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- Technologic Approaches 2
- Device-related Complications 3
- Identification Errors 2
- Medical Complications 9
- Medication Safety 4
- Surgical Complications
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Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Journal Article > Study
Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.
Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-183.
This AHRQ-funded multicenter prospective study used data from a previously described voluntary reporting system, the Intensive Care Unit Safety Reporting System (ICUSRS), to compare the types and severity of safety problems for medical and surgical ICU patients. Despite differences in the types of patients, the types of errors reported were generally similar between the two groups, with most errors being attributable to training and team system factors (such as communication). Prior studies using data from the ICUSRS have analyzed factors contributing to medication order entry errors and procedural errors.
Journal Article > Study
Encinosa WE, Hellinger FJ. Health Serv Res. 2008;43:2067-2085.
The financial costs associated with medical errors have gained increasing attention, due to the Centers for Medicare and Medicaid Services policy of nonpayment for certain preventable adverse events. This study sought to estimate costs associated with adverse events (measured by the Agency for Healthcare Research and Quality's Patient Safety Indicators) in surgical patients. Importantly, by measuring costs for a 90-day period after surgery, the authors were able to estimate the postdischarge financial impact of adverse events. Up to 20% of costs were incurred after hospital discharge, and the investigators found significant impact of adverse events on mortality and hospital readmissions. The implications of this study and prior research in this area help formulate a business case for safety.
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-08-00220.
The Center for Medicare and Medicaid Services (CMS) no longer reimburses hospitals for the costs associated with certain preventable adverse events, many (but not all) of which are considered never events. This report from the federal Office of the Inspector General (OIG) examines the adverse events in a sample of Medicare beneficiaries. As outlined in a previous report, the OIG chose to evaluate the overall incidence of adverse events, including "no pay for errors" conditions, never events, and all other adverse consequences of hospitalization, including non-preventable adverse events. Therefore, the 15% overall incidence of adverse events found in this study should be interpreted with caution. Less than 1% of patients experienced a never event, and approximately 4% experienced a condition on CMS's no pay for errors list.
QualityNet. February 18, 2009.
The Centers for Medicare and Medicaid Services is conducting a field test of nine AHRQ quality and patient safety indicators. Hospitals participating in the review process receive confidential reports on their performance results and national comparative data.
Journal Article > Study
Friedman B, Encinosa W, Jiang HJ, Mutter R. Med Care. 2009;47:583-590.
Preventable medical errors have been linked to longer hospitalizations, excess costs, and increased mortality. This study explored the longer term effects of patient safety incidents by exploring whether adverse events, as measured by AHRQ's Patient Safety Indicators, were linked to an increased risk of hospital readmission. Patients who suffered a pulmonary embolism or an accidental puncture or laceration during hospitalization were significantly more likely to be readmitted within 1 month, and a broad array of adverse events were linked to a 3-month increased readmission risk. Two cases of preventable readmissions are discussed in this AHRQ WebM&M commentary.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. Providing a 5-year update on the National Quality Strategy, this report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Journal Article > Study
Agency for Healthcare Research and Quality pediatric indicators as a quality metric for surgery in children: do they predict adverse outcomes?
Rhee D, Zhang Y, Papandria D, Ortega G, Abdullah F. J Pediatr Surg. 2012;47:107-111.
The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) are widely used to screen administrative data for evidence of adverse events in adult inpatients. The Pediatric Quality Indicators (PDIs) aim to fill the same role for pediatric hospitals, and this study provides strong evidence that they can identify patients who experience preventable harm. Evaluation of nearly 2 million pediatric discharges over a 20-year period found that patients who experienced one PDI had a 20% increased risk of mortality. The PDIs include postoperative complications such as respiratory failure, a case of which is discussed vividly in this AHRQ WebM&M commentary.
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Journal Article > Study
Implementing hospital-based communication-and-resolution programs: lessons learned in New York City.
Mello MM, Senecal SK, Kuznetsov Y, Cohn JS. Health Aff (Millwood). 2014;33:30-38.
This study reports on an AHRQ-funded effort to establish communication-and-resolution protocols for general surgery in five New York City hospitals. The participating hospitals improved their incident disclosure but also encountered many critical obstacles to full implementation.
Tools/Toolkit > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; March 2019.
Ambulatory surgery centers are increasingly being used to provide surgical care. This survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Ambulatory surgery centers that have used the survey can submit their data to the database from June 3–July 22.
Journal Article > Review
Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis.
Winters BD, Bharmal A, Wilson RF, et al. Med Care. 2016;54:1105-1111.
The ability to use administrative data to measure patient safety is critical, because chart review is time-consuming and resource-intensive. The AHRQ Patient Safety Indicators (PSIs) and the CMS Hospital-acquired Conditions (HACs) aim to measure and track patient safety using administrative data. PSIs are often used for pay-for-performance, and CMS has a policy of nonpayment for hospitalizations associated with HACs. This systematic review found that PSIs and HACs have not been adequately validated compared to chart review and therefore may be subject to coding error. Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety efforts. These results suggest that unless further development and validation of administrative metrics occurs, widespread implementation of pay-for-performance efforts may not significantly improve patient safety.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016.
Rockville, MD: Agency for Healthcare Research and Quality; June 2018.
Reducing hospital-acquired conditions (HACs) such as health care-associated infections has been a major focus of quality improvement efforts, motivated in part by Medicare nonpayment and reporting. According to the Agency for Healthcare Research and Quality (AHRQ), HAC rates decreased by just over 20% between 2010 and 2015. In this report, AHRQ estimates that between 2014 and 2016, HAC reduction efforts resulted in an 8% decrease in events, $2.9 billion dollars in savings, and the prevention of about 8,000 deaths. While infections and adverse drug events decreased, pressure ulcers increased and represent an opportunity for further improvement. Overall, this report suggests that HAC reduction efforts continue to be successful.
Journal Article > Study
Magill SS, O'Leary E, Janelle SJ, et al; Emerging Infections Program Hospital Prevalence Survey Team. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.