AHRQ Quality and Safety Review System

Improved patient safety monitoring

Background

The Institute of Medicine report, To Err Is Human, revealed more than 15 years ago the extent of medical errors that occur in U.S. hospitals. 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. In response to this challenge, CMS created the Medicare Patient Safety Monitoring System (MPSMS) to measure the magnitude of adverse events among hospital patients covered by Medicare and to create a baseline to assess the impact of national patient safety initiatives. Transferred to AHRQ in 2009, MPSMS is now in its 15th year. This chart review-based surveillance system determines national rates for 21 types of adverse events, including certain hospital-acquired conditions (HACs), such as post-surgical complications and pressure ulcers, but has some limitations that AHRQ is addressing with a new surveillance system.

Current Project

AHRQ is developing and testing an improved patient safety surveillance system to replace MPSMS that is known as the Quality and Safety Review System (QSRS). The QSRS relies on clinical information recorded in medical records, and the system has been designed to make use of structured data where it is or may become available. 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. Overall, the QSRS will generate adverse event rates, trend performance over time and unlike MPSMS, QSRS was designed to serve as a local hospital and health system tool to identify and measure adverse events.

The QSRS also will:

• 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.
• Capture an “all-cause harm” measurement that hospitals and clinicians can use to better target and measure quality improvement efforts.
• Provide additional detail for the most frequently occurring events, e.g., not just fall rates over a given time, but also the percentage of falls that resulted in injury and the rates of each specific type of injury.
• Use standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event Reporting, and other measures such as those associated with the CDC's National Healthcare Safety Network. This will ensure that an event identified at one institution is the same as one identified elsewhere.

Pilot Testing

AHRQ has awarded contracts to Johns Hopkins University, Baltimore, MD, and the MedStar Health Research Institute, Washington, DC to assess the accuracy, efficiency and usability of the QSRS during a pilot test in hospitals.