AHRQ’s Making Healthcare Safer III Report Identifies 47 Practices To Improve Patient Safety

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Today's Headlines:

• AHRQ’s Making Healthcare Safer III Report Identifies 47 Practices To Improve Patient Safety.
• Twitter Chat Set for March 12 on Safety During Care Transitions.
• AHRQ Grantee Eric J. Thomas, M.D., M.P.H., Brings Insight Into Understanding Diagnostic Errors.
• Hospitals, Clinicians Can Make Healthcare Safer by Working With Patient Safety Organizations.
• Study Identifies Recommendations To Reduce Pneumonia Risk Following Bypass Surgery.
• Available Now: Survey Results on Patient Safety Culture in Medical Offices.
• AHRQ Releases Network of Patient Safety Databases Chartbook
• Highlights From AHRQ’s Patient Safety Network.
• AHRQ in the Professional Literature.

AHRQ’s Making Healthcare Safer III Report Identifies 47 Practices To Improve Patient Safety

A new AHRQ report identifies 47 practices that can improve patient safety for a variety of settings and stakeholders. The report, Making Healthcare Safer III, was published as AHRQ and the nation mark Patient Safety Awareness Week, sponsored by the Institute for Healthcare Improvement. The report's evidence-based, field-tested practices focus on medication management, healthcare-associated infections, nursing-sensitive practices, safety and injury and other issues. They include technological and staffing innovations, hygiene and disinfection interventions to prevent infections and practices to prevent medication error and reduce opioid misuse/overdose. Access an AHRQ press release, comparative information about previous Making Healthcare Safer reports, and more from AHRQ on Patient Safety Awareness Week. 

Twitter Chat Set for March 12 on Safety During Care Transitions

Join a Twitter chat on safer care transitions, set for March 12 from noon to 1 p.m. ET. Use the hashtag #PSAW20 to join the conversation. AHRQ and the Institute for Healthcare Improvement are co-hosting the event as part of Patient Safety Awareness Week. Access more information from AHRQ on care transitions.

AHRQ Grantee Eric J. Thomas, M.D., M.P.H., Brings Insight Into Understanding Diagnostic Errors

Our latest grantee profile examines how AHRQ-funded research by Eric J. Thomas, M.D., M.P.H., professor of medicine at the University of Texas McGovern School of Medicine, Houston, has helped establish the magnitude of diagnostic errors. One in 20 U.S. adults are affected by a diagnostic error each year, his research found. Attaching a definitive number to diagnostic errors helped clarify the scope of the problem and establish it as an AHRQ research priority. Check out Dr. Thomas' profile and others that show how AHRQ grantees have made major advances in health services research.

Hospitals, Clinicians Can Make Healthcare Safer by Working With Patient Safety Organizations

Hospitals and clinicians that want to make healthcare safer for patients can benefit from working with a Patient Safety Organization (PSO). These entities were created as part of the Patient Safety Act of 2005 and encourage individual providers and healthcare organizations to voluntarily report quality and safety information confidentially and without fear of legal discovery. A large majority (80 percent) of hospitals that work with a PSO found the feedback and analysis from PSOs to be helpful in preventing future patient safety events, a recent survey found. Access a list of PSOs certified by AHRQ. Access a new brochure  (PDF, 815 KB) from AHRQ that explains the benefits of working with a PSO.

Study Identifies Recommendations To Reduce Pneumonia Risk Following Bypass Surgery

An AHRQ-funded study published in Annals of Thoracic Surgery identified three strategies to significantly lower patients’ pneumonia risk following coronary artery bypass graft (CABG) surgery. Pneumonia is the most common healthcare-associated infection following CABG, but strategies to lower risk had not been established. After researchers conducted a literature review and interviewed healthcare personnel, they developed several recommendations that were then implemented at 18 Michigan hospitals. Among nearly 2,500 patients undergoing CABG from 2016 to 2017, three treatment measures—lung-protective ventilation, progressive postoperative ambulation, and ending postoperative ventilation before the six-hour mark—were shown to  significantly reduce pneumonia risk. Postoperative bronchodilator therapy was associated with higher pneumonia risk, and early extubation had no significant impact. Implementing the more successful pneumonia prevention strategies may help reduce this major post-CABG complication, authors concluded. Access the abstract. 

Available Now: Survey Results on Patient Safety Culture in Medical Offices

AHRQ has released the SOPS® 2020 Medical Office Database Report (PDF, 441.4 KB). The repository provides survey data from medical offices that administered the AHRQ patient safety culture survey instrument and have chosen to submit data to the Medical Office Survey on Patient Safety (SOPS) database. Among other findings, the database shows that 56 percent of respondents reported that their medical office is “excellent” or “very good” at minimizing waits and potentially harmful delays. These insights and others are based on survey results from 1,475 participating medical offices and more than 18,000 respondents. Access more information about submitting patient safety culture data and using the data in research. For questions about the SOPS databases, email DatabasesOnSafetyCulture@westat.com or call (888) 324-9790. 

AHRQ Releases Network of Patient Safety Databases Chartbook

AHRQ has released the Network of Patient Safety Databases Chartbook, 2019 which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations from across the nation. The newly released chartbook and accompanying dashboards (released in June 2019) outline the extent of harm reported, distribution of patient safety events, near misses (close calls) and unsafe conditions. Data within the chartbook cannot be used for statistical comparisons with clinical quality measures because submission of data to the NPSD is voluntary. 

Highlights From AHRQ’s Patient Safety Network

AHRQ’s Patient Safety Network (PSNet) highlights journal articles, books and tools related to patient safety. Articles featured this week include:

• Patient safety in marginalised groups: a narrative scoping review.
• Reduce the likelihood of patient harm associated with the use of anticoagulant therapy: commentary from the Anticoagulation Forum on the Updated Joint Commission NPSG.03.05.01 Elements of Performance.
• Systemic causes of in-hospital intravenous medication errors: a systematic review.

Review additional new publications in PSNet’s current issue or access recent cases and commentaries in AHRQ’s WebM&M (Morbidity and Mortality Rounds on the Web).

AHRQ in the Professional Literature

Disparities in opioid related mortality between United States counties from 2000 to 2014. McClellan CB. Drug Alcohol Depend 2019 Jun 1;199:151-8. Epub 2019 Apr 25. Access the abstract on PubMed®.

Predictive abilities of machine learning techniques may be limited by dataset characteristics: insights from the UNOS database. Miller PE, Pawar S, Vaccaro B, et al. J Card Fail 2019 Jun;25(6):479-83. Epub 2019 Feb 6. Access the abstract on PubMed®.

Implementation of a Clostridioides difficile prevention bundle: understanding common, unique, and conflicting work system barriers and facilitators for subprocess design. Musuuza JS, Hundt AS, Carayon P, et al. Infect Control Hosp Epidemiol 2019 Aug;40(8):880-8. Epub 2019 Jun 13. Access the abstract on PubMed®.

Improvement in mental health following total hip arthroplasty: the role of pain and function. Nguyen UDT, Perneger T, Franklin PD, et al. BMC Musculoskelet Disord 2019 Jun 29;20(1):307. Access the abstract on PubMed®.

A real-time automated patient screening system for clinical trials eligibility in an emergency department: design and evaluation. Ni Y, Bermudez M, Kennebeck S, et al. JMIR Med Inform 2019 Jul 24;7(3):e14185. Access the abstract on PubMed®.

Premedication with neuromuscular blockade and sedation during neonatal intubation is associated with fewer adverse events. Ozawa Y, Ades A, Foglia EE, et al. J Perinatol 2019 Jun;39(6):848-56. Epub 2019 Apr 2. Access the abstract on PubMed®.

Barriers and facilitators to implementing a pragmatic trial to improve advance care planning in the nursing home setting. Palmer JA, Parker VA, Mor V, et al. BMC Health Serv Res 2019 Jul 29;19(1):527. Access the abstract on PubMed®.

Assessing quality improvement capacity in primary care practices. Parchman ML, Anderson ML, Coleman K, et al. BMC Fam Pract 2019 Jul 25;20(1):103. Access the abstract on PubMed®.