New York State Department of Health - NYPORTS
The New York Patient Occurrence
Reporting and Tracking System
Annual Report 2000/2001
Introduction and Background
The New York Patient Occurrence Reporting and Tracking System (NYPORTS) is an adverse event reporting system implemented pursuant to New York State Public Health Law Section 2805-l, Incident Reporting. For the purpose of NYPORTS reporting, an occurrence is an unintended adverse and undesirable development in an individual patient's condition, such as a patient death or impairments of bodily functions in circumstances other than those related to the natural course of illness, disease or proper treatment, in accordance with generally accepted medical standards. Most occurrences reported are tracked and trended as groups and are reported on a short form. More serious occurrences are investigated individually by the hospital and require the hospital to conduct a Root Cause Analysis (RCA). All adverse events are not medical errors and should not be considered as such. NYPORTS does collect reports on medical errors, but the volume of medical errors in the system is a small percentage compared to the overall volume of reporting. It should be noted that New York State Public Health Law Section 2805-m Confidentiality prevents disclosure of incident reports under the Freedom of Information Law.
In this second report on the NYPORTS system, the Department will provide information regarding the upgrading of NYPORTS, as well as, analysis of data collected regarding adverse events that occurred during the years 2000 and 2001. We will also provide information regarding activities undertaken to assure complete reporting by hospitals into this mandatory system and present a description of future plans. Future plans include ongoing improvement of the system, ongoing training and support, and continuing in-depth data analysis by occurrence code, to improve the quality of care and safety of patients in hospitals in New York State. Sanctions will continue to be imposed on those hospitals that repeatedly fail to report as required.
New York State has had a long history of implementing efforts to improve patient safety by mandating hospitals to report and initiate improvement actions based on adverse events occurring in their facilities. Since October 1, 1985, a mandatory incident reporting system has been in place in New York State. Initially, the incident reporting system was a paper reporting system; later, an e-mail based system was developed. Neither of these systems allowed adequate feedback to the hospitals, which limited the use of the data for quality improvement. At the direction of Governor Pataki through a regulatory reform effort, NYPORTS was created to simplify reporting, streamline coding, coordinate with other reporting systems to reduce duplication, and most importantly, allow hospitals to obtain feedback on their own reporting patterns and compare them with other facilities in the region and the State.
The development of the electronic internet-based system began in 1995, utilizing a statewide workgroup of industry experts and a consumer representative. The workgroup included a practicing surgeon, a practicing anesthesiologist, a consumer representative, facility medical directors, internal medicine practitioners, and professionals from nursing, quality assurance, and risk management. The workgroup was chaired by the chief quality officer at a major academic medical center. That group continues to meet and oversee the ongoing implementation and continued improvement of NYPORTS. The Department participated with the group and provided the necessary support to carry out development and implementation activities. The statewide hospital association and its regional affiliates also participated in development and implementation in support of the group's activities. The resulting system is based on objective criteria and information and provides hospitals with clear definitions of what must be reported. It was extensively field tested, refined, and implemented on a statewide basis in April 1998. The system made it easier for hospitals to report adverse incidents, as required by law, and to obtain comparative data.
NYPORTS is an Internet based system with all the required security measures included in its construct. Hospitals can query the database to compare their experience with reported events to the statewide, regional or peer group experience. While the identity of individual hospitals in the comparative groups is not disclosed, the comparative database is a useful tool in support of hospital quality improvement activities. Additionally, hospitals can use the system to create comparative reports in a variety of graphic formats.
Significant systems improvements were implemented effective June 1, 2000. These improvements included improved definitions of reportable events, increased reporting requirements regarding medication errors, a detailed definition manual and a revised and improved instructional manual. Additional system improvements were implemented in 2001, including the installation of a new server, a "bulletin board" to post information and documents, a home screen that will display changes in case status, the ability to create RCAs for all 900 code occurrences, and unlimited time to enter data.
The Department believes that before patient safety improvements can be made, there must be an awareness and recognition of adverse events by facilities (i.e., before one can fix a problem, it must be identified.) Therefore, the Department views hospitals with the highest reporting rates as those most keenly aware of occurrences within their facilities and in the best position to bring about systems improvements. For events with significant negative or lasting impact on patients, facilities must conduct internal investigations into the system of care. These investigations, known as Root Cause Analyses, must identify root causes for such events, enact systems improvements and build in back-up, "fail-safe" procedures to prevent reoccurrence. Hospitals are then required to monitor the implementation and effectiveness of these system improvements through quality assurance activities to assure that they function as intended. For events of lesser patient consequence, hospitals are expected to collect and aggregate data regarding these occurrences to identify system weaknesses before more consequential events occur. Through access to a comparative database, a hospital can identify through its own reporting circumstances where the hospital stands by comparison. This helps to identify the system of care upon which the hospital should focus its attention and efforts and to monitor the effectiveness of improvement efforts. By completing this process, the number of adverse events will be reduced over time and the quality of care and the level of safety for hospital patients will improve. The Department oversees hospital compliance with NYPORTS reporting responsibilities to ensure the process is fulfilled. The Department also directly investigates a portion of the most significant occurrences. Further, through NYPORTS system management and analysis, the Department identifies areas of significant concern noted by individual hospitals and provides alerts to all hospitals in the State. It is expected that hospitals will institute measures, known as "risk reduction strategies", to prevent or reduce these occurrences in their own facilities. By sharing such pertinent information with all hospitals in the State, the Department endeavors to bring about industry-wide improvement in patient safety.
Based on published reports, the National Academy for State Health Policy (NASHP) supports mandatory reporting systems, such as NYPORTS, as a tool to address quality and safety issues related to hospital care. NASHP states, "Proponents of mandatory reporting view it as a way to make healthcare organizations responsive to public expectations for safe, high quality health care. Mandatory reporting systems are intended to hold providers accountable for performance in two ways. First, they may help assure that serious mistakes are reported and investigated and that appropriate follow-up action is taken. And second, they provide disincentives (e.g., citations, penalties, sanctions, possible public exposure, and possible loss of business) for organizations to continue unsafe practices." By fulfilling and exceeding these criteria set forth by NASHP, NYPORTS has distinguished itself as a model state reporting system.