Checklists are widely utilized in health care to promote patient safety. Management of trauma patients is complex, and checklists may facilitate adherence to known standards of care. This pre–post study looked at the impact of the World Health Organization Trauma Care Checklist program across 11 hospitals in 9 countries. Researchers found that adherence to 18 out of 19 care process measures improved after the checklist program was implemented. Although investigators discerned no difference in mortality for the overall study population, they found a 50% reduction in mortality for patients with more severe trauma injuries after implementation of the program. A prior PSNet perspective discussed components of an effective checklist.

Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.

This narrative review provides a broad perspective on the current understanding of medical errors and the evidence behind commonly adopted prevention strategies. The authors then highlight a series of recommendations to improve patient safety.

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.

Warfarin therapy is frequently associated with adverse drug events. Past efforts to identify potential prevention strategies have focused on using specific indicators or triggers to detect such events. This study examined more than 9000 errors in warfarin use submitted voluntarily through MEDMARX, a database that tracks medication information from participating hospitals. Investigators discovered that inpatient warfarin-related errors occurred most frequently during transcription/documentation and administration, while outpatient errors occurred most frequently during prescribing and dispensing. Using warfarin data as an example, the authors discuss the utility of voluntary error reporting systems and outline the limitations in their use.

This study demonstrated the value of hierarchically optimal classification tree analysis as a promising method for evaluating and providing surveillance of administrative data for adverse drug events.

This study showed that inverse probability weighting demonstrated less bias than conventional regression methods in analyzing the impact of adverse events on hospital length of stay.

Medical errors have been estimated to cost the US health care system more than $17 billion per year, but whether those costs are borne by patients, hospitals, or insurers is not clear. This economic analysis used administrative data to identify adverse events during hospitalizations, determine the Medicare payments made for hospital claims, and estimate the excess payments made for hospitalizations in which an adverse event occurred. The analysis revealed that adverse events account for a small but significant proportion of overall Medicare hospital spending. Contrary to a prior study, these data revealed that hospitals generally do not receive additional compensation when an error occurs. The authors argue that both individual hospitals and the health care system stand to benefit economically from improving patient safety.

… after thoracentesis, but also during other procedures. … Zhan C, Smith M, Stryer D. Accidental iatrogenic pneumothorax in hospitalized …

The investigators from the Agency for Healthcare Research and Quality (AHRQ) and United States Pharmacopeia (USP) compared MedMarx reports from facilities using computerized prescriber order entry (CPOE) with those utilizing conventional methods of ordering.

This AHRQ-supported study discovered few existing relationships between the Joint Commission on Accreditation of Healthcare Organizations accreditation scores and AHRQ’s Inpatient Quality and Patient Safety Indicators (IQIs/PSIs). Given the increasing focus on public reporting of such information to guide consumers in making health care choices, the investigators sought to determine if current reports of accreditation scores reflect more recent and evidence-based IQIs/PSIs. Discussion includes detailed analyses illustrating the relationships, or lack thereof, between the different systems. While many argue that accreditation and performance measurement capture different aspects of quality and safety, this study suggests a need for greater vigilance in defining how and what to measure if the goal is to provide an accurate representation of quality and safety to the public.

This AHRQ–funded study estimates the national prevalence of adverse drug events by capturing data from outpatient physician visits. Using survey data, investigators report on more than 4 million office visits associated with a diagnostic code for an adverse drug event. Although upward trends over time were not statistically significant, the authors conclude that their findings and methods may offer a mechanism for continued tracking of this important safety concern on a national level.

This AHRQ-funded study illustrates potentially harmful drug-drug and drug-disease combinations that occur in ambulatory care in the elderly population. Solutions are provided for minimizing the opportunities for harm associated with these combinations.

… will help improve assessment in the future. … Zhan C, Kelley E, Yang HP, et al. Assessing patient safety in the United …

Using the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, this study identified medial injuries from more than 7.4 million hospital discharge abstracts. Investigators determined significant variability in both the need for extended hospitalization and the associated costs depending on the specific injury experienced. Building on past work reflecting data from individual institutions (Classen et al and Bates et al), the authors here share specific estimates for excess length of stay, charges, and mortality due to 18 specific types of medical injuries analyzed in nearly 1000 hospitals across the country. For example, infection due to medical care resulted in more than 9.5 extra hospital days, nearly $40,000 in excess charges, and 4.3% attributable mortality.