Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.

… preferences for various possible related outcomes (e.g., readmissions, reoperation, long-term care stay, death). …

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.

The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.

… J Med Syst … Clinical decision support (CDS) alerts can … measure dosing errors and clinician-level quality of care. J Med Syst. 2020;44(10):185. Epub 2020/09/09. …

This cross-sectional study examined the impact of safety climate on adverse events occurring in Veterans Administration (VA) nursing homes and community living centers. Survey results suggest that nursing homes may reduce adverse events by increasing supportive supervision and a safer physical environment. The survey found that supervisor commitment to safety was associated with lower rates of major injuries from falls and catheter use, and that environmental safety was associated with lower rates of pressure ulcers, major injuries from falls, and catheter use.

… J Racial Ethn Health Disparities … This study recruited … difference in incidence by race. … Costello WG, Zhang L, Schnipper J, et al. Post-discharge adverse events among African …

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.

… Am. J. Surg. … Am J Surg … In this study, researchers analyzed 245 … through both surgical debriefings and the hospital's incident reporting system. They found a positive …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Reducing readmissions remains a major …

As outpatient surgery becomes more prevalent, attention around related safety concerns grows. Researchers analyzed postprocedure emergency department visits and hospital admissions to better understand factors associated with the safety of outpatient procedures performed within the Veterans Health Administration.

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.

… J Patient Saf … J Patient Saf … This qualitative study asked surgical staff …

… the International Society for Quality in Health Care … Int J Qual Health Care … For the first time, the World Health …

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.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … High reliability organizations operate …