Reporting Patient Safety Events Challenge

Submission Deadline

Submissions are Closed


Hemali Thakkar


  • First Place $50,000 + demo opportunity
  • Second Place $15,000
  • Third Place $5,000

First Place

Team 90

Team 90 logo

Team Members

Douglas Dotan, Noah Smith, Chris Stephens, Anthony DeMoss

KBCoreSM is a unified platform for the collection and analysis of safety event reports using a web and mobile application for easy reporting and feedback. It includes a linguistic analytical module for the automatic identification of events integrating into institutional systems to extract data from EHRs, the blood bank and the Device and medication databases. It includes a health information exchange platform that enables secure communication between health professionals, and organizations.

Second Place

IDinc & Shands

IDinc & Shands logo

Team Members

Didier Salem, Linda Allen

IDinc a developer of Incident Management Systems for the North American Healthcare market has collaborated with Shands Healthcare (University of Florida), the premier healthcare provider in Central and North Florida to develop an AHRQ 1.2 Common Format compliant system. The system accommodates on-line reporting and management of incidents, assigns tasks and notifies assignees via email, requires no training and includes an extraction engine for submitting data to PSO's

Third Place

Midas+ Solutions

Midas+ Solutions logo

Team Members

TJ McGreevy, Travis Baker, Lois Gillette

The Midas+ AHRQ PSO Acute Care Data Collection and Extraction Toolkit is designed to support acute care hospitals that elect to participate in the voluntary reporting collaborative established by the Patient Safety and Quality Improvement Act of 2005. The data collection forms conform to the AHRQ Common Formats for Acute Care and the data extraction file conforms to the Provider to PSO Data Submission Supplemental Specification.


Click here to join the Reporting Patient Safety Events Challenge Google group!
Joining will allow participants to communicate and discuss questions, comments, or concerns regarding the topics of this Challenge.

Patient Safety Organizations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ) create a safe environment for health care providers to collect, aggregate, and analyze data without fear of legal discovery. This flow of information is designed to improve the quantity and quality of actionable information available and ultimately improves the safety of health care by identifying and reducing the risks associated with patient care.

The Institute of Medicine, in its 2011 report on Health IT and Patient Safety: Building Safer Systems for Better Care, recommended voluntary adverse event reporting by health care providers and promoted PSOs using AHRQ’s Common Formats as the “best option” for advancing effective reporting. Because medical errors occur in a complex environment and are caused by multiple factors, adverse event reporting must capture a wide range of data, which may go beyond structured data required by Common Formats. Furthermore, providers may need to send the same or similar data to more than one PSO as well as to other public health or health oversight agencies.

The Reality This Challenge Addresses: Hospitals and other health care organizations have multiple adverse event reporting relationships – with 1) the PSO of a national organization or a PSO recently formed through a trusted state hospital association, 2) one or more specialty PSOs (e.g., that concentrate on adverse events associated with lab, anesthesia or medication errors), 3) a state agency that receives reports mandated by the state, and 4) the Food and Drug Administration for reports on regulated medical devices.

Hospitals struggle to increase internal incident reporting, especially by busy care providers, and to create effective systems for the quality and risk management staff to complete root cause analyses and follow-up which are required by both CMS and the Joint Commission. Hospitals enter relationships with PSOs because of Board commitments to quality patient care and a culture of safety. They do this while attesting to Stage 1 of Meaningful Use at a fierce pace. Many Boards intend to use EHRs to drive quality and safety, but they also hear reports about new patient safety hazards associated with the introduction of EHRs.

Quality and risk management staff suffer from reporting fatigue in a paper-based reporting system, which affects reporting frequency and quality – all of their energy is spent on convincing physicians and nurses to report incidents (not just talk about them in the halls), doing enough of an investigation to fill out the appropriate forms, and faxing them to the appropriate agencies.

These reporting issues would be partially alleviated through the deployment of an effective software reporting solution. The solution needs to make it easier for any qualified individual to file a report electronically, using Common Formats but allowing for additional elements and narratives. It must allow the hospital quality and risk management staff to add information from follow-up investigation, submit reports as appropriate to PSOs, the state, or the FDA (which may differ, and need to be tracked separately), and track follow-up activities.

In order to improve our understanding of patient safety issues, it is important to innovate beyond the existing tools so that a new system will:

  1. Collect and analyze information that characterizes patient safety events in a standardized, discrete, measurable way
  2. Increase the rate of reporting of patient safety events and improve the quality of the reported data
  3. Leverage existing health information technology (HIT) to eliminate duplicate data entry, as well as transcription and transposition errors
  4. Analyze patient safety event data to provide useful reports and actionable information to providers and PSOs


The “Reporting Patient Safety Events Challenge” asks multi-disciplinary teams to develop an application that facilitates the reporting of patient safety events, whether implemented in hospital or ambulatory settings. This application would:

  • Increase the ease of reporting patient safety events to the provider or parent organization;
  • Enable providers to import relevant EMR, PHR, and other electronic information, including screen shots, to the patient safety report and, in turn, submit an AHRQ Common Formats-compliant report to one or more PSOs;
  • Capture useful demographic and other relevant information from each patient including age, gender, race, and relevant diagnoses;
  • Capture information about the type of organization submitting the report using AHRQ’s PSO Information format;
  • Reduce burden of reporting by enabling the provider or parent organization to have the option of submitting information in the patient safety report to non-PSO public health or health oversight organizations, including state or federal programs or accrediting or certifying bodies.
  • Be platform-agnostic;
  • Leverage and extend NwHIN standards and services including, but not limited to, transport (Direct, web services), content (Transitions of Care, CCD/CCR), and standardized vocabularies


  • Submission Period Begins: April 12, 2012
  • Submission Period for Entries Ends: August 31, 2012
  • Evaluation Process for Entries Begins: September 6, 2012
  • Evaluation Process for Entries Ends: September 30, 2012
  • Winners notified: October
  • Winners Announced: November 14, 2012

Review Panel

    • Diane Cousins
    • Agency for Healthcare Research and Quality, HHS
    • Amy Helwig
    • Agency for Healthcare Research and Quality, HHS
    • David Hunt
    • HHS
    • Kathy Kenyon
    • HHS
    • Terrie Reed
    • FDA HHS

Evaluation Criteria

The ONC review panel will make selections based upon the following criteria:

  1. Effectiveness of the system in facilitating patient safety event reporting including its compliance with AHRQ’s Common Formats
  2. Usability and design from the standpoint of all stakeholders
  3. Ability to integrate with electronic health records and other HIT data sources
  4. Creativity and innovation
  5. Leverage NwHIN standards including transport, content, and vocabularies

Submission Requirements

In order for an entry to be eligible to win this Challenge, it must meet the following requirements:

  • General – Contestants must provide continuous access to the tool, a detailed description of the tool, instructions on how to install and operate the tool, and system requirements required to run the tool (collectively, “Submission”)
  • Acceptable platforms – The tool must be designed for use with the Web, a personal computer, a mobile handheld device, console, or any platform broadly accessible on the open Internet
  • Data used – Where applicable, the app must utilize 508 or W3C compliant EHR modules and associated data.
  • No ONC logo – The app must not use ONC’s logo or official seal in the Submission, and must not claim endorsement.
  • Functionality/Accuracy – A Submission may be disqualified if the software application fails to function as expressed in the description provided by the user, or if the software application provides inaccurate or incomplete information.
  • Security – Submissions must be free of malware. Contestant agrees that the ONC may conduct testing on the app to determine whether malware or other security threats may be present. ONC may disqualify the app if, in ONC’s judgment, the app may damage government or others’ equipment or operating environment

Participating Teams

IDinc Shands
Decide Mobility
Empower IT
Midas+ Solutions
Morgridge Institute for Researech PSO (MIRPSO)
Healthcare SafetyZone
Active Safety
Hearst Healthcare Incubator
Verge Solutions
iSurgList Team
iSurgList Team
OOPS Gurus
stellar Inc.
Adrian's Endeavour
The App3

Terms & Conditions



SPONSOR:  US Department of Health and Human Services, the Office of the National Coordinator for Health IT ("Sponsor").

ADMINISTRATOR:  The administrator of the Challenge is Health 2.0, LLC, 650 Delancey St, #221, San Francisco, CA 94107 ("Administrator")

CHALLENGE DESCRIPTION:  The Challenge begins at 1:00 PM Eastern Time on Wednesday, April 11, 2012 and ends at 11:59 PM Eastern Time on Friday, August 31, 2012 ("Challenge Period"). The Reporting Patient Safety Events Challenge challenges multidisciplinary teams to develop an application that facilitates the reporting of patient safety events, whether implemented in hospital or ambulatory settings. The teams that submit the winning applications will win: 1.) First Place - $50,000 and a demo opportunity, 2.) Second Place - $15,000 and 3.) Third Pace - $5,000.  Entry into the Challenge does not constitute entry into any other challenge or promotion, including, without limitation, other similar challenges or promotions offered by Sponsor and/or Administrator.  By participating in the Challenge, each entrant unconditionally accepts and agrees to comply with and abide by these Official Rules and the decisions of Sponsor, Administrator, and/or the individual advisors, which shall be final and binding in all respects.

ELIGIBILITY:  To be eligible to win a prize under this challenge, an individual or entity: (a) Shall have registered to participate in the competition under the rules promulgated by the Office of the National Coordinator for Health Information Technology; (b) Shall have complied with all the requirements under this section; (c)  In the case of a private entity, shall be incorporated in and maintain a primary place of business in the United States, and in the case of an individual, participating in a group, shall be a citizen or permanent resident of the United States and 18 years old or older as of the time of entry; and (d) May not be a Federal entity or Federal employee acting within the scope of their employment.  An individual or entity shall not be deemed ineligible because the individual or entity used Federal facilities or consulted with Federal employees during a competition if the facilities and employees are made available to all individuals and entities participating in the competition on an equitable basis.  Employees of Sponsor, Administrator, each of their affiliates, and/or any other individual or entity associated with the development, evaluation, or administration of the Challenge as well as members of such persons' immediate families (spouses, children, siblings, parents), and persons living in the same household as such persons, whether or not related, are not eligible to participate in the Challenge.

HOW TO ENTER:  To enter:  (a) develop an application that facilitates the reporting of patient safety events, whether implemented in hospital or ambulatory settings.  ("Submission"); (b) go to the website located at (the "Challenge Website"), complete the Official Registration Form to officially register for the competition; (c) prior to the submission deadline you will receive additional instructions to submit your entry, a video demonstrating the Submission's capabilities and functionality, and an electronic slide presentation describing the submission according to the instructions posted on the Challenge Website.  You may only enter as part of a team.  Teams must include no less than two (2) people and each team member must be clearly identified on the team's Official Entry Form to be eligible.  All participants are required to provide written consent to the rules upon or before submitting an entry.  Submissions must be received during the Challenge Period to be eligible.  Administrator is the official timekeeper for the Challenge.  No substitutions of new versions of Submissions will be accepted under any circumstances once the original Submission is submitted for consideration.  In the event of a dispute regarding the identity of the individual or team who actually submitted the entry cannot be resolved to Sponsor's and/or Administrator's satisfaction, the affected entry will be deemed ineligible.  Except as otherwise stated in these Official Rules, personal information collected in connection with the Challenge will be used by Sponsor in accordance with Sponsor's privacy policy and by Administrator in accordance with Administrator's privacy policy available on the Website and with any additional consent given by an entrant at the time of entry.  All entry information and materials, including any copy of the Submission submitted to Sponsor, become the property of Sponsor and will not be acknowledged or returned.  Proof of submission is not considered proof of delivery to or receipt of such entry.  Furthermore, Sponsor and Administrator shall have no liability for any Submission that is lost, intercepted, or not received by Sponsor and/or Administrator.  Sponsor and Administrator assume no liability or responsibility for any error, omission, interruption, deletion, theft, or destruction or unauthorized access to, or alteration of, Submissions.

REPRESENTATIONS AND WARRANTIES/INDEMNIFICATION:  By participating in the Challenge, each entrant represents, warrants, and covenants as follows: (a) entrant is the sole author, creator, and owner of the Submission; (b) the Submission is not the subject of any actual or threatened litigation or claim; (c) the Submission does not and will not violate or infringe upon the intellectual property rights, privacy rights, publicity rights, or other legal rights of any third party; (d) the Submission does not and will not contain any harmful computer code (sometimes referred to as "malware," "viruses" or "worms"); and (e) the Submission, and entrants use of the Submission, does not and will not violate any applicable laws or regulations, including, without limitation, applicable export control laws and regulations of the U.S. and other jurisdictions.  If the Submission includes any third party works (such as third party content or open source code), entrant must be able to provide, upon Sponsor and/or Administrator's request, all appropriate licenses and releases for such third party works.  In the event entrant cannot provide all required licenses and releases, Sponsor reserves the right, in Sponsor's sole discretion, to disqualify the applicable Submission, or seek to secure the licenses and releases for Sponsor's benefit and allow the applicable Submission to remain in the Challenge.  Entrants will indemnify, defend, and hold harmless Sponsor and Administrator from and against all third party claims, actions, or proceedings of any kind and from any and all damages, liabilities, costs, and expenses relating to or arising from entrant's Submission or any breach or alleged breach of any of the representations, warranties, and covenants of entrant hereunder.  Sponsor and/or Administrator reserves the right to disqualify any Submission that Sponsor and/or Administrator, in its sole discretion, deems to violate these Official Rules.

SUBMISSION LICENSE:  Each entrant retains title and full ownership in and to their Submission.  Entrant expressly reserves all intellectual property rights not expressly granted under this Agreement.  By participating in the challenge, each entrant hereby irrevocably grants to Sponsor and Administrator a limited, non-exclusive, royalty free, worldwide, license and right to reproduce, publicly perform, publicly display, and use the Submission to the extent necessary to administer the challenge, and to publically perform and publicly display the Submission, including, without limitation, for advertising and promotional purposes relating to the challenge.

PUBLICITY RELEASE:  By participating in the Challenge, in addition to any other grants granted herein or which may be granted in any other agreement entered into between Sponsor and/or Administrator, on the one hand, and any entrant in the Challenge, on the other hand, each entrant hereby irrevocably (a) grants to Sponsor and Administrator the right to use such entrant's name, likeness, image, and biographical information in any and all media for any purpose, including, without limitation, advertising and promotional purposes relating to the Challenge and (b) releases Sponsor and Administrator from any liability with respect thereto.

U.S. GOVERNMENT SUPPORT, RIGHTS, AND WAIVER:   Sponsor and Administrator are administering the Challenge with the support of the U.S. Department of Health & Human Services pursuant to the American COMPETES Reauthorization Act (the "Act").  Subsection (j) of section 24 of the Act establishes that the Government is prohibited from acquiring an interest in intellectual property developed by a participant in a prize competition, such as the Challenge, without the written consent of the participant.  Registered participants shall be required to agree to assume any and all risks and waive claims against the Federal Government and its related entities, except in the case of willful misconduct, for any injury, death, damage, or loss of property, revenue, or profits, whether direct, indirect, or consequential, arising from their participation in a competition, whether the injury, death, damage, or loss arises through negligence or otherwise. Participants shall be required to obtain liability insurance or demonstrate financial responsibility, in amounts determined by the head of the Office of the National Coordinator for Health Information Technology, for claims by (a) a third party for death, bodily injury, or property damage, or loss resulting from an activity carried out in connection with participation in a competition, with the Federal Government named as an additional insured under the registered participant's insurance policy and registered participants agreeing to indemnify the Federal Government against third party claims for damages arising from or related to competition activities; and (b) the Federal Government for damage or loss to Government property resulting from such an activity.

WINNER SELECTION/EVALUATION CRITERIA:  The ONC review panel will make selections based upon the following criteria:

  1. Effectiveness of the system in facilitating patient safety event reporting including its compliance with AHRQ’s Common Formats
  2. Usability and design from the standpoint of all stakeholders
  3. Ability to integrate with electronic health records and other HIT data sources
  4. Creativity and innovation
  5. Leverage NwHIN standards including transport, content, and vocabularies

The evaluation criteria are to be applied in the sole discretion of Sponsor and the individual advisors.  By participating in the Challenge, each entrant into the Challenge acknowledges and agrees that such evaluations may differ from person to person and agrees to be bound by and not challenge the final decisions of Sponsor and the individual advisors.

NOTICE TO WINNERS:  Attempts to notify potential winners will be made using the contact information provided on the winner's Official Entry Form.  Sponsor and Administrator are not responsible for e-mail or other communication problems of any kind.  If, despite reasonable efforts, a potential winner does not respond within five (5) days of the first notification attempt (or a shorter time as exigencies may require), or if the prize or prize notification is returned as unclaimed or undeliverable to such potential winner, such potential winner will forfeit his or her prize and an alternate winner may be selected.  If any potential prize winner is found to be ineligible, or if he or she has not complied with these Official Rules or declines the applicable prize for any reason prior to award, such potential prize winner will be disqualified and an alternate winner may be selected.  Sponsor may successively attempt to contact up to two (2) potential prize winners in accordance with such procedure, and if there is still no confirmed prize winner after such attempts have been made, if any, the applicable prize may go unawarded.

ANTICIPATED NUMBER OF ENTRANTS:  Many will enter, three winning submissions will be selected.  Actual odds of winning depend on the number of eligible entries received.  Sponsor and Administrator cannot accurately predict the number of entrants who will participate in the Challenge. 

PRIZES:  The winning teams will receive: 1.) First Place - $50,000 and a demo opportunity 2.) Second Place - $15,000 and 3.) Third Pace - $5,000.

GENERAL PRIZE CONDITIONS:  The potential winner may be required to execute an Affidavit of Eligibility, a Liability Release and (where imposing such condition is legal) a Publicity Release (collectively "Prize Claim Documents).  If a winner fails or refuses to sign and return all Prize Claim Documents within five (5) days of Sponsor's and/or Administrator's request (or a shorter time as exigencies may require), the winner may be disqualified and an alternate winner may be selected.  No more than the advertised number of prizes will be awarded.  Prizes will be delivered only to an address in the U.S.  No cash alternative or substitution or transfer of prizes will be allowed, except Sponsor reserves the right in its sole discretion to substitute prizes of comparable value, in whole or in part, for any reason.  THE WINNER IS RESPONSIBLE FOR REPORTING AND PAYING ANY INCOME TAXES OR OTHER TAXES THAT MAY APPLY TO ACCEPTING A PRIZE; SPONSOR AND ADMINISTRATOR ARE NOT RESPONSIBLE FOR AND WILL NOT PAY ANY SUCH TAXES.

DATES/DEADLINES:  Because of the unique nature and scope of the Challenge, Sponsor and Administrator reserve the right, in addition to those other rights reserved herein, to modify any dates or deadlines set forth in these Official Rules or otherwise governing the Challenge.

GENERAL LIABILITY RELEASE/FORCE MAJEURE:  Each entrant agrees that Sponsor and Administrator (a) shall not be responsible or liable for any losses, damages, or injuries of any kind (including death) resulting from participation in the Challenge or any Challenge-related activity, or from entrants' acceptance, receipt, possession, use, or misuse of any prize, and (b) have not made any warranty, representation, or guarantee, express or implied, in fact or in law, with respect to any prize, including, without limitation, regarding such prize's merchantability or fitness for a particular purpose.  Entrants will indemnify, defend, and hold harmless Sponsor and Administrator from and against all third party claims, actions, or proceedings of any kind and from any and all damages, liabilities, costs, and expenses relating to or arising from entrant's participation in the Challenge.  Sponsor and Administrator assumes no responsibility for any damage to an entrant's computer system which is occasioned by accessing the Website or other Challenge-related websites or participating in the Challenge, or for any computer system, phone line, hardware, software, or program malfunctions, or other errors, failures, delayed computer transmissions, or network connections that are human or technical in nature.  Without limiting the generality of the foregoing, Sponsor and Administrator are not responsible for incomplete, illegible, misdirected, misprinted, late, lost, postage-due, damaged, or stolen entries or prize notifications; or for lost, interrupted, inaccessible, or unavailable networks, servers, satellites, Internet Service Providers, websites, or other connections; or for miscommunications, failed, jumbled, scrambled, delayed, or misdirected computer, telephone, cable transmissions or other communications; or for any technical malfunctions, failures, difficulties, or other errors of any kind or nature; or for the incorrect or inaccurate capture of information, or the failure to capture any information.  Sponsor and Administrator each reserve the right in their sole discretion to disqualify any individual who is found to be tampering with the entry process or the operation of the Challenge or Website or other Challenge-related websites, to be acting in violation of these Official Rules, or to be acting in an unsportsmanlike or disruptive manner, or with the intent to disrupt or undermine the legitimate operation of the Challenge, or to annoy, abuse, threaten, or harass any other person, and Sponsor and Administrator each reserve the right to seek damages and other remedies from any such person to the fullest extent permitted by law.  In the event an insufficient number of eligible entries are received or Sponsor and/or Administrator is prevented from awarding the prize or continuing with the Challenge as contemplated herein by any event beyond its control, including, without limitation, fire, flood, natural or man-made epidemic, earthquake, explosion, labor dispute or strike, act of God or public enemy, satellite or equipment failure, riot or civil disturbance, terrorist threat or activity, war (declared or undeclared) or any federal state or local government law, order, or regulation, public health crisis, order of any court or jurisdiction, or other cause not reasonably within Sponsor's control ("Force Majeure"), Sponsor and/or Administrator shall have the right to modify, suspend, or terminate the Challenge.  If the Challenge is terminated for Force Majeure before expiration of the Challenge Period, Sponsor and/or Administrator will (if reasonably possible) select a winner from all eligible, non-suspect entries received as of the date of the event giving rise to the termination.  These Official Rules cannot be modified or amended in any way except in a written document issued in accordance with the law by a duly authorized representative of both Sponsor and Administrator.  The invalidity or unenforceability of any provision of these Official Rules shall not affect the validity or enforceability of any other provision.  In the event that any provision is determined to be invalid or otherwise unenforceable or illegal, these Official Rules shall otherwise remain in effect and shall be construed in accordance with their terms as if the invalid or illegal provision were not contained herein.

GOVERNING LAW/JURISDICTION:  All issues and questions concerning the construction, validity, interpretation, and enforceability of these Official Rules or the rights and obligations of entrants, Sponsor and/or Administrator in connection with the Challenge shall be governed by and construed in accordance with the laws of the State of California without giving effect to any choice of law or conflict of laws rules or provisions.  Any legal claims arising from or relating to the Challenge or these Official Rules must be brought in the federal or state courts located in San Francisco, California.

WINNERS LIST/OFFICIAL RULES:  To obtain any legally-required winners list (after the conclusion of the Challenge) or a copy of these Official Rules, send a self-addressed envelope with the proper postage affixed to:  Health 2.0, LLC, Attn: Health 2.0 Developer Challenges, 650 Delancey Street #221, San Francisco, CA 94107.  Please specify "winners list" or "Official Rules" and the name of the specific Challenge in your request.

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