… recommend deprescribing to their patients. … Davila H, Rosen AK, Stolzmann K, et al. Factors influencing providers' willingness to …

Over a three-year period, this study audio-recorded handoffs of outpatient clinics to a pediatric emergency department (ED) to determine whether use of a receiver-driven structured handoff intervention can reduce miscommunication and increase perceived quality, safety, and efficacy. Implementation of the tool resulted in a 23% relative reduction in miscommunication and in increased compliance with handoff elements, including illness severity, pending tests, contingency plans, and detailed callback requests, as well as improved perceptions of healthcare quality, safety, and efficiency.

In this qualitative study, researchers applied an organizational learning perspective to characterize the various approaches used by four Veterans Health Administration hospitals to determine their patient safety priorities.

In this study, researchers analyzed 245 intraoperative errors and adverse events reported by physicians through both surgical debriefings and the hospital's incident reporting system. They found a positive association between the presence of intraoperative events and increased postoperative morbidity for patients. In keeping with prior research, the authors conclude that using multiple sources of data provided a more comprehensive picture of safety during surgery.

Reducing readmissions remains a major patient safety priority. Project Re-Engineered Discharge (RED) was designed to improve the hospital discharge process. This qualitative study evaluated the implementation of Project RED across five Veterans Health Administration hospitals.

Readmissions occur frequently after hospital discharge and may reflect opportunities to improve the quality and safety of care provided during the index admission. Using a modified Delphi process, an expert panel reviewed 30-day postoperative readmissions over a 7-year period for patients who had received surgery within the Veterans Affairs system. The study suggests that more than 50% of postoperative readmissions may be related to the quality of surgical care provided during the index admission.

The Veterans Affairs Surgical Quality Improvement Program (VASQIP) and the private sector National Surgical Quality Improvement Program have transformed both safety measurement and quality in surgery. Historically, VASQIP has placed comparatively little emphasis on outpatient surgical safety. This study examined trends in hospital admission within 7 days of all outpatient surgeries performed among veterans age 65 and older in the United States. Researchers found that 16% of these procedures were associated with 7-day admission, higher than what has been observed in younger, healthier patients. Common reasons for admission included surgical, medical, or device complications and inability to secure safe aftercare at home. The authors posit that, while not every admission represents a preventable adverse event, measurement is a critical step toward improving outpatient surgical safety. A recent PSNet interview and perspective explored the evolution of surgical patient safety.

This pre–post study aimed to increase error reporting by pediatric resident physicians and medical students. Residents and medical students reported more errors after implementation of a monthly educational conference in which event reports were reviewed. The authors conclude that trainee-led adverse event review conferences can increase event reporting.

This qualitative study asked surgical staff about risk factors for adverse events in outpatient surgery. Respondents identified safety vulnerabilities including patient adherence, equipment, safety culture, and postoperative instructions and care. The authors suggest further research on these topics with regard to outpatient surgery.

The AHRQ Patient Safety Indicators (PSIs) use hospitals' administrative data to measure quality and carry financial consequences for hospitals as part of pay-for-performance initiatives. Prior research has raised concerns about the validity of PSIs compared with directly using clinical data to identify safety events. AHRQ recently restructured PSI-90 (a composite measure containing multiple distinct PSIs) from volume-based to harm-based weighting. Using data from 132 Veterans Health Administration hospitals, this retrospective study compared hospital performance using the previous PSI-90 with performance under the redesigned measure. Although there was strong association between the volume-based and harm-based PSI-90 measures, use of the harm-based version had a significant impact on pay-for-performance because of changes in the weights of the component measures. Approximately 15% of hospitals in the study would face changes in financial penalties under the Hospital-Acquired Condition Reduction Program when using the new PSI-90. A past PSNet perspective discussed the impact of pay-for-performance.

High reliability organizations operate in high-hazard domains with consistently safe conditions. Through individual interviews, investigators determined that staff perceptions of patient safety largely matched their conceptual model of a high reliability health care organization and found two additional characteristics: teamwork and systems approaches to improvement. The authors suggest their model of high reliability organizations can be used to assess organizational reliability.

Even though disclosure of medical errors reduces litigation and patient distress, many providers remain uncomfortable with disclosing and apologizing for errors. In this survey of 67 surgeons across 3 medical centers, most reported prompt disclosure of adverse events. Surgeons who had difficult disclosure conversations experienced more anxiety. These results highlight the continued importance of supporting providers who experience emotional distress after medical errors.

Progress in patient safety has been limited by a lack of reliable measures. This problem is compounded in ambulatory care, as most existing metrics have sought to measure safety in hospitalized patients. This systematic review identified 182 published safety measures in primary care and categorized them according to Donabedian's triad and the safety target. The majority of metrics sought to measure safety in medication management, with laboratory testing and care coordination among the other types of safety issues being assessed. The authors note several limitations with the metrics they identified—most had not been validated, and there were no published measures identified for diagnostic error (despite increasing evidence that such errors are common in the outpatient setting). A PSNet interview discusses the challenges of measuring and improving safety in the ambulatory care environment.

Trigger tools have been shown to be an efficient way to screen for adverse events. This AHRQ-funded study assessed the usefulness of different adverse drug event triggers in the outpatient setting. Five of the triggers performed reasonably well for either detecting harm or leading to a change in care plan.

This survey study found that most resident physicians did not use incident reporting systems for adverse events in which they were involved, often because they did not know what or how to report. These results highlight the shortcomings of voluntary reporting for patient safety.

This study reports the development of a comprehensive patient safety tool for Veterans Administration medical centers, with input from frontline stakeholders, to integrate data sources including incident reports, AHRQ Patient Safety Indicators, and other quality measures related to safety in a single location in order to facilitate collaboration at local sites.

The AHRQ Patient Safety Indicators (PSIs) are increasingly used as publicly reported measures of hospital quality performance. This study investigated Veterans Health Administration hospitals with low and high PSI composite scores. Although high performers exhibited some distinctions in leadership and communication, overall the relationship between PSI score and organizational processes was inconsistent.

There is consensus that multiple methods must be used in order to detect adverse events during hospitalization. This study found that the AHRQ Patient Safety Indicators had poor sensitivity for identifying preventable harm in surgical patients when compared directly to the National Surgical Quality Improvement Program methodology.

This retrospective study of hospital data found that estimated adverse event rates varied between use of AHRQ Patient Safety Indicators and chart abstraction. These differences translated into substantial changes in hospital performance ratings and payments, emphasizing the challenge in using administrative data to assess hospital safety.

The AHRQ Patient Safety Indicators (PSIs) have traditionally been used to detect adverse events during hospitalization. However, in this study the PSIs were able to identify adverse events after discharge in patients who did not experience preventable harm while hospitalized. As readmission rates are proving to be a problematic measure of discharge safety, screening for adverse events may more reliably assess care transitions' effectiveness.