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Fruit or Vegetable? What does this have to do with Common formats for Patient Safety Information?

By: Barbara Rebold

At a dinner recently, we began a conversation about rhubarb which led to a discussion about whether it is a fruit or a vegetable. This led to everyone pulling out their smart phones to search the web for the answer. Then we started talking about other questionable fruits and vegetables such as olives. It was really fun and there was no consensus. Some at our dinner thought rhubarb was a fruit. After all, we eat rhubarb pie. And most pies are made from fruit. But rhubarb grows in the ground. Don’t all things that grow in the ground get categorized as a vegetable? Tomatoes are classified as fruit and, well, if that’s the case then growing in the ground can’t be a way vegetables are defined. Fruit grows on trees, so olives are then fruit. Right?

This fun and spontaneous dinner conversation led us to think about why there is a need for a common language. In patient safety and quality improvement, we often talk about creating taxonomy for gathering data. The Common Formats created by the Agency for Healthcare Research and Quality (AHRQ) are one such taxonomy. They are one of the first common taxonomies now available to report and categorize adverse events. On its website for patient safety organizations, it states that “AHRQ coordinates the development of Common Formats for reporting patient safety events to Patient Safety Organizations (PSOs). This activity is authorized by the Patient Safety and Quality Improvement Act of 2005 and the Patient Safety and Quality Improvement Final Rule.” In collaboration with the interagency Federal Patient Safety Work Group, AHRQ has developed Common Formats for two settings of care—acute care hospitals and skilled nursing facilities. The Common Formats for hospitals have been finalized and implemented; the skilled nursing formats are in the comment phase.

Common formats now give us the benefit of one language for one aspect of patient safety and quality improvement/adverse events. Healthcare organizations, up until now, collected information on incident reports and adverse events in their own ways. Sometimes, hospitals within a health system don’t even use the same terms. The lack of a common language hampers pulling together similar information to look for patterns, trends or unusual events. With a common language, health systems can take that trend analysis and pass it along to all its member hospitals to help prevent the same error or medical mistake from happening again. Take this further. Sometimes organizations—even those using the same adverse event reporting software vendor—can’t compare their information with others because the software system allowed each hospital to customize and create its own methods of reporting. Until the advent of the Common Formats, there wasn’t anything close to a nationwide sharing of adverse event information.

Using Common Formats to report events to patient safety organizations now provides an opportunity to share learning within organizations; regionally between quality, risk management, and patient safety professionals; professionally through specialty organizations; and nationally through nationwide collaboratives and PSOs. We now have a common language. This will be a long effort as these formats are developed for all of the healthcare settings in the continuum of patient care.

Since it will be a long effort, we can still work now to help the patient safety improvement effort be successful. There is other sharing and learning that can be done through patient safety organizations while our common language about adverse events is determining if “rhubarbs are vegetables or fruit.” Some of the other opportunities for patient safety and quality improvement including sharing and analysis of root cause analyses, peer review findings, quality improvement projects, collaboratives, and other types of patient safety work product that can be shared so that all of us can benefit from the experience of others who have gone through similar issues, done research into best practices, or created tools to help improve patient safety and quality.

Just as we talk about a fall not always being defined the same way, a vegetable is not always a vegetable. Defining criteria and common terminology are necessary. So what is rhubarb? According to Wikipedia, the word vegetable “is not scientific, and its meaning is largely based on culinary and cultural tradition. Therefore, the application of the word is somewhat arbitrary and subjective.” So let’s get more scientific and less arbitrary or subjective about our approach to patient safety improvement. Let’s use a common language. By the way, the jury is still out on whether rhubarb is a vegetable or fruit. According to the CDC, “Botanically speaking, rhubarb is considered a vegetable, but it's most often treated as a fruit.” And olives are fruit!

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