… and developmental) rather than performance goals. … Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf . …

Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is limited if adverse events (AE) go unreported. In this study, researchers compared rates of AE submitted to the VER against those identified using the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool to identify disparities based on patient characteristics (i.e., weight, race, English proficiency). The GAPPS tool identified 37 AE in patients with limited English proficiency; none of these were reported to the VER system, suggesting a systematic underreporting of AE in this population.

Previous research has identified an association between patient weight and certain adverse events and patient safety threats, such as medication dosing errors and airway management. After analyzing data for pediatric patients discharged from a single children’s hospital, researchers in this study did not identify an association between patient body mass index (BMI) and the rate, severity, or preventability of adverse events.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Patient safety efforts increasingly seek patient input and engagement to improve care. In this qualitative study, patients and families reported on recent hospitalizations and their perceptions of their care and safety. Four main themes were elicited: (1) experiences with safety problems were not unusual, (2) patients and families developed “care stories” about their experiences, (3) there was a spectrum of trust between patients and providers, and (4) having someone advocate for them was important.

Patients and caregivers should be actively engaged in identifying and preventing patient safety events. This article describes the process of designing an app to engage patients and their caregivers in decision making that might impact safety.  The authors note important themes arising from this process, including appropriate messaging for patients, creating an app promotes actions (such as suggesting questions), and presenting information accessible for a lay audience.

A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.

The groundbreaking National Academy of Medicine report Unequal Treatment highlighted the pervasive nature of racial and ethnic disparities in United States health care. Racial and ethnic minorities experience more adverse events, including adverse drug events and hospital-acquired infections. Investigators used a pediatric global trigger tool to delineate disparities in safety events for a large, random sample of pediatric patients across 16 hospitals (4 hospitals in each US region). Latino children experienced nearly twice the rate of adverse events when compared with white children. Publicly insured children also had a higher adverse event rate. An accompanying editorial reviews study limitations and highlights the need to develop risk-prediction models for different types of adverse events.

Most health care organizations primarily rely on retrospective techniques such as incident reporting systems to detect and respond to patient harm. Retrospective techniques do not capture a substantial proportion of patient safety events and are not effective for real-time feedback or safety incident prevention. By contrast, electronic health record–based trigger tools detect safety incidents in real time. Investigators developed and piloted the patient safety active management (PSAM) at two large community hospitals. The PSAM employed machine learning and expert clinician review of years of adverse event data to refine the Institute for Healthcare Improvement Global Trigger Tool and distilled this into a real-time risk score for patient safety incidents. The PSAM identified 10 times more safety incidents than were detected through retrospective techniques. It reliably predicted both serious adverse events and mortality. A prior PSNet perspective explored how to leverage electronic health records to enhance safety. The Moore Foundation provides free access to this article.

This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.

The Centers for Medicare and Medicaid Services (CMS) has successfully reduced preventable harm from hospital-acquired conditions (HACs) through financial penalties to hospitals. Hospitals nationwide have invested substantial resources in reducing the HACs on the CMS nonpayment list, raising concern about whether institutions may be neglecting other types of preventable harm. Researchers used an all-cause harm trigger tool to assess what proportion of harms that occurred at six children's hospitals were HACs versus harms excluded from the CMS list. Only 58 of 240 harms were considered HACs. Some common harms identified outside the scope of HACs were intravenous catheter infiltration, surgical complications, and pain. Prior WebM&M commentaries have discussed harms from hospital-acquired infections as well as the unintended consequences of public hospital quality reporting.

This retrospective cohort study identified frequent treatment-related adverse events for patients with breast, colorectal, or lung cancer, with 34% of patients experiencing an adverse event during their treatment course. Advanced disease and chemotherapy conferred higher risk for adverse events, as did non-White race and Hispanic ethnicity. The authors suggest that such factors could be used for prospective identification of patients at highest risk for adverse events.

Trigger tools harness electronic health record data to detect and ameliorate safety hazards. Triggers can identify errors in a specific area or more globally measure an organization's safety. Researchers at a large community hospital developed a robust trigger tool to measure all-cause patient harm and assessed what predicted lower all-cause harm at the unit level. Units with increased employee engagement, stronger safety culture, and better patient experience were all correlated with lower rates of all-cause harm. The authors suggest that their tool could serve as a composite measure of patient safety, replacing the hundreds of safety metrics institutions are required to report. A PSNet perspective reinforced the value of a strong safety culture and discussed techniques for bringing about culture change.

Cancer care has been the setting for seminal, practice-changing errors. This retrospective study aimed to identify adverse events in cancer care through medical record review, using a random sample of breast, colorectal, and lung cancer cases from 2012. As with prior studies, physician investigators determined preventability and extent of harm. Over a third of patients experienced an adverse event, and about 32% of adverse events were deemed preventable. Most adverse events occurred in the inpatient setting. Adverse events included medication errors and hospital-acquired conditions, such as pressure ulcers and falls. The authors conclude that patient safety remains an important consideration for cancer care that merits further research and improvement efforts.

… events in oncology . A past PSNet interview featured David Classen, one of the pioneers of the trigger tool methodology …

Trigger tools seek to identify adverse events by flagging cases for review based on a particular data point (the "trigger"). Investigators, working through a Patient Safety Organization, sought an alternative to the widely used Institute for Healthcare Improvement Global Trigger Tool, one that would require less time and fewer resources. They developed a single, automated trigger encompassing a multitude of possible harms that could be implemented in real time. The most common harm identified by the novel trigger tool was hypoglycemia. The authors note that their tool detected more adverse events than the AHRQ Patient Safety Indicators. An accompanying editorial lauds this study as a step forward in efforts to harness the electronic health records to enhance patient safety through data analysis.

Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.

Centralized reporting of adverse events data is seen as a cornerstone to learning and safety improvement. This commentary introduces the Patient Safety Organization program, including its work to collect data using the standardized common formats system and the future role of the program.

The Medicare Patient Safety Monitoring System was developed to track adverse events nationally to support robust safety improvement. This review summarizes the history of the Medicare Patient Safety Monitoring System and its evolution into a new system that seeks to enhance the standardization and utilization of the collected data.

Although computerized provider order entry (CPOE) for medications has reduced medication errors, it has also had unintended consequences. This simulation study used the validated Leapfrog evaluation tool to assess the safety of CPOE for medications for pediatric patients across multiple electronic health record (EHR) platforms. The investigators had clinicians familiar with the EHR enter prespecified unsafe orders into simulated patient records and note whether alerts or messages ensued. As demonstrated in prior work, many potentially unsafe medication orders did not lead to alerts. The authors report that repeated use of the tool led to improvement over time, which suggests the need for regular safety testing for EHRs after implementation.