For decades healthcare organizations have relied almost exclusively on voluntary event reporting to identify adverse events, or patient harm. No longer. The evidence overwhelmingly shows the cost in injury & death as well as dollars (e.g. excessive length of stay) is not sustainable or credible. Surveillance by health IT is replacing reporting by clinicians as the foundational standard of care in patient safety and risk management.

The culture of the field has long been to claim that the problem is poor culture and, if only we improved culture, the patient harm problem would be solved. Hence, most leaders and health systems have spent a few decades doing cultural assessment and cultural interventions. This optimistic view, while helpful in the absence of any other better methods, was understandably where the field needed to start. But it is not the answer, and certainly not useful alone.

The answer is to use outcomes data in this domain, and specifically clinically validated adverse event outcomes based on real-time EHR data (“AE Outcomes”). Using outcome data in this domain enables us to measure and manage with outcomes like any other successful area in performance improvement. Again, measuring to generate outcomes is essential for organizations to improve. For those who understand how operations work, improving cannot be done by prediction alone; moreover, optimal predictive models should be trained with outcomes.

But until Pascal was able to show that this is operationally efficient and clinically effective at scale, many sophisticated MDs, PhD, and researchers did not believe that generating and using this optimal data was feasible. And so, with event reporting as our “hammer”, we as a field simply made due.

However, cultural interventions informed by event reporting have not worked to change patient safety materially for the better. Most damningly, patient advocates — those who have lost the most — would attest that, industry-wide efforts have not been successful as key leaders in that community pointed out in “Who Killed Patient Safety?”

The Problem: Voluntary Event Reporting is Unreliable.

The evidence offered by the Bates et al “Inpatient Safety” landmark article in The New England Journal of Medicine — adding to many years of evidence — is conclusive: the trigger-based patient detection method is far more productive in identifying patient harm and related cost. The study across 11 Harvard hospitals conclusively shows a trigger method identifying 25% patients suffering from harm, adding over five days of excessive length of stay, and much more. In an accompanying editorial, modern patient safety movement founder, Dr. Don Berwick, states:

“Voluntary event reporting is so unreliable as to be nearly worthless in the calculation of [patient harm] rates.”

And for all of those on high reliability journeys, is calculating rates to assess progress not important?

The Solution: Trigger-based Harm Detection Identifies 10x More Serious Harm.

Consistent with and alongside the Bates et al landmark article, leading hospitals and health system data from the Pascal Metrics Community Collaborative have shown that a trigger-based harm detection method identifies 10x the serious harm of event reporting — and within 24 hours. Pascal hospitals are reducing over 25% of this greater share of harm found and associated cost.

This point of timely patient harm identification opens new vistas for risk management, as the Community Collaborative has also shown the trigger-based capability to identify 10x the level of potentially compensable events as voluntary event reporting — and, likewise, within 24 hours.


Virtual Patient Safety (VPS) solutions have commercialized this long-validated trigger method for clinical operations. To get beyond one-off projects using manual or automated triggers (e.g. research/science projects) but yielding no long-term sustainable value, health systems are implementing Pascal VPS to support daily clinical operations to improve patient safety & risk.

The Roadmap for Voluntary Event Reporting

So what do we do with voluntary event reporting? Do we stop doing it? By no means. Here’s the roadmap:

  1. Adopt the new standard. Trigger-based adverse event identification is the new standard of care for patient safety and risk management. Further, trigger-based surveillance of all patient harm, all the time, and for all patients becomes the core workflow for avoiding preventable harm and preventable risk.
  2. Supplement with voluntary reporting. We will also have event reporting with us, but our safety and risk efforts should not depend on it. Useful for near misses and identification of harm not electronically documented, reporting by humans should feed into the a core workflow whose complexity first defers to trigger-based requirements.
  3. Reallocate costs to value. Costs incurred to protect and extend safety and to minimize risk should be reduced for legacy approaches based on event reporting and reallocated to the trigger-based method that is proven to be far more productive and support both timely intervention and improvement.
  4. Eliminate non-value added costs. Leaders should review and eliminate those costs that are not required to support the new standard of care and availability of reporting. For example, building a whole infrastructure of software and people to review near misses and events not resulting in more serious harm is neither clinically nor financially more important than finding more serious harm on a timely basis and changing care to avoid it.
  5. Collaborate to change the model. While item #4 above will prove disruptive, it will reward those clinical and executive leaders who embark on this journey with both clinical and financial value. Those health systems interested in embarking on a patient safety & risk journey that is able to measure clinical value in injury and death avoided and CFO-grade ROI achieved should consider joining Pascal’s Community Collaborative.

Our clients are operationalizing how people, technology, and process will deliver value in the next generation of patient safety & risk, and we welcome committed leaders to join us.