AHRQ Views: Blog posts from AHRQ leaders
New System Aims To Improve Patient Safety Monitoring
More than 15 years after the Institute of Medicine report, To Err Is Human, first revealed the extent of medical errors that occur in U.S. hospitals, recent estimates by AHRQ indicate that the rate of hospital-acquired conditions (HACs) or adverse events remains too high—about 120 incidents per 1,000 hospital stays.
But over that time, substantial progress has been made—and is set to continue—in monitoring and measuring patient harms, according to a new article co-authored by AHRQ patient safety researchers in the Journal of Patient Safety. This knowledge can then help organizations focus on addressing the specific types of adverse events that continue to occur.
But like all good science, accurately measuring patient harm is an exacting and time-consuming effort.
Following the To Err is Human report, patient safety experts—including AHRQ, the Centers for Medicare & Medicaid Services (CMS), and other Federal partners—realized that hospitals needed to understand specifically how and where adverse events were occurring in order to prevent them. To advance this understanding, a Federal program known as the Medicare Patient Safety Monitoring System (MPSMS), was created by CMS to measure the magnitude of adverse events among hospital patients covered by Medicare. The system’s second goal was to create a baseline to assess the impact of national patient safety initiatives.
Transferred to AHRQ in 2009 and now in its 15th year, MPSMS has provided valuable insight on both goals. Using a chart review-based surveillance system, the MPSMS provides rates for 21 measures of adverse events, including certain HACs, such as postsurgical complications and pressure ulcers. In 2014, the MPSMS national sample drew from more than 1,100 hospitals and included approximately 20,000 medical records.
AHRQ relied on data from the MPSMS to estimate the national rate of HACs, including bloodstream and urinary tract infections, pressure ulcers, and adverse drug events, for the Partnership for Patients program. AHRQ’s National Scorecard, which provided summary data on the national HAC rate for the quality improvement initiative, showed a 17-percent decline in HAC rates between 2010 and 2014. This improvement in safety is credited with preventing 2.1 million HACs and saving 87,000 lives and nearly $20 billion in health care costs.
While the MPSMS has advanced the science of patient safety measurement, the current system’s usefulness has approached its limits, according to the article.
One limit is its reliance on an outdated software tool. Another is potentially obsolete specifications for some types of adverse events that have become better understood in recent years. MPSMS also cannot identify rare or unusual events, such as wrong-site surgeries; nor can it be used to measure any type of adverse event not defined as one of its 21 measures.
To overcome these drawbacks, AHRQ is developing the Quality and Safety Review System (QSRS). The use of reliable structured data, such as medication prescriptions and laboratory test results that are relevant to patient safety events, offers opportunities to further enhance the efficiency of QSRS by automatically drawing this information from an electronic health record. QSRS will also offer an expanded array of adverse event measures, including ones related to opioid use/misuse, surgical site infections and other surgical and anesthesia-related adverse events, as well as obstetric and neonatal adverse events.
As part of this effort, AHRQ has sought to maintain consistency in the QSRS definitions of adverse events with those used by the AHRQ Common Formats for Event Reporting and other measures, such as those associated with CDC’s National Healthcare Safety Network. Patient Safety Organizations (PSOs) use Common Formats to aggregate and analyze patient safety events that hospitals and nursing homes voluntarily report to PSOs.
In addition to the eventual use of electronic data, an important goal of the transition from MPSMS to QSRS is to capture an “all-cause harm” measurement that hospitals and clinicians can use to better target and measure their quality improvement efforts. Unlike MPSMS, QSRS has been designed to allow voluntary use at individual hospitals and systems.
AHRQ recently awarded contracts to Johns Hopkins University, Baltimore, and the MedStar Health Research Institute, Washington, D.C., to assess the accuracy, efficiency, and usability of the QSRS during a pilot test in hospitals.
The science of adverse event monitoring and measurement is complex, but the ultimate goal that it supports is simple: making patient care safer. AHRQ will continue to develop the tools and resources, including the QSRS, to ensure that this goal moves within our reach.