patient safety hospital report

The Hospital Patient Safety Indicator Report (HPSIR) is a monthly report that collates a range of patient safety indicators and is then reviewed by the Senior Accountable Officer at both hospital-level and hospital group-level before publication on the website.

Full Answer

What exactly is patient safety?

What Exactly Is Patient Safety?

• INTRODUCTION. A defining realization of the 1990s was that, despite all the known power of modern medicine to cure and ameliorate illness, hospitals were not safe places for healing.
• INTELLECTUAL HISTORY OF PATIENT SAFETY. Critical assumptions in health care were rewritten by patient safety thinking. ...
• A PATIENT SAFETY MODEL OF HEALTH CARE. ...

How to manage patient safety?

• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk
• Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality
• Use of maximum sterile barriers while placing central intravenous catheters to prevent infections

More items...

What is a patient safety reporting tool?

The Patient Safety Reporting System (PSRS) is a voluntary, confidential, non-punitive reporting system available to collaborate with both private and federal medical facilities..

What is a patient safety reporting program?

The Patient Safety Reporting System (PSRS) is a non-punitive, confidential, and voluntary program which collects and analyzes safety reports submitted by healthcare personnel. Staff can report close calls, suggestions, and incident / event related information and data to improve patient safety.

What is a patient safety report?

Patient Safety Reporting (PSR) gives military treatment facility personnel the ability to anonymously report medical events that impact the safety of patients.

What is hospital patient safety?

Patient safety includes prevention of diagnostic errors, medical errors, injury or other preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care.

Which types of events should be reported in a safety report?

All team members are required to participate in the detection and reporting of any error, medication error, near miss, hazardous/unsafe condition, process failure, injuries involving patients, visitors and staff or a sentinel event.

What is leapfrog report?

The Leapfrog Hospital Survey is an annual voluntary survey in which Leapfrog asks hospitals to report quality and safety data and then publicly reports that information by hospital.

How do you ensure patient safety in hospital?

Here are 5 basic ways to ensure patient safety and care:Hand Hygiene. Research shows that effective hand hygiene improves knowledge of when to clean and how to clean. ... Checklist. ... Avoid abbreviations. ... Rapid Response System. ... Promote reporting.

How do hospitals measure patient safety?

A structural measure of patient safety might assess whether a hospital has key resources in place to improve safety, such as an electronic health record or a mechanism to rapidly start the work of root cause analysis teams after a serious adverse event has occurred.

What is an example of a patient safety event?

A patient safety incident occurs but does not result in patient harm – for example a blood transfusion being given to the wrong patient but the patient was unharmed because the blood was compatible. or expected treatment – for example he/she did not receive his/her medications as ordered.

How do you write a patient report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

What should be documented in the safety event report for this patient?

Filling Out an Effective Incident Report Include the full names of those involved and any witnesses, as well as any information you have about how, or if, they were affected. Add other relevant details, such as your immediate response—calling for help, for example, and notifying the patient's physician.

What is Lean and Six Sigma in Healthcare?

Lean Six Sigma in Healthcare Both methodologies strive to optimize operations and increase value for patients. However, while Lean focuses on eliminating waste, Six Sigma seeks to reduce variation by decreasing defects to a specific statistical measure.

What is hospital leapfrog?

The flagship Leapfrog Hospital Survey collects and transparently reports hospital performance, empowering purchasers to find the highest-value care and giving consumers the lifesaving information they need to make informed decisions.

How do you determine the quality of a hospital?

Quality Check Website On the site, consumers have the option to: Search for accredited and certified organizations by city and state, by name or by zip code and by the organization's Joint Commission ID number, if known. Find organizations by type of service provided within a geographic area.

What is the number to call 911?

If you are having thoughts of harming yourself, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Online: Submit a new patient safety event or concern. Online: Submit an update to your incident (You must have your incident number)

Can the Joint Commission accept medical records?

By policy, The Joint Commission cannot accept copies of medical records, photos or billing invoices and other related personal information. These documents will be shredded upon receipt. Download the form for reporting a patient safety concern by mail.

What is AHRQ common format?

AHRQ has also developed Common Formats —standardized definitions and reporting formats for patient safety events— in order to facilitate aggregation of patient safety information. Since their initial release in 2009, the Common Formats have been updated and expanded to cover a broad range of safety events.

What is the Patient Safety and Quality Improvement Act?

The legislation provides confidentiality and privilege protections for patient safety information when health care providers work with new expert entities known as Patient Safety Organizations (PSOs). Health care providers may choose to work with a PSO and specify the scope and volume of patient safety information to share with a PSO. Because health care providers can set limits on the ability of PSOs to use and share their information, this system does not follow the pattern of traditional voluntary reporting systems. However, health care providers and PSOs may aggregate patient safety event information on a voluntary basis, and AHRQ will establish a network of patient safety databases that can receive and aggregate nonidentifiable data that are submitted voluntarily. AHRQ has also developed Common Formats —standardized definitions and reporting formats for patient safety events—in order to facilitate aggregation of patient safety information. Since their initial release in 2009, the Common Formats have been updated and expanded to cover a broad range of safety events.

How is event reporting used in health care?

A 2016 article contrasted event reporting in health care with event reporting in other high-risk industries (such as aviation), pointing out that event reporting systems in health care have placed too much emphasis on collecting reports instead of learning from the events that have been reported. Event reporting systems are best used as a way of identifying issues that require further, more detailed investigation. While event reporting utilization can be a marker of a positive safety culture within an organization, organizations should resist the temptation to encourage event reporting without a concrete plan for following up on reported events. A PSNet perspective described a framework for incorporating voluntary event reports into a cohesive plan for improving safety. The framework emphasizes analysis of the events and documenting process improvements arising from event analysis, rather than encouraging event reporting for its own sake.

What is patient safety event reporting?

Patient safety event reporting systems are ubiquito us in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions, in contrast to more active methods of surveillance such as direct observation of providers or chart review using trigger tools. The Patient Safety Primer Detection of Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems.

What is PSNet perspective?

A PSNet perspective described a framework for incorporating voluntary event reports into a cohesive plan for improving safety. The framework emphasizes analysis of the events and documenting process improvements arising from event analysis, rather than encouraging event reporting for its own sake.

Why are event reports limited?

The spectrum of reported events is limited, in part due to the fact that physicians generally do not utilize voluntary event reporting systems.

What is structured mechanism?

A structured mechanism must be in place for reviewing reports and developing action plans. While traditional event reporting systems have been paper based, technological enhancements have allowed the development of Web-based systems and systems that can receive information from electronic medical records.

Overview

The Hospital Patient Safety Report, conducted each year since 2019, serves as a barometer of safety performance within U.S. hospitals. Based on insights from physicians, infection preventionists, pharmacists, and other hospital leaders, the findings reveal hospitals’ top patient safety challenges and priorities and how they are changing over time.

Key Findings

The findings point to a significant shift in hospitals’ strategic priorities. For the first time since 2019, improving patient safety outranked reducing costs. COVID-19 is likely a key contributor to this shift, as 77% of respondents said it has made improving patient safety a higher organizational priority.

What is SOPS in healthcare?

In 2004, the Agency for Healthcare Research and Quality (AHRQ) released the Surveys on Patient Safety Culture™ (SOPS ®) Hospital Survey for providers and other staff to assess patient safety culture in their hospitals. Since then, hundreds of hospitals across the United States and internationally have implemented the survey. In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The original survey—Version 1.0—is still available; however, the use of Version 2.0 is encouraged.

Is the SOPS survey still available?

In 2019, AHRQ released a new version, the SOPS Hospital Survey 2.0. The original survey—Version 1.0—is still available; however, the use of Version 2.0 is encouraged.

How many items are in the SOPS 2.0?

AHRQ funded the development of the SOPS Hospital Survey 2.0, which includes 32 items that make up 10 composite measures of patient safety culture. Table 1-1 defines each of the 10 SOPS Hospital Survey 2.0 composite measures.

What is SOPS 2.0?

In response to requests from hospitals interested in comparing results with those of other hospitals on the Surveys on Patient Safety CultureTM (SOPS®) Hospital Survey 2.0, the Agency for Healthcare Research and Quality (AHRQ) established the SOPS Hospital Survey 2.0 Database. The SOPS Hospital Survey 2.0, released by AHRQ in 2019, is a different version than the original SOPS Hospital Survey 1.0. The SOPS Hospital Survey 2.0 has fewer items and item wording is different than the 1.0 survey, as well as the names of some composite measures. More information about the 2.0 survey can be found on the AHRQ website at

What does a * mean in survey?

An * denotes a negatively worded item, where the % Disagree/Strongly Disagree or % Rarely/Never indicates a positive response.

Why is AHRQ important?

The AHRQ Surveys on Patient Safety Culture are important sources of information for healthcare organizations striving to improve patient safety and can be used as an effective starting point for action planning to make culture changes. Organizations may find it useful to brainstorm the potential barriers that make it difficult to implement initiatives and strategies to overcome them.

What are the 5 points in SOPS?

Most of the survey items ask respondents to answer using 5-point response categories in terms of agreement (Strongly agree, Agree, Neither Agree nor Disagree, Disagree, Strongly disagree) or frequency (Always, Most of the time, Sometimes, Rarely, Never). Three of the 10 SOPS composite measures use the frequency response option (Communication About Error, Communication Openness, and Reporting Patient Safety Events) while the other 7 composite measures use the agreement response option. The composite measure items also contain a “Does not apply or Don’t know” response option that is not included in the calculation of valid responses.

What is the chart 5-2?

Chart 5-2 shows the average percent positive response for each of the 32 survey items. Items are listed in their respective composite measure, grouped by positively and negatively worded items and then in the order in which they appear in the survey.

What is standard deviation in medical terms?

The standard deviation (s.d.) is a measure of the spread or variability of hospital scores around the average. The standard deviations presented in Chapter 6 tell you the extent to which hospital’s scores differ from the average:

Background

The 1999 Institute of Medicine To Err Is Human report drew national attention to the problem of preventable harm in medicine and led to the creation of the modern patient safety field.

A Framework for Measuring Patient Safety

In the 1960s, health services researcher Avedis Donabedian defined a taxonomy for measuring the quality of health care. The "Donabedian triad," which is still widely used today, defines three lenses through which quality may be viewed:

Methods for Measuring Patient Safety

Several methods that can be used for measuring patient safety events are described in the Table below.

Problems and Controversies in Measuring Patient Safety

Despite the importance of accurately measuring adverse events, existing tools all have limitations, and controversy continues to plague efforts to measure safety and compare safety between organizations.

Current Context

Progress has been made toward measuring trends in safety at the national level. The Partnership for Patients —a public-private initiative launched in 2011—uses a combination of 28 metrics to determine a national Hospital-Acquired Conditions (HAC) rate. The HACs include certain health care–associated infections, medication errors, and never events.

Background

See more on psnet.ahrq.gov

Characteristics of Incident Reporting Systems

Limitations of Event Reporting

Using Event Reports to Improve Safety

Current Context