RCHE Publications


Data-sharing systems—where healthcare providers jointly implement a common ‎reporting system to promote voluntary reporting, information sharing, and learning—are ‎emerging as an important regional, state-level, and national strategy for improving ‎patient safety. The objective of this chapter is to review the evidence regarding the ‎effectiveness of these data-sharing systems and to report on the results of an analysis of ‎data from the Pittsburgh Regional Healthcare Initiative (PRHI). PRHI consists of 42 ‎hospitals, purchasers and insurers in southwestern Pennsylvania that implemented ‎Medmarx, an on-line medication error reporting systems. Analysis of data from the PRHI ‎hospitals indicated that the number of errors and corrective actions reported initially ‎varied widely with organizational characteristics such as hospital size, JCAHO ‎accreditation score and teaching status. But the subsequent trends in reporting errors ‎and reporting actions were different. Whereas the number of reported errors increased ‎significantly, and at similar rates, across the participating hospitals, the number of ‎corrective actions reported per error remained mostly unchanged over the 12month ‎period. A computer simulation model was developed to explore organizational changes ‎designed to improve patient safety. Four interventions were simulated involving the ‎implementation of computerized physician order entry, decision support systems and a ‎clinical pharmacist on hospital rounds. The results of this study carry implications for the ‎design and assessment of data-sharing systems. Improvements in patient safety require ‎more than voluntary reporting and clinical initiatives. Organizational changes are ‎essential in order to significantly reduce medical errors and adverse events.‎

Date of this Version

August 2007