New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors

AHRQ Stats

Access more data on this topic in the associated statistical brief.

Today's Headlines:

• New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors.
• Now Available: Summary Trend Tables From AHRQ’s Healthcare Cost and Utilization Project.
• Webinar Highlighted AHRQ Report on Pediatric Cancer Survivorship Care.
• Webinars Support Use of Data From Healthcare Cost and Utilization Project.
• AHRQ in the Professional Literature.

New Patient Safety Network Cases Offer Commentaries on Avoiding Severe Medical Errors

Two new Web M&M (Morbidity & Mortality Rounds on the Web) from AHRQ’s Patient Safety Network (PSNet) include expert analyses of medical errors submitted by PSNet users. In one case, a frail 71-year-old woman with a fever, sweating and a dry cough was discharged from a three-day hospital stay with no source of infection identified. Her exam was incomplete, however, and she was readmitted in septic shock due to a necrotizing soft tissue infection. She died following surgery. In another case, a 93-year-old man with chronic heart failure, atrial fibrillation and a ventricular assist device was hospitalized and found to have been given inappropriate doses of warfarin by his daughter. An expert commentary discusses the importance of understanding patient safety risk and communication across transitions of care. In addition the most recent Web M&M, PSNet regularly highlights journal articles, books and tools related to patient safety. Articles featured this week include:

• Crisis checklists in emergency medicine: another step forward for cognitive aids.
• A new argument for no-fault compensation in health care: the introduction of artificial intelligence systems.
• Common general surgical never events: analysis of NHS England never event data.

Review additional new publications in PSNet’s current issue.

Now Available: Summary Trend Tables From AHRQ’s Healthcare Cost and Utilization Project

AHRQ has updated the Healthcare Cost and Utilization Project (HCUP) Summary Trend Tables, downloadable tabulations containing state-specific monthly trends in hospital utilization. This product now includes 2020 inpatient data for 18 states, 2019 data for 40 states, and 2018 inpatient data for 48 states. Another update is planned for Summer 2021. The HCUP family of healthcare databases and related software tools and products is made possible by a federal-state-Industry partnership sponsored by AHRQ.

Webinar Highlighted AHRQ Report on Pediatric Cancer Survivorship Care

The National Cancer Institute sponsored a webinar on April 20, 2021, about AHRQ's recently released technical brief, Disparities and Barriers to Pediatric Cancer Survivorship Care. The NCI commissioned the report to support the development of a research agenda associated with the Childhood Cancer Survivorship, Treatment, Access, and Research (STAR) Act. Webinar presenters discussed the report's background and findings, as well as crucial next steps to address disparities and barriers in survivorship care. Paul Jacobsen, Ph.D., associate director of the Healthcare Delivery Research Program in NCI's Division of Cancer Control and Population Sciences, moderated a panel that included:

• Emily S. Tonorezos, M.D., M.P.H., director, Office of Cancer Survivorship in NCI's Division of Cancer Control and Population Sciences.
• Susanne Hempel, Ph.D., director of AHRQ's Southern California Evidence-Based Practice Center.
• Erin M. Mobley, Ph.D., M.P.H., assistant professor, Department of Surgery, University of Florida College of Medicine-Jacksonville.
• Lionel L. Bañez, M.D., medical officer, AHRQ's Center for Evidence and Practice Improvement.

Webinars Support Use of Data From Healthcare Cost and Utilization Project

Three webinars were held that aimed to support the use of data from AHRQ’s Healthcare Cost and Utilization Project (HCUP), the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988:

• April 20: This overview introduced health services and policy researchers to HCUP, explain the HCUP Partnership, discuss HCUP's state and nationwide databases and review how to obtain and access the data.
• April 21: This session provided an overview of the Nationwide Ambulatory Surgery Sample (NASS), including information about the database design, file structure and the importance of weighting the data to produce national and regional estimates of major ambulatory surgery encounters. Four use cases showcased how the NASS can be used.
• April 22: This session on HCUP products and tools helped participants learn about the free online query tool, HCUPnet, as well as resources that provide readily available hospital utilization statistics derived from the HCUP databases.

AHRQ in the Professional Literature

A novel cluster sampling design that couples multiple surveys to support multiple inferential objectives. O'Malley AJ, Park S. Health Serv Outcomes Res Methodol 2020 Sep;20(2-3):85-110. Epub 2020 Jun 9. Access the abstract on PubMed®.

Inter-region transfers for pandemic surges. Michelson KA, Rees CA, Sarathy J, et al. Clin Infect Dis 2020 Oct 10. [Epub ahead of print.] Access the abstract on PubMed®.

Assessing burden of central line-associated bloodstream infections present on hospital admission. Leeman H, Cosgrove SE, Williams D, et al. Am J Infect Control 2020 Feb;48(2):216-8. Epub 2019 Sep 9. Access the abstract on PubMed®.

Using appropriateness criteria to identify opportunities to improve perioperative urinary catheter use. De Roo AC, Hendren S, Ameling JM, et al. Am J Surg 2020 Sep;220(3):706-13. Epub 2020 Jan 10. Access the abstract on PubMed®.

Addressing unmet basic needs for children with sickle cell disease in the United States: clinic and staff perspectives. Loo S, Brochier A, Wexler MG, et al. BMC Health Serv Res 2021 Jan 12;21(1):55. Access the abstract on PubMed®.

Untold stories in user-centered design of mobile health: practical challenges and strategies learned from the design and evaluation of an app for older adults with heart failure. Cornet VP, Toscos T, Bolchini D, et al. JMIR Mhealth Uhealth 2020 Jul 21;8(7):e17703. Access the abstract on PubMed®.

Geographic variation in the consolidation of physicians into health systems, 2016-18. Kimmey L, Furukawa MF, Jones DJ, et al. Health Aff 2021 Jan;40(1):165-9. Access the abstract on PubMed®.

Understanding how health systems facilitate primary care redesign. Harvey JB, Vanderbrink J, Mahmud Y, et al. Health Serv Res 2020 Dec;55(Suppl 3):1144-54. Access the abstract on PubMed®.