Developing and Testing the Health Care Safety Hotline

Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events

Eric C. Schneider
M. Susan Ridgely
Denise D. Quigley
Lauren E. Hunter
Kristin J. Leuschner
Saul N. Weingart
Joel S. Weissman
Karen P. Zimmer
Robert C. Giannini
Copyright Date: 2016
Published by: RAND Corporation
Pages: 205
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  • Book Info
    Developing and Testing the Health Care Safety Hotline
    Book Description:

    This report describes the design, development, and testing of the Health Care Safety Hotline, a prototype consumer reporting system for patient safety events. Reports obtained were considered useful and had little overlap with information received through health care organizations’ monitoring systems, but the frequency of reporting was low. It might be necessary to raise awareness by actively soliciting reports from patients and caregivers.

    eISBN: 978-0-8330-9578-7
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-i)
  2. Preface
    (pp. ii-ii)
  3. Table of Contents
    (pp. iii-iv)
  4. Figures
    (pp. v-v)
  5. Tables
    (pp. vi-vi)
  6. Summary
    (pp. vii-xii)
  7. Acknowledgments
    (pp. xiii-xiii)
  8. Abbreviations
    (pp. xiv-xv)
  9. I. Introduction
    (pp. 1-8)

    Patient safety is a public health problem in the United States and abroad. In the late 1990s, up to 42 percent of the respondents in a Louis Harris Poll reported that they or a close friend or relative had experienced a medical mistake (Louis Harris and Associates, 1997). A more recent public opinion poll in Massachusetts found that nearly one in four adults had personally experienced a medical error in the past five years (or someone close to them had), and half of them reported that the medical error resulted in serious health consequences (Harvard School of Public Health, 2014)....

  10. II. Hotline Design and Development
    (pp. 9-26)

    Although a number of entities and organizations—including governments, professional societies, hospitals, and consumer advocacy organizations—have developed consumer reporting tools to elicit information that might inform patient awareness and improvement initiatives,¹⁰ no well-established model exists for eliciting consumer-identified patient safety events on a national scale, as envisioned by AHRQ. Therefore, with support from AHRQ and knowledge gleaned from prior efforts, the project team undertook the design and development of a new prototype for a consumer hotline for reporting patient safety events. The first phase of the effort, design and development, was completed between September 2011 and September 2013.


  11. III. Hotline Implementation and Refinement
    (pp. 27-33)

    The second phase of the project, from September 2013 to September 2015, included both implementation and refinement of the prototype and involved the following activities:

    Selecting the pilot community and health care organizations

    Developing and implementing an outreach and marketing plan

    Launching the hotline

    Refining the prototype

    Extending the outreach.

    We used multiple methods for selecting the pilot community and participating health care delivery organizations; clarifying the legal framework for prototype operation; developing and carrying out an outreach and marketing plan for notifying organizational leadership, physicians, nurses, professional associations, and other community stakeholders about the prototype; developing and implementing a...

  12. IV. Evaluation Aims, Methods, and Results
    (pp. 34-52)

    The goal of the evaluation was to test the capability of the hotline prototype to collect meaningful information about patient safety concerns across a wide range of settings and to understand challenges in triaging and sharing that information with professionals who can improve the safety of health care and (as appropriate) with the public. Therefore, the evaluation effort had three principal aims:

    1. To characterize the hotline reports entered by patients and caregivers. This part of the evaluation effort was designed to analyze how resources related to the marketing and promotion of the hotline and the modes used to provide...

  13. V. Challenges Identified and Lessons Learned
    (pp. 53-58)

    This research project highlighted several challenges to obtaining consumer-generated reports about safety concerns (Weissman, Schneider, Weingart, et al., 2008). Safety-related events do not surface in a predictable way, and their causation is complex. This makes standardized surveys and other data collection approaches difficult to design and implement. Moreover, the reporting process must be acceptable to the person making a report. Serious problems may arise during transitions among a wide variety of delivery organizations, creating uncertainty about how best to notify relevant professionals and organizations about patient and caregiver reports. New information technologies are evolving rapidly, so patients and caregivers may...

  14. VI. Summary and Conclusions
    (pp. 59-65)

    It is important to emphasize not only how much was known, but also how much was not known at the outset of this project. What was known after two decades of prior research is that adverse events, errors, and even near-miss events can be identified, a nomenclature can be created to structure and catalog reports of such events, and systems can be built to enable health care professionals to reliably report these events in real time. What was less well known was whetherpatientscould contribute unique information that health care organizations did not already have—that is, whether a...

  15. References
    (pp. 66-69)
  16. Appendix A. Recommendations for Ideal Consumer Reporting Systems
    (pp. 70-71)
  17. Appendix B. Technical Expert Panel Members
    (pp. 72-72)
  18. Appendix C. Operations Manual
    (pp. 73-180)
  19. Appendix D. Hotline Site-Visit Interview Protocol
    (pp. 181-189)