AHRQ Developing New Tool To Update Monitoring of Patient Safety

Issue Issue #529
AHRQ's Electronic Newsletter summarizes Agency research and programmatic activities.
October 25, 2016

AHRQ Stats: Teen Childbirth

AThe rate of teen hospital stays for childbirth fell 40 percent nationwide between 2004 and 2013. Reductions ranged from 25 percent to 50 percent among 36 states. The smallest decreases were in Kentucky (down 19 percent), Nebraska (12 percent) and West Virginia (5 percent). (Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project Statistical Brief #208: Teen Hospital Stays for Childbirth, 2004-2013.)

Today's Headlines:

AHRQ Developing New Tool To Update Monitoring of Patient Safety

A new online patient safety tool being developed by AHRQ is intended to track adverse events in hospitals by capturing data from Medicare patients' electronic health records. The Quality and Safety Review System (QSRS) will be tested by Johns Hopkins University and MedStar Health Research Institute as a replacement for the current Medicare Patient Safety Monitoring System (MPSMS). While substantial progress has been made in monitoring and measuring patient harms, MPSMS has approached its useful limits because it relies on outdated software, can't identify rare or unusual events and is unable to measure adverse events not currently defined by one of the system's 21 measures, according to a recent article in the Journal of Patient Safety. The AHRQ-funded article, "Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future)," reviewed the strengths and limitations of MPSMS and other methods for measuring patient safety. Authors also explored expected future directions in patient safety measurement while focusing on issues that are informing the development and implementation of QSRS. Access the abstract and a new AHRQ Views blog post, "New System Aims To Improve Patient Safety Monitoring."

AHRQ Teach-Back Strategies Help Primary Care Providers Engage Patients and Families

To learn more about how clinicians use "teach-back" to improve communication with patients, access AHRQ's Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients. The new resource features evidence-based interventions for implementing the teach-back technique in primary care practices.  With teach-back, clinicians ask patients or family members to explain in their own words what they need to know or do. It is more than repeating what patients or family members heard—clinicians ask them to teach it back. Effective communication is a clinician's first step to helping a patient with a health problem. The evidence-based, low-technology teach-back technique can be the gateway to better communication and better understanding, and ultimately it can improve patient outcomes.

AHRQ Technical Brief Recommends New Research in Ambulatory Care Safety Practices

A recently released AHRQ-funded technical brief explored fundamental questions about patient safety practices in ambulatory care, including which evidence-based practices used in hospitals may be applicable to the ambulatory care setting, as well as identified promising safety initiatives that have not been broadly implemented or studied beyond a single ambulatory care center. The brief found significant gaps exist in ambulatory safety research, including a notable lack of studies on patient engagement and timely and accurate diagnosis. The brief recommended conducting prospective, large-scale studies in diverse ambulatory settings to develop and test ambulatory safety interventions. Access the brief, Patient Safety in Ambulatory Settings, and a recent AHRQ Views blog post, "Taking Steps To Protect Safety in Ambulatory Care."

Compliance With Prostate Cancer Quality Measures Not Tied to Patient Outcomes

Prostate cancer treatment that complied with nationally endorsed quality measures did not produce clinically relevant changes in patients' reported outcomes, according to an AHRQ-funded study. The study included 2,600 men treated with prostate cancer therapies including surgery, radiation and active surveillance. Researchers explored whether their care complied with six nationally endorsed quality measures designed to boost effective and efficient care. Compliance ranged from 64 percent to 88 percent. Patients rated their health-related quality of life, satisfaction and treatment-related complications in the first 12 months following treatment. Researchers did not find clinically meaningful improvement in functional outcomes, satisfaction scores or treatment-related complication rates associated with adherence to the quality measures. Study authors recommended further study to identify quality measures that correlate better with patient-centered outcomes. "Impact of Adherence to Quality Measures for Localized Prostate Cancer on Patient-reported Health-related Quality of Life Outcomes, Patient Satisfaction, and Treatment-related Complications" appeared in the August issue of Medical Care. Access the abstract.

Model Used To Explore Work Schedules' Effect on Resident Physician Performance

A new AHRQ-funded study on the relationship between physician work schedules and performance found that mathematical modeling provides an approach that may help residency programs analyze and redesign work schedules. Using a mathematical model to explore the effects of circadian rhythms and length of time awake on performance and alertness, researchers simulated two traditional schedules and three novel schedules. Among resident physicians on novel work schedules (with shifts limited to 16 hours), the model predicted less poor performance and more alertness when compared with traditional work schedules (featuring shifts of more than 24 hours). Predicted times of worse performance and alertness were at night, which is also a time when supervision of trainees is lower. The study, "Applying Mathematical Models to Predict Resident Physician Performance and Alertness On Traditional and Novel Work Schedules," and abstract appeared in the September issue of BMC Medical Education.

AHRQ in the Professional Literature

Recommendations for the conduct and reporting of modeling and simulation studies in health technology assessment. Dahabreh IJ, Trikalinos TA, Balk EM, et al. Ann Intern Med 2016 Oct 18;165(8):575-81. Epub 2016 Sep 20. Access the abstract in PubMed®.

Resolving rivalries and realigning goals: challenges of clinical and research multiteam systems. Gerber DE, Reimer T, Williams EL, et al. J Oncol Pract 2016 Sep 13. [Epub ahead of print.] Access the abstract on PubMed®.

Challenges in patient safety improvement research in the era of electronic health records. Russo E, Sittig DF, Murphy DR, et al. Healthc (Amst) 2016 Jul 26.  [Epub ahead of print.] Access the abstract on PubMed®.

Building the mental health workforce capacity needed to treat adults with serious mental illnesses.  Olfson M. Health Aff (Millwood) 2016 Jun 1;35(6):983-90. Access the abstract on PubMed®.

Risk-adjustment simulation: plans may have incentives to distort mental health and substance use coverage. Montz E, Layton T, Busch AB, et al. Health Aff (Millwood) 2016 Jun 1;35(6):1022-8. Access the abstract on PubMed®.

Rates and consequences of posttraumatic distress among American Indian adults with type 2 diabetes.  Aronson BD, Palombi LC, Walls ML. J Behav Med 2016 Aug;39(4):694-703. Epub 2016 Mar 21. Access the abstract on PubMed®.

Engaging hospitalized patients in clinical care: study protocol for a pragmatic randomized controlled trial. Masterson Creber R, Prey J, Ryan B, et al. Contemp Clin Trials 2016 Mar;47:165-71. Epub 2016 Jan 18. Access the abstract on PubMed®.

Using the NIATx model to implement user-centered design of technology for older adults. Gustafson DH Jr, Maus A, Judkins J, et al. JMIR Hum Factors 2016 Jan 14;3(1):e2. Access the abstract on PubMed®.

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Page last reviewed October 2016
Page originally created October 2016
Internet Citation: AHRQ Developing New Tool To Update Monitoring of Patient Safety. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/e-newsletter/539.html