) 'never events' standard using data from the Massachusetts Department of Public Health statewide reporting system.


Hal Kaplan, Columbia University


Barbara Doyle Presentation 
Virginia Hinrichsen Presentation 
Eric Schneider Presentation

Monday June 5, 10:30am-12:00pm 
Renaissance Ballroom West B

Track 6-II Using Reporting Systems to Track Changes Over Time

This session focuses on the use of reporting systems to identify and monitor error rates and patterns over time. Presenters will share experiences tracking various types of errors in a range of health care settings including: adverse events in West Virginia's Critical Access Hospitals, clinical incident reports in operating rooms, general and vascular surgery cases (using the National Surgical Quality Improvement Program) in Non-VA hospitals, and near miss errors in a primary care setting.


Ronda Hughes, Agency for Healthcare Research and Quality


Anthony Antonacci Presentation 
Gail Bellamy Presentation 
David Lomely Presentation 
William Henderson Presentation 
Robert Phillips Presentation

Monday June 5, 1:30pm-3:00pm 
Renaissance Ballroom West B

Track 6-III Using Reporting Systems to Track Adverse Drug Events (ADEs)

This session will describe methods to detect and track medication errors and adverse drug events using electronic reporting systems. Those attending will learn about measuring the risk of ADEs resulting in hospitalization among the Elderly, evaluating ADEs in primary care settings, comparing medication errors between specialties for errors related to antibiotics and cancer chemotherapy and examining the National Center for Patient Safety chemotherapy incident reports.


Deborah Queenan, Agency for Healthcare Research and Quality


Joshua Metlay Presentation 
Grace Kuo Presentation 
Anna Schorer Presentation 
Catherine Annas Presentation

Monday June 5, 4:00pm-5:30pm 
Renaissance Ballroom West B

Track 6-IV Innovative Applications of Reporting Systems

This session will highlight novel approaches to the implementation of error reporting systems. Panelists will describe: a claims and reporting system developed for local healthcare units in the Tuscany region, an information system that connects information in the pre-hospital setting with ED and hospital information, the Medical Error Prevention and Reporting System (MEPARS), and an innovative error reporting and review process for nurses.


Marge Keyes, Agency for Healthcare Research and Quality


Denise Daudelin Presentation 
Rollin (Terry) Fairbanks Presentation 
Debora Simmons

June 6, 1:00pm-2:30pm 
Renaissance Ballroom West B

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