Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

… J Cardiac Failure … Misdiagnosis of cardiovascular conditions … obstructive pulmonary disease (COPD). … Wong CW, Tafuro J, Azam Z, et al. Misdiagnosis of heart failure: a systematic …

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

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.

The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.

Engaging patients in health care–acquired infection (HAI) prevention, such as asking providers about hand hygiene compliance, has shown promise. This commentary recommends providing patients with information about infection risks and hospital policies as additional areas to involve patients in reducing HAIs.

The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.

The continued progress in eliminating central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) stands as one of the patient safety movement's major successes. The initial efforts to prevent CLABSI in the ICU at Johns Hopkins Hospital, championed by Dr. Peter Pronovost, were subsequently replicated in the landmark Keystone ICU project in Michigan. This study describes the results of an AHRQ-funded effort to extend the Keystone ICU approach nationwide, attempting to prevent infections in more than 1000 ICUs in 44 states. The initiative, which combined the well-publicized infection control checklist with interventions to enhance safety culture (such as the comprehensive unit-based safety program) and continuous data measurement and feedback, achieved a reduction in CLABSI rates of more than 40%. This remarkable series of interventions exemplifies the value of using a sociotechnical approach to improving safety and has likely saved thousands of lives.

All hospitals are required to maintain a voluntary error reporting system, and such systems serve an important role in detecting safety problems. However, prior research has extensively documented the limitations of such systems. The success of a reporting system rests on four key components, including a supportive safety culture and an effective mechanism for acting on reported issues. This AHRQ-funded survey of risk managers found that most hospitals' systems did not meet these effectiveness criteria, although some improvement had taken place between 2005 and 2009. Proposals for improving the utility of error reporting systems are advanced in a recent AHRQ WebM&M perspective and interview.

Controversy exists regarding whether children should be required to undergo an electrocardiogram before participating in competitive sports. This study found a significant rate of diagnostic error among pediatric cardiologists in the interpretation of abnormal screening electrocardiograms.

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.