… stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents …

Preventable harm encompasses both physical injury and emotional harm to patients and families. Increasingly, the Agency for Healthcare Research and Quality, researchers, and patient advocacy groups have focused on studying and preventing emotional harm. Researchers convened a multidisciplinary expert group to identify best practices for enhancing respect and reducing emotional harm in health care. The group determined 25 strategies, including leading with an emphasis on respect and dignity, promoting accountability, partnering with patients, and supporting frontline staff. They provide a list of practical tactics to shift health care organizations toward a more respectful and just culture. A PSNet perspective examined how to accelerate organizational culture change in health care.

Under the Centers for Medicare and Medicaid Service Hospital Readmissions Reduction Program, hospitals are subject to nonpayment if patients with certain medical conditions are readmitted. Research supports the effectiveness of this program in decreasing readmissions and some have argued for expansion to a hospital-wide readmission measure. Using Medicare claims data, investigators concluded that transitioning to a hospital-wide readmission measure would lead to greater penalties for safety-net hospitals compared to other hospitals, a concern that has been raised with regard to Medicare's Hospital-Acquired Condition Program.

A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.

Patient engagement is increasingly recognized as a priority for patient safety efforts. This study team developed and tested a reporting system for patients and families to bring safety concerns to the attention of health care systems. Only 37 errors were reported during the study period of 17 months; most reports did not involve patient harm. As with prior studies of patient safety reporting, not all reports were related to a safety concern. The most common category of mistakes reported was problems with diagnosis or advice from a provider. These results demonstrate the feasibility of implementing an incident reporting system for patients and families, and they underscore the need to focus on diagnostic safety in outpatient settings. A past PSNet interview featured Dave deBronkart, a leading advocate for engaging patients in their care.

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.

The Centers for Medicare and Medicaid Service's policy on nonpayment for certain hospital readmissions has reduced their incidence. However, this policy change may have unintended consequences. One possible outcome is an increased number of patients who return to the hospital being placed on observation status. Comparing readmission rates and observation stays for targeted and nontargeted conditions, this secondary data analysis examined how observation stay rates changed in parallel with readmission rates. The authors found that readmissions decreased, consistent with prior studies, and observation stays increased. Interestingly, a within-hospital analysis determined that the decline in readmissions was not explained by an increase in observation stays. This finding should allay concerns about this specific unintended consequence of the readmission policy, although other issues such as length of stay changes should be addressed.

In order to characterize outpatient safety, this study of small- and medium-sized ambulatory clinics surveyed administrators about organizational safety and staff about communication and existing safety processes. Administrators reported a lack of safety systems, consistent with prior discussion of ambulatory settings. As with earlier research in hospitals, frontline staff describe difficulty speaking up about errors. Staff responses suggested that insufficient time to manage their workload leads to safety problems, echoing a recent focus group study of physicians. Respondents also reported weaknesses in outpatient referral processes. Overall, staff and administrators in ambulatory practices continue to identify gaps in care that contribute to adverse events, highlighting opportunities to improve safety in primary care settings. A recent AHRQ WebM&M interview and perspective discuss patient safety in ambulatory care.

Hospital-wide mortality rates are widely used as a marker of health care quality, but it remains unclear how to most accurately measure them. In this classic study, investigators provided standard hospital discharge data to four vendors who independently calculated hospital mortality rates. These methods produced varying rates of hospital mortality, and classification of hospitals as either higher or lower than average differed depending on the estimation method. These findings demonstrate that in-hospital mortality remains difficult to estimate and underscore the need for caution in considering it a marker of hospital care quality.

A recent systematic review found that better patient experiences of care are associated with improved patient safety and quality of care. This survey of more than 2500 adults discharged from 16 hospitals in Massachusetts adds to our understanding of this relationship. Patients who self-reported having experienced an adverse event (AE) while hospitalized rated the overall quality of hospital care lower, but this finding was primarily among patients who did not report that the AE they experienced was explicitly disclosed to them. Among patients who experienced an AE, it appeared that patient satisfaction was highest (and nearly equal to satisfaction of patients with error-free hospitalizations) when the error was disclosed, the patients were engaged in their own care, and discharge was perceived as timely. These findings imply that even when patients experience complications, "service recovery" efforts, such as formal error disclosure programs, can positively affect patients' perceptions of the care quality.

Recognizing and weighing harms associated with treatment is a core aspect of patient safety. Recently, low-dose computed tomography (LDCT) screening for lung cancer has been promoted by the 20% relative reduction in lung cancer-specific mortality found in a large clinical trial. This study evaluated National Lung Cancer Screening Trial data to determine an estimate of LDCT-detected lung cancer that would not otherwise become clinically apparent—or cancer overdiagnosis. Using these calculations, approximately 20% of cancers detected by LDCT screening represented overdiagnosis. From a research perspective, this study advances our understanding of the measurement of overdiagnosis, and this approach may also be useful for evaluating overdiagnosis of other conditions. A recent AHRQ WebM&M interview with Dr. Rebecca Smith-Bindman discussed radiation safety and the implications of increasing use of CT scans.

Being admitted to the hospital on a weekend is potentially dangerous, as studies have shown that preventable complications and mortality are increased across a range of common diagnoses for weekend admissions compared with weekdays. One exception appears to be trauma, as a prior study found equal outcomes in patients with traumatic injuries regardless of the day of admission, a finding ascribed to the protocolized and closely supervised nature of trauma care. However, this study of older adults admitted with traumatic brain injury did find increased mortality for those patients admitted on the weekend, despite the fact that patients admitted on the weekend were less severely injured. A limitation of this study is that the authors were not able to analyze outcomes for patients cared for at specialized trauma centers. Nevertheless, the study adds to the considerable body of research documenting the dangers of weekend hospital admission.

This study noted that nearly 80% of surveyed resident and attending physicians experienced a serious emotional stressor in the past year. Medical errors and adverse events were significant contributing factors, leading the authors to advocate for greater peer support to address these needs.

Mortality after inpatient surgery varies widely between hospitals, with much of this variation thought to be due to differences in how well hospitals treat specific postoperative complications. This study of nearly 80,000 Medicare patients sought to determine whether implementation of the National Quality Forum's (NQF) Safe Practices for Better Healthcare was associated with more effective treatment of postoperative complications. The authors found that hospitals that had fully implemented the safe practices had a lower incidence of failure to rescue and lower overall postoperative mortality. Although a prior study found that adoption of the NQF recommendations was not associated with improved mortality, that study was not able to distinguish between full or partial implementation of the NQF safe practices, as was done in this study.

Traditional methods of error detection have relied mainly on provider input or administrative data, without emphasizing the role of the patient in safety. This study of more than 2000 patients recently discharged from Massachusetts hospitals found that patients could identify unique adverse effects of hospitalization that may not have been identified by other methods. Importantly, physician reviewers agreed that the patient-reported events constituted a true clinical adverse event in more than 70% of cases. This finding corroborates prior research showing that patient-reported adverse events provide an important complementary perspective in assessing organizational safety problems.

In this analysis of nearly 200,000 electronic prescriptions, more than 20% were not filled by the patient. This phenomenon, termed primary medication non-adherence, was particularly common for medications for chronic conditions such as diabetes and hypertension.

… Dr. Robert Wachter, discusses the importance of this study's findings while reflecting on the 10-year anniversary of the landmark IOM report . A past AHRQ WebM&M conversation and  perspective also discussed the many …

This study surveyed more than 700 board chairs and found that fewer than half rated quality as one of their top two priorities. Few board chairs reported any dedicated training in quality, and large differences were present between board activities in high-performing versus low-performing hospitals. The latter provides opportunities for future intervention and policy change.

… decision support systems are discussed in an AHRQ WebM&M perspective . …

The full potential of computerized provider order entry (CPOE) systems to prevent potentially harmful errors may require concomitant use of decision support–alerts or reminders for providers. This analysis of over 270,000 prescriptions from a commercial outpatient prescribing application found that more than 400 adverse drug events (ADEs) were likely prevented by such alerts. More than 300 alerts were required to prevent one ADE, so in order to combat alert fatigue, the authors recommend reducing or eliminating alerts with little clinical value. A related editorial discusses the current state of electronic prescribing systems in the context of recent policy initiatives. The phenomenon of alert fatigue and other unintended consequences of CPOE are discussed in an AHRQ WebM&M commentary.