HA 645 Unit 3 event reporting system audit example

2,412 Reports and Eleven About Diagnosis: An Audit of Northfield's Event Reporting System, From the Harm Scale to the Categories the Form Cannot Hold

Student Name

Health Care Administration, Herzing University

HA 645: Quality Improvement and Patient Safety in Healthcare

Instructor Name

January 29, 2026

2,412 Reports and Eleven About Diagnosis: An Audit of Northfield's Event Reporting System, From the Harm Scale to the Categories the Form Cannot Hold

Scope and the Harm Classification Used

This audit examines the machinery of event reporting at Northfield Regional Medical Center: what gets reported, what the numbers mean, what happens to a report after it is filed, and what the reporting form cannot capture. It covers all 2,412 reports filed in fiscal year 2025, July 2024 through June 2025.

Reports are classified using the categories Northfield's system already applies, which follow the federal Common Formats for patient safety event reporting: an unsafe condition, with no patient involved; a near miss, which did not reach a patient; an incident that reached the patient without harm; and incidents that reached the patient with mild, moderate or severe harm or death. The patient safety officer reclassified a random 10% of reports to check the reporter's own classification and agreed with 91% of them; the counts below use the reviewed classification.

What Was Filed

Counts for fiscal year 2025, with about 58,600 patient days.

What the Numbers Are Evidence Of

The total, about 41 reports per 1,000 patient days, is often presented to the board as evidence of a healthy reporting culture, and the high share of near misses and no-harm events supports that reading in part: staff are reporting events that did no harm, which is where learning is cheapest. But filed volume measures reporting behavior, not the amount of harm. In a study of three leading hospitals, voluntary reporting and administrative safety indicators missed about 90% of the adverse events that a structured chart review found, and adverse events occurred in about a third of admissions (Classen et al., 2011). Northfield's 322 reports of harm, mild through death, across about 11,600 admissions a year would suggest harm in under 3% of admissions if taken at face value. The honest reading is that the system captures a fraction of harm, weighted toward events that are visible and quick to recognize, such as falls and medication errors caught at the bedside.

The distribution by type makes the point. Of the 2,412 reports, 612 concerned medications, 388 falls, 301 skin and pressure injuries, and 11 diagnosis or test results, less than half of one percent. Diagnostic errors are among the most common kinds of harm in health care, with outpatient estimates on the order of one adult in twenty every year (Singh et al., 2014). Eleven reports is not evidence that Northfield rarely misses or delays a diagnosis. It is evidence that such events are rarely recognized as reportable, or that the form makes them hard to report.

The Path of a Report

Every stop from filing to decision was traced for a sample of 60 reports.

1. Filing: any staff member files through the intranet form; median time to complete, 9 minutes. 2. Automatic notification to the manager of the unit named on the form. 3. Manager review: the manager is asked to investigate and comment within 7 days; the median time to first manager comment was 19 days, and 38% of the 60 reports had no manager comment at 30 days. 4. Patient safety officer triage: the officer reviews every report each weekday morning and flags any report of moderate harm or worse. 5. Serious event pathway: flagged reports are assessed against Pennsylvania's definition of a serious event, which triggers a report to the state within 24 hours of confirmation and written disclosure to the patient, as 40 P.S. § 1303.313 and the related disclosure section require; all 14 severe and death reports were assessed on time, and 6 were reported as serious events. 6. Review: serious events receive a formal event review; other reports are summarized monthly for the patient safety committee. 7. Closure and feedback: the reporter receives a closure message; only 22% of the 60 sampled reporters received any feedback beyond the automatic acknowledgment.

Two stops carry most of the delay and most of the lost learning: manager review, where reports wait, and feedback, where most reporters never learn what happened. Reporting behavior depends heavily on whether staff believe reports lead to action, so the feedback gap is likely to depress future reporting.

Categories the Form Cannot Hold

Three kinds of events fit poorly into the current form, and each is relevant to the hospital's patient safety priorities.

Delays that span encounters. The form requires one event date, one location and one unit. A missed follow-up of an incidental lung nodule involves an emergency department visit, a radiology report, a discharge, and an outpatient practice months later. No single unit owns it, and the form forces the reporter to pick one or to give up.

Harm discovered after discharge. The form is linked to a current encounter. An outpatient physician who learns that a patient's nodule was never followed up, and who is not a Northfield employee, has no way in; a Northfield physician who learns of it at a later visit must file against the new encounter, which misplaces the event.

Events caught by patients or families. The form asks who discovered the event but offers only staff roles. Near misses caught by a family member, such as a wrong medication brought to the bedside, are filed as staff catches or not at all, and the hospital loses a picture of how often patients are its last defense.

Recommendations

Add a multi-encounter event type with a free-text timeline and no single owning unit, routed directly to the patient safety officer. Open a simple external reporting route for affiliated outpatient physicians. Add patient and family as discovery options. Reduce the manager review target to 7 days with an escalation at day 10, and make reporter feedback a required step before closure. Report diagnostic event counts to the patient safety committee monthly, with the expectation that they will rise as the form changes, and say in advance that a rise will be read as better detection, not worse care.

References

Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., Whittington, J. C., Frankel, A., Seger, A., & James, B. C. (2011). 'Global trigger tool' shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30(4), 581-589. https://doi.org/10.1377/hlthaff.2011.0190

Serious event reporting, 40 P.S. § 1303.313 (2025).

Singh, H., Meyer, A. N. D., & Thomas, E. J. (2014). The frequency of diagnostic errors in outpatient care: Estimations from three large observational studies involving US adult populations. BMJ Quality & Safety, 23(9), 727-731. https://doi.org/10.1136/bmjqs-2013-002627