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.

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 review uses a case study as a platform to discuss the role of medication reconciliation, pharmacist engagement, and other strategies to prevent and disclose medical errors in critically ill patients.

This study developed a taxonomy for coding patient complaints to provide opportunities for quality improvement in patient care and satisfaction.

This study discovered that patients isolated for colonization or infection with methicillin-resistant Staphylococcus aureus suffered more preventable adverse events, less satisfaction with care, and less documentation for their care, but no difference in mortality compared to a control group. Examples of the reported differences in care quality included absence of accurately recorded vital signs, missing daily physician progress notes, and less delivery of disease-specific standards for heart failure management. While safety precautions and isolation of selected patients certainly reduce the transmission of communicable infections, a potential patient safety issue results from the care these patients receive once isolated—an unintended adverse consequence.