Quality Components

These components are designed to serve as indicators of whether an event review and analysis will minimize the risk of similar events.

We review each Patient Safety Reporting Program report for six quality components. This review is part of our role to help reduce the risk of patient harm in Oregon’s healthcare system.

Quality Components

Additional detail about our quality component review is described in Oregon laws: OAR 325-010-0035, 325-015-0035, 325-020-0030, and 325-025-0035.

  1. Pertinent information to fully understand what happened

    Report describes what happened, the sequence of actions, relevant surrounding circumstances/conditions and clinical information in a way that someone unfamiliar with the event could easily understand. Report does not leave obvious questions unanswered.

  2. Relevant system-level contributing factors

    Report demonstrates that your facility’s event analysis:

    • Identified the system and process factors directly associated with the event

    • Did not focus on individual performance, but rather identified system reasons why an individual performed as they did (e.g., “human error” or mistake)

    • Did not focus only on individual patient factors, but rather identified system factors that affected a patient and their care needs

  3. Consistent information

    Report demonstrates that the event analysis was internally consistent (i.e., information is not contradictory). Facility provides clear and logical connections between the four major components of the report: the complete account, contributing factors, causes, and action plans.

  4. Leadership participation in the event analysis (only required for serious harm events)

    Report demonstrates that the event analysis included participation by senior management either through notification of individual/aggregate events, as a member of review team, or in a post-analysis briefing.

  5. One or more root cause(s)

    Report demonstrates that your facility’s event analysis:

    • Identified the core reasons (“root causes”) the event occurred

    • Did not focus on individual performance, but rather identified system reasons why an individual performed as they did (e.g., “human error” or mistake)

    • Did not focus only on individual patient factors, but rather identified system factors that affected a patient and their care needs

  6. One or more system-level action plans designed to minimize risk

    Report includes action plan(s) that clearly describe meaningful improvement strategies to address root causes and/or contributing factors, and prevent similar events from occurring. Plans focus on systems, not individuals, and are specific and concrete.