patient safety intelligence report nyumc

Can artificial intelligence help identify patient risk from clinical notes?

The HIPAA regulations identify risk analysis as part of the administrative safeguard requirement to improve patient safety. The HHS advocates analysis of clinical notes to track, detect, and evaluate potential risks to patients. Many studies (n=21) in our review used AI to identify patient risk from clinical notes.

Should we use AI to evaluate patient safety outcomes?

Future studies should report the importance of evaluation metrics and determine which measure (single or multiple measures) is more important and a better representation of patient safety outcomes. More studies are needed to explore the evaluation metric (s) that should be considered before recommending an AI model.

What is the patient safety and Quality Improvement Act of 2009?

At the national level, regulations implementing the Patient Safety and Quality Improvement Act became effective on January 19, 2009. 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).

What is the difference between patient safety event reporting and incident reporting?

Patient safety event reporting systems are ubiquitous 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.

What is a patient safety intelligence?

Safety Intelligence (SI) is. • A voluntary, real-time web-based event/variance reporting system used by the staff to report variances. • Non-punitive. • Used to improve patient safety.

Is there a best measure of patient safety?

Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the 'best way' or the 'best measure' of patient safety.

What are the key elements of patient safety?

The key elements of a culture of safety include (1) a shared belief that although health care is a high-risk undertaking, delivery processes can be designed to prevent failures and harm to participants; (2) an organizational commitment to detecting and analyzing patient injuries and near misses; and (3) an environment ...

Who is the father of patient safety?

Lucian Leape is the physician father of the patient safety movement in the United States.

What are the 4 core measures?

These measures specify best clinical practice in four areas: Heart Failure, Acute Myocardial Infarction (AMI, i.e. Heart Attack), Pneumonia, and Surgical Site Infection prevention. Health organizations' performance on the Core Measures is assessed by examining documentation in patients' medical records.

How do you ensure patient safety?

5 Factors that can help improve patient safety in hospitalsUse monitoring technology. ... Make sure patients understand their treatment. ... Verify all medical procedures. ... Follow proper handwashing procedures. ... Promote a team atmosphere.

What are the top 5 medical errors?

These frequent errors can lead to negative consequences for the patients and those who love and care for them.Misdiagnosis. ... Medication Error. ... Faulty Medical Devices. ... Infection. ... Failure To Account For Surgical Equipment. ... Improper Medical Device Placement.

What are examples of patient safety?

The Nurse's Role in Patient SafetyIdentify “wrong site, wrong procedure, wrong patient” errors. High quality hospitals view nurses as the physician's partner in avoiding errors such as these. ... Catch medication mistakes. ... Educate patients about their medications. ... Reduce patient falls. ... Monitor patients for deterioration.

What is the first step in ensuring patient safety?

the first step to ensure patient safety is the careful observation of patient behavior. uniforms may be work in nonwork settings if they have not been stained with bodily fluids from patients.

Who is Dr James Reason?

Professor James Reason is the intellectual father of the patient safety field.

Risk of Complications After THA Increases Among HIV and Hepatitis C Patients

Read more: Risk of Complications After THA Increases Among HIV and Hepatitis C Patients. Opens in a new tab

Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients

Read more: Patterns of Narcotic Prescribing by Orthopedic Surgeons for Medicare Patients. Opens in a new tab

Lack of Cost Savings for Complex Lumbar Spine Fusions After Bundled Payments

Read more: Lack of Cost Savings for Complex Lumbar Spine Fusions After Bundled Payments. Opens in a new tab

Socioeconomic Status Negatively Affects HCAHPS Scores in Orthopedic Patients

Read more: Socioeconomic Status Negatively Affects HCAHPS Scores in Orthopedic Patients. Opens in a new tab

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.

Background

See more on psnet.ahrq.gov

Characteristics of Incident Reporting Systems

Limitations of Event Reporting

Using Event Reports to Improve Safety

Current Context