Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.

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.

Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.

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.

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.

Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

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 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.

For the first time, the World Health Organization ICD-11 will include a taxonomy for quality and safety events. Researchers applied the new system to 45 patient safety vignettes gleaned from sources such as AHRQ WebM&M, then they described its strengths and limitations. Explicit identification of adverse events in administrative datasets could improve detection of errors, adverse events, and near misses on a population level.

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.

AHRQ Patient Safety Indicators (PSIs) have been utilized to identify safety problems and suboptimal care quality in acute care settings using ICD-9 codes in administrative discharge data. Despite limitations in the accuracy of PSIs, they have been widely employed as a quality metric. The implementation of ICD-10 and diagnosis timing codes necessitate development of a new set of PSIs. This consensus and validation study used a Delphi panel process to determine ICD-10 codes associated with safety and quality concerns. Experts grouped the 640 identified diagnostic codes into 18 PSI categories. Application of these novel PSIs in over 10 years of hospital discharge data uncovered safety problems in 5% of hospitalizations. The authors recommend that these proposed PSIs should be further validated using record review or prospective case review.

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.

Although the 10th revision of the International Classification of Diseases (ICD-10) was recently introduced in the United States in October 2015, the World Health Organization is already working on the next iteration (ICD-11) to be released in 2018. This survey study of nearly 250 stakeholders from around the world identified priorities for improvements, including the need for code clustering and improved codes for adverse events and diagnosis timing. A related study outlines the recommendations made by the ICD-11 Quality and Safety Topic Advisory Group, advancing specific frameworks to address many of these suggestions.