Incident reporting systems offer important opportunities for health systems to learn from safety events and improve outcomes. This systematic review of 22 studies identified barriers and facilitators influencing how health systems use and learn from incident reporting systems. Barriers included inadequate organizational support and resources, weak safety culture, lack of training and feedback, and a punitive environment. Factors supporting continuous improvement based on incident reporting systems included continuous training for staff, a just culture, leadership investment, and tangible improvements stemming from incident analysis.

The COVID-19 pandemic had wide-ranging impacts on care delivery and patient safety. This study examined the relationship between critical care clinician experiences related to patient safety during the pandemic and COVID-19 caseloads during the pandemic. Findings suggest that as COVID-19 caseloads increased, clinicians were more likely to perceive care as less safe.

Performance feedback is an essential component of patient safety and quality improvement. In this participatory study, researchers engaged hospitalists in design sessions and surveys to develop a performance dashboard and feedback system. Physicians preferred that the dashboard be used to aid in clinical practice improvement as part of a non-punitive system.

The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are widely used for measuring and reporting hospital quality and patient safety. This paper describes the process of reweighing the composite patient safety indicator (PSI 90) to incorporate excess harm reflecting patients’ preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). Compared to the original frequency-based weighting, some component indicators in the reweighted composite – including postoperative respiratory failure, postoperative sepsis, and perioperative pulmonary embolism or deep vein thrombosis – contributed to the greatest harm.

… strengthening dual diagnosis detection. … Calder LA, Perry J, Yan JW, et al. Adverse events among emergency department patients with cardiovascular conditions: a multicenter study. Ann Emerg Med. Epub 2021 Feb 23. doi: 10.1016/j.annemergmed.2020.12.012. …

… Int J Qual Health Care … Prior research has raised concerns about … PSI measurement with administrative data, manual review of a subsample of charts, and validity adjustment, and found … concerns in estimating adverse event rates. … Boussat B, Quan H, Labarere J, et al. Int J Qual Health Care. Epub 2021 …

Clinical decision support (CDS) alerts can improve patient safety, and prior research suggests that monitoring alert overrides can identify errors. The researchers describe a novel approach to using existing CDS systems to detect medication prescribing errors based on drug-drug interaction and allergy alert overrides. Dose alert overrides had high sensitivity to detect medication prescribing errors occurring in an inpatient setting.

… J Hosp Med … Based on a survey of hospital medicine groups at … in patients admitted for other reasons). … Auerbach A, O'Leary KJ, Greysen SR, et al. Hospital ward adaptation during the COVID-19 pandemic: a national …

Researchers in this multicenter cohort study found that 19% of patients experienced an adverse event during the transition from the intensive care unit (ICU)  to the hospital ward, with most (62%) occurring within three days of transfer. Compared to patients who did not experience an adverse events, those with adverse events were at increased risk for negative outcomes including ICU readmission, increased length of stay and inpatient morality. Approximately one-third (36%) of these events were deemed preventable by the research team.

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.

Medication reconciliation aims to prevent adverse events after hospital discharge. In this cluster randomized trial, researchers evaluated the impact of an electronic medication reconciliation intervention involving automatic integration of community drug data and found that this process reduced medication discrepancies but did not reduce adverse events. 

The AHRQ Patient Safety Indicators (PSIs), which are used to screen administrative data for patient safety events, have been revised in response to the new ICD-10 coding system. This study sought to validate the accuracy of ICD-10-based PSIs for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program reference standard. Although the PSIs had relatively high negative predictive value (meaning that the absence of a PSI meant that the patient likely had not experienced an adverse event), the overall accuracy was not sufficient to warrant using PSIs as the sole strategy to detect adverse events.

… J Am Med Inform Assoc … J Am Med Inform Assoc … This systematic review found that …

The just culture paradigm shifts the response to error from a retrospective focus on blame to the system that contributed to the incident. This commentary describes one hospital's strategic and operational approach to just culture development and the results of the initiative.

This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.

This prospective study used a trigger tool approach to identify potential adverse events among hospitalized patients in real time. Researchers found widely varying adverse rates among the five hospitals and concluded that event detection among the trigger event reviewers was responsible for some of the variation in observed events. These results underscore the challenge of accurate adverse event surveillance.

This study examined the implementation of a tool integrated into the electronic health record to export surgical discharge data to an adverse event reporting platform. The tool demonstrated high sensitivity and specificity when compared to a chart audit and identified a higher proportion of adverse surgical events than traditional reporting mechanisms. The authors recommend implementation of these automated reporting mechanisms.

Preventing adverse events after hospital discharge remains a top patient safety priority. In this randomized controlled trial, researchers found that the implementation of an electronic discharge communication tool did not significantly reduce death or readmission within 90 days of discharge.