AHRQ's Common Formats are a set of standardized definitions and formats that make it possible to collect, aggregate, and analyze uniformly structured information about patient safety for local, regional, and national learning. They have been developed for use by healthcare providers that choose to work with patient safety organizations (PSOs) listed by AHRQ under the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). The Common Formats are also available in the public domain to encourage their widespread adoption. An entity does not need to be listed as a PSO or working with one to use the Common Formats. However, the Federal privilege and confidentiality protections only apply to information developed as patient safety work product by providers and PSOs working under the Patient Safety Act.
AHRQ has developed Common Formats for Event Reporting for several healthcare settings and event types. AHRQ has also developed Common Formats for Surveillance and continues to work on developing new Common Formats.
What Are the Common Formats for Event Reporting (CFER)?
Generally, the CFER can be used to report:
- Incidents: patient safety events that reached the patient, whether or not there was harm involved.
- Near misses (or close calls): patient safety events that did not reach the patient.
- Unsafe conditions: circumstances that increase the probability of a patient safety event occurring.
Currently, there are CFER that include several event-specific modules for hospitals (CFER-H) and nursing homes (CFER-NH). There is also a CFER designed for community pharmacies (CFER-CP) and development of a CFER for Diagnostic Safety (CFER-DS) is underway.
What Are the Common Formats for Surveillance (CFS)?
The CFS is a set of event descriptions used in retrospective review of medical records to identify whether certain patient safety events occurred. The CFS is designed to provide information that is complementary to that derived from event reporting systems. The term "surveillance" in this context refers to the improved detection of events and calculation of adverse event rates in populations reviewed that will facilitate collection of comparable performance data over time and across populations of patients. A beta version of the CFS, which includes only the event descriptions, designed for hospitals, is currently available. The CFS will also be used in the AHRQ Quality and Safety Review System (QSRS).
Where To Find More Information and Current Versions of the Common Formats
The current versions of all of the Common Formats can be found at the PSO Privacy Protection Center (PSOPPC) website.
To learn more about the Common Formats development process, visit the webpage Development of Common Formats.
We Welcome Your Feedback
Development of the Common Formats is an ongoing process. AHRQ welcomes feedback, especially from all users, to improve the current Common Formats and inform the development of new types of Common Formats.
To comment on any of the current Common Formats, visit the Common Formats for Patient Safety Data page at the National Quality Forum (NQF) website.
If you have questions or suggestions for new types of Common Formats, contact the PSOPPC.
Department of Health and Human Services Office of Inspector General (OIG) Studies Related to Adverse Events in Rehabilitation and Long-Term-Care Hospitals
The OIG has published a series of reports regarding adverse events experienced by Medicare beneficiaries in healthcare settings. AHRQ is disseminating this information to increase understanding of adverse events and harm that occur in different healthcare settings.
OIG Report on Adverse Events in Rehabilitation Hospitals
The OIG's study of the incidence of adverse events among Medicare beneficiaries in rehabilitation hospitals found that an estimated 29 percent of Medicare beneficiaries experienced preventable and non-preventable adverse or temporary harm events during their rehabilitation hospital stays resulting in temporary harm; prolonged stays or transfers to other hospitals; permanent harm; life-sustaining intervention; or death.
Link to the OIG Report: U.S. Department of Health and Human Services, Office of Inspector General (OIG). Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Report No. OEI-06-14-00110, July 2016.
OIG Report on Adverse Events in Long-Term-Care Hospitals
The OIG's study of adverse events in long-term-care hospitals (LTCHs) found that 46 percent of patients in LTCHs experienced preventable and non-preventable adverse or temporary harm events. However, the OIG noted that there are more opportunities for harm with longer hospital stays, and that the number of harm events per patient day was similar between LTCHs and other post-acute-care settings and lower than in non-LTCH acute-care hospitals.
Link to the OIG Report: U.S. Department of Health and Human Services, Office of Inspector General (OIG). Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries. Report No. OEI-06-14-00530, November, 2018.
Lists of Potentially Preventable Adverse Events
Using the adverse events identified by the OIG as potentially preventable, the lists posted below were developed to raise awareness and encourage reporting for the purpose of learning and reducing patient harm.
Link to the List Developed for Rehabilitation Hospitals: Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in Office of Inspector General Report as Clearly Preventable or Likely Preventable, by Clinical Category (PDF, 218 KB). NOTE: AHRQ has determined that the majority of these events could be captured using either version of the current Common Formats for Event Reporting–Hospital.
Link to the List Developed for Long-Term-Care Hospitals: Adverse and Temporary Harm Events in Long-Term-Care Hospitals Designated in Office of Inspector General Report as Clearly Preventable or Likely Preventable, by Clinical Category (PDF, 253 KB).