AHRQ Celebrates Patient Safety Awareness Week
March 16, 2021
AHRQ Stats: Toolkit Significantly Reduces Hospital Falls
A safety toolkit funded by AHRQ helped hospitals reduce patient falls overall by 15 percent and falls resulting in injuries by 34 percent, according to a study published in JAMA Network Open.
- AHRQ Celebrates Patient Safety Awareness Week.
- Tuberculosis Patients Suffer Multiple Missed Opportunities for Diagnosis.
- Researchers Identify, Prioritize Questions To Advance Diagnostic Safety Research.
- AHRQ Grantee Works To Enhance Diagnostic Process Safety.
- Highlights From AHRQ’s Patient Safety Network.
- Toolkit Helps Rural Clinicians Improve Management of Sepsis Care.
- AHRQ Perspective Offers Strategies To Improve Patient Safety Through Better Communication.
- AHRQ in the Professional Literature.
AHRQ Celebrates Patient Safety Awareness Week
In recognition of Patient Safety Awareness Week 2021, a new AHRQ Views blog post highlights the growing momentum for addressing some of the nation’s most pressing safety issues, including threats related to the COVID-19 pandemic. Blog authors Jeff Brady, M.D., M.P.H., director of AHRQ’s Center for Quality Improvement and Patient Safety, and David Meyers, M.D., AHRQ’s acting director, note that Patient Safety Awareness Week is an opportunity for the agency to reaffirm its mission of helping advance a healthcare system that delivers high-quality, safe, equitable, high-value care. Two webinars scheduled this week are aimed at helping healthcare professionals improve safety:
- Today, from 1 to 2 p.m. ET, the Institute for Healthcare Improvement (IHI) will sponsor a webinar on “Workplace Violence: Protecting Healthcare Workers.” Dr. Brady and Patricia A. McGaffigan, R.N., M.S., IHI’s vice president, safety programs, will co-moderate a panel featuring leaders who have helped their organizations reduce workplace violence. Register.
- On Wednesday, from 1 to 2:30 p.m. ET, a webinar hosted by AHRQ, the Health Resources and Services Administration and other federal partners will highlight the potential of high-reliability organizations to increase patient safety. Kathleen M. Sutcliffe, Ph.D., a Bloomberg Distinguished Professor at Johns Hopkins University, will discuss how organizations can operationalize high-reliability concepts. Register.
Follow AHRQ and #PSAW2021 on Twitter, LinkedIn to see and hear from top patient safety experts and to learn more about AHRQ's proven tools and resources for improving diagnostic safety, preventing healthcare-associated infections and more.
Tuberculosis Patients Suffer Multiple Missed Opportunities for Diagnosis
Many patients with tuberculosis (TB) experience multiple missed diagnostic opportunities prior to diagnosis, a new study has found. The study, published in BMJ Open, analyzed records of nearly 3,500 TB patients across the nation over 17 years and found that more than three-quarters of them had experienced at least one missed opportunity for diagnosis in the year before they were finally diagnosed with TB. When diagnosis was delayed, the average duration of the delay was nearly 32 days. Missed opportunities occurred most commonly in outpatient settings. Access the abstract.
Researchers Identify, Prioritize Questions To Advance Diagnostic Safety Research
A panel of researchers has identified a set of 20 questions that can be used to guide a diagnostic safety research agenda over the next three to five years. The panel, partially funded by AHRQ, surveyed an international group of patient safety and diagnostic safety experts to determine the potential research priorities. The questions also included the input of non-researcher stakeholders including risk managers, funders, developers of decision support systems, and patients and families. The questions addressed mostly system factors (e.g., information technologies), teamwork factors (e.g., the role of nurses in the diagnostic process), and strategies to engage patients. It is estimated that outpatient diagnostic errors affect one in 20 adults, or approximately 12 million Americans each year. Access the abstract of the article, which appeared in Journal of General Internal Medicine.
AHRQ Grantee Works To Enhance Diagnostic Process Safety
AHRQ is highlighting the work of Harvard Medical School associate professor of radiology Ronilda Lacson, M.D., Ph.D., whose research has focused on diagnostic safety. With AHRQ grant funding, Dr. Lacson studied interventions to improve follow-up on critical test results during transitions from the hospital to an ambulatory setting. She also helped researchers better understand how human factors can help to make tasks, such as scheduling exams and follow-up, more efficient, effective and safe. Her work has led to widespread adoption of an electronic alert notification system that automates communication and management of test results across care settings by information technology vendors. Access Dr. Lacson’s profile and the profiles of other AHRQ grantees.
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:
- High nursing staff turnover in nursing homes offers important quality information.
- Racial/ethnic inequities in pregnancy-related morbidity and mortality.
- Implementing a human factors approach to RCA(2): tools, processes and strategies.
Toolkit Helps Rural Clinicians Improve Management of Sepsis Care
A toolkit funded by AHRQ uses virtual simulation training to improve the quality and safety of managing sepsis, a potentially life-threatening infection, in rural emergency departments (ED). The resource—which includes case scenarios, templates and checklists—focuses on helping critical care clinicians guide ED bedside staff on how to integrate virtual patient monitoring into their workflow. The toolkit could be used to integrate telehealth into any healthcare setting and could be applied to other medical conditions. An article based on the toolkit was published in Advances in Simulation. Access the abstract.
AHRQ Perspective Offers Strategies To Improve Patient Safety Through Better Communication
A new AHRQ Patient Safety Network Perspective explores how lessons learned during the COVID-19 pandemic may improve patient safety via better communication between providers, patients and families. Communication between patients and providers may improve, for example, if expanded access to electronic health records allows patients to review and report errors in medical notes. The use of simplified discharge education programs and information cards can enhance patients’ understanding of instructions and care information at home. Structured techniques such as bedside rounding may help clinicians share patient information and collaborate on care plans. Lessons learned across providers during the pandemic include the use of distance communication with interdisciplinary teams, transparent decision-making and continuous communication with the workforce, telemedicine and interdisciplinary community learning through social media platforms.
AHRQ in the Professional Literature
Risk of bleeding with exposure to warfarin and nonsteroidal anti-inflammatory drugs: a systematic review and meta-analysis. Villa Zapata L, Hansten PD, Panic J, et al. Thromb Haemost 2020 Jul;120(7):1066-74. Epub 2020 May 26. Access the abstract on PubMed®.
A Markov Chain model for transient analysis of handoff process in emergency departments. Zhu W, Patterson BW, Smith M, et al. IEEE Robot Autom Lett 2020 Jul;5(3):4360-7. Epub 2020 May 20. Access the abstract on PubMed®.
Association of a safety program for improving antibiotic use with antibiotic use and hospital-onset Clostridioides difficile infection rates among US hospitals. Tamma PD, Miller MA, Dullabh P, et al. JAMA Netw Open 2021 Feb;4(2):e210235. Access the abstract on PubMed®.
Development and validation of a deep learning model for detection of allergic reactions using safety event reports across hospitals. Yang J, Wang L, Phadke NA, et al. JAMA Netw Open 2020 Nov 2;3(11):e2022836. Access the abstract on PubMed®.
Association between parent comfort with English and adverse events among hospitalized children. Khan A, Yin HS, Brach C, et al. JAMA Pediatr 2020 Dec;174(12):e203215. Epub 2020 Dec 7. Access the abstract on PubMed®.
A multimodal intervention to improve the quality and safety of interhospital care transitions for nontraumatic intracerebral and subarachnoid hemorrhage. Sather J, Littauer R, Finn E, et al. Jt Comm J Qual Patient Saf 2021 Feb;47(2):99-106. Epub 2020 Oct 22. Access the abstract on PubMed®.
Improving postoperative rescue through a multifaceted approach. Ghaferi AA, Wells EE. Surg Clin North Am 2021 Feb;101(1):71-80. Epub 2020 Nov 2. Access the abstract on PubMed®.
A sociotechnical framework for Safety-Related Electronic Health Record Research reporting: the SAFER Reporting Framework. Singh H, Sittig DF. Ann Intern Med 2020 Jun 2;172(11 Suppl):S92-s100. Access the abstract on PubMed®.