… validity concerns in estimating adverse event rates. … Boussat B, Quan H, Labarere J, et al. Int J Qual Health Care. Epub 2021 Feb 6. …

This commentary discusses the challenges associated with detecting and measuring adverse events, the limitations of measurement alone, and the existing methodologies that can be leveraged to improve the accuracy of adverse event detection.

… negative predictive value (meaning that the absence of a PSI meant that the patient likely had not experienced an …

This systematic review found that while interventions designed to improve inpatient documentation within electronic health records (EHRs) are highly varied, education and EHR reporting systems seem to be more effective in improving electronic documentation for hospitalized patients than other efforts.

… … BMJ Qual Saf … This study examined the implementation of a tool integrated into the electronic health record to export … high sensitivity and specificity when compared to a chart audit and identified a higher proportion of adverse surgical events than …

… PloS one … PLoS One … This study describes how a French hospital implemented a multidisciplinary root cause analysis infrastructure called …

… Preventing adverse events after hospital discharge remains a top patient safety priority. In this randomized controlled …

… time, the World Health Organization ICD-11 will include a taxonomy for quality and safety events . Researchers … safety vignettes gleaned from sources such as AHRQ WebM&M, then they described its strengths and limitations. … detection of errors, adverse events, and near misses on a population level. …

… in the accuracy of PSIs, they have been widely employed as a quality metric. The implementation of ICD-10 and diagnosis timing codes necessitate development of a new set of PSIs. This consensus and validation study used a Delphi panel process to determine ICD-10 codes associated …

… BMJ open … BMJ Open … Patient-centeredness is considered a crucial aspect of high quality care. Patient satisfaction …

Patient reports of adverse outcomes are one critical method to detect safety hazards. This study used patient reports of adverse outcomes to develop a framework for identifying adverse events. The authors suggest that patient reports could be used as a trigger tool to prompt review of cases for adverse events.

… improved codes for adverse events and diagnosis timing. A related study outlines the recommendations made by the …

… BMJ quality & safety … BMJ Qual Saf … Innovation within a health care system can be hindered when different … and funding. This commentary discusses insights from a health system that, due to restructuring, found various …

This commentary introduces the justifications for and processes being used to expand the current ICD program to map existing safety classification schemes, like the AHRQ common formats and the WHO taxonomy, to augment data collection of hospital-related harm.

Several AHRQ patient safety indicators had acceptable positive predictive value for identifying adverse events when tested using the new ICD-10 administrative coding system.

Clinical care handoffs occur multiple times every day for each hospitalized patient, and the use of information technology has been advocated as a means of standardizing and improving the quality of handoffs. Although this systematic review identified six controlled studies of computerized handoff tools, it found only limited evidence linking use of such a tool to improved patient outcomes. The available evidence (including a recently published study that was not included in this review) does indicate that computerized handoff tools improve the accuracy and completeness of physician tools, and may improve physician efficiency. A case of a preventable adverse event due to suboptimal handover is discussed in this AHRQ WebM&M commentary.

Physicians and patients generally expressed satisfaction with the handoff process when patients were transferred from the intensive care unit to the general ward. However, direct verbal communication occurred in only a small minority of cases, and several preventable errors did occur, implying the need for a more standardized process.

This systematic review noted that computer-enabled discharge communication appears beneficial for timeliness, accuracy, and provider/patient satisfaction, but its impact on mortality and readmissions is less studied.

This study applied the AHRQ patient safety indicators (PSIs) to acute care hospitals internationally and discovered that certain indicators (e.g., birth trauma and complications of anesthesia) may be unreliable for comparison. However, the authors suggest that publishing comparable international data is feasible after addressing the global challenges with data reliability and quality. The latter is complicated by suspected variations in coding and clinical documentation that require further investigation.

In this single-institution study, surgeon fatigue (defined as having performed clinical services after 10 PM the night before performing rectal cancer surgery) was not associated with adverse clinical outcomes.