patient safety final report, fall 2017

What is QSRS in AHRQ?

These changes take the form of AHRQ’s new patient safety surveillance system —the QSRS that was mentioned above. It will replace the MPSMS and attempt to address some of the prior measurement limitations by 1) simplifying event descriptions, 2) expanding the scope of adverse events collected, and 3) creating consistency across other patient safety data collection initiatives (e.g., the AHRQ Common Formats for Surveillance definitions for hospital-acquired infections are based on the CDC’s National Healthcare Safety Network definitions). 21,22 With these new definitions being used in QSRS and represented in the aforementioned PfP 2019 goals, it is important to update estimates of additional cost and excess mortality associated with HACs. These estimates can then inform patient safety and quality improvement efforts to measure success in reducing HACs and the burdens associated with them.

What is AHRQ and CMS?

AHRQ and CMS are partnering with other HHS agencies to conduct a range of activities to address HACs, hospital-acquired-infections (HAIs), and medical errors specifically, as well as patient health and safety more generally. For example, both AHRQ and CMS encourage the practice of evidence-based quality and infection control—including through a national technical-assistance program implemented by CMS-funded Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs), and through the Community-Based Care Transitions Program (CCTP), which aims to reduce hospital readmissions for high-risk Medicare beneficiaries by more effectively managing their care and transitions. 14 The goals of the PfP program are to improve safety in acute-care hospitals, and achieve a 20 percent reduction in HACs and a 12 percent reduction in 30-day readmissions as a population-based measure (readmissions per 1,000 people) from 2014 to 2019. 15, 16

How do HACs affect the health system?

Despite advancements in infection control and injury prevention, hospital-acquired conditions (HACs) continue to have a high financial burden on the health care system and contribute significantly to inpatient morbidity and mortality in the United States. Multiple Federal initiatives in patient safety highlight the need for better understanding of additional cost and excess mortality due to HACs, including the U.S. Department of Health and Human Services (HHS) National Quality Strategy 1, 2 the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination, 3 and the National Action Plan for Adverse Drug Event Prevention. 4 Several efforts are underway at the Agency for Healthcare Research and Quality (AHRQ),Centers for Medicare & Medicaid Services (CMS), and the Centers for Disease Control and Prevention (CDC) to target and reduce the incidence of HACs through implementation of evidence-based strategies and better measurement and reporting. Federal agencies are leading significant efforts in these areas: for example, the public-private Partnership for Patients (PfP), 5 AHRQ's Comprehensive Unit-Based Safety Programs (CUSP), 6 National Scorecard for HACs, 7 Quality and Safety Review System (QSRS), 8 and CMS' HAC Reduction Program related to payment reform. 9

What is the probability of death among the cases?

Probability of death among the cases (Pr D|E) is divided by the probability of death for the controls (Pr D|E’) to obtain the relative risk. When the RR was not reported or could not be calculated, we used the OR value to approximate RR, based on an assumption that the overall mortality rate was low.

What is the first step in systematic review?

The first step in the systematic review process was to define potentially relevant literature for each HAC. We developed HAC-specific search criteria to search publication databases, including PubMed, Scopus, and grey literature search engines. We then conducted forward and backward searches on relevant literature (e.g., references, articles that cited the original search results) and supplemented these searches with articles identified from the reference list of prior meta-analyses and systematic reviews. This multipronged search strategy better ensured that we captured the most relevant literature for each HAC.

Does HAC reflect additional deaths?

Definitions of mortality do not reflect additional deaths associated with the HAC.

Is the population studied inpatient or outpatient?

Population studied was not in an inpatient setting.

Who prepared the report for Inpatient Falls?

This report was prepared by the members of the National Audit of Inpatient Falls workstream project team.

What is the National Audit of Inpatient Falls?

The National Audit of Inpatient Falls is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and managed by the Royal College of Physicians (RCP) as part of the Falls and Fragility Fracture Audit Programme (FFFAP) alongside the Fracture Liaison Service Database (FLS‐DB) and the National Hip Fracture Database (NHFD).  FFFAP aims to improve the delivery of care for patients who have falls or sustain fractures through effective measurement against standards and feedback to providers.

What percentage of patients had their lying and standing blood pressure measured?

1 9 %19% of patients had their lying and standing blood pressure measured

How was the 2015 LHB data collected?

As in 2015, all data were collected and entered locally into a secure webtool, which was designed so that each hospital could log in with an individual password and hospital code.  The webtool validated the data at the point of entry by rejecting invalid responses.  The organisational component was completed per trust or LHB, and each hospital could access the same organisational audit for their trust or LHB so that the data only needed to be entered once.

How much can a multidisciplinary team reduce falls?

Multiple interventions by the multidisciplinary team and tailored to the patient can reduce falls by 20–30%

Why do people fall in hospital?

Acute illness, particularly in frail older people or those recovering from serious injury or surgery, increase s the risk of a fall in hospital.  Patients are vulnerable to delirium, dehydration and deconditioning, all of which affect balance and mobility, especially in unfamiliar surroundings.  The majority of falls occur among medical inpatients during the first few days after admission.

Should data collected through incident reporting systems be presented as though they represented actual incidents or actual harm?

Data collected through incident reporting systems or as serious incidents should never be presented as though they represented actual incidents or actual harm … to do so is counterproductive to the purpose of incident reporting.3