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AHRQ Developing New Patient Safety Surveillance Tool

October 26, 2016
by Heather Landi
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With the aim of improving patient safety monitoring, the Agency for Healthcare Research and Quality (AHRQ) within the U.S. Department of Health and Human Services (HHS) is currently developing and testing an improved patient safety surveillance system.

The Quality and Safety Review System (QSRS) will replace the system developed 15 years ago by the Centers for Medicare & Medicaid Services (CMS), called the Medicare Patient Safety Monitoring System (MPSMS).

AHRQ has awarded contracts to Baltimore-based Johns Hopkins University and the MedStar Health Research Institute in Washington, D.C. to assess the accuracy, efficiency and usability of the QSRS during a pilot test in hospitals.

Fifteen years ago, a report form the Institute of Medicine, To Err Is Human, revealed the extent of medical errors that occur in U.S. hospitals. Safety experts—including AHRQ, CMS and other federal partners -- realized that hospitals needed to understand specifically how and where adverse events were occurring in order to prevent them. In response to this challenge, CMS created the MPSMS to measure the magnitude of adverse events among hospital patients covered by Medicare and to create a baseline to assess the impact of national patient safety initiatives. Transferred to AHRQ in 2009, MPSMS is a chart review-based surveillance system that determines national rates for 21 types of adverse events, including certain hospital-acquired conditions (HACs), such as post-surgical complications and pressure ulcers.

In a blog post, Jeffrey Brady, M.D., Rear Admiral, U.S. Public Health Service, and director, AHRQ Center for Quality Improvement and Patient Safety, wrote, “More than 15 years after the Institute of Medicine report, To Err Is Human, first revealed the extent of medical errors that occur in U.S. hospitals, recent estimates by AHRQ indicate that the rate of hospital-acquired conditions (HACs) or adverse events remains too high—about 120 incidents per 1,000 hospital stays.”

Brady continued, “But over that time, substantial progress has been made—and is set to continue—in monitoring and measuring patient harms, according to a new article co-authored by AHRQ patient safety researchers in the Journal of Patient Safety. This knowledge can then help organizations focus on addressing the specific types of adverse events that continue to occur.”

AHRQ’s National Scorecard, which provided summary data on the national HAC rate for the quality improvement initiative, showed a 17-percent decline in HAC rates between 2010 and 2014, Brady wrote, and this improvement in safety is credited with preventing 2.1 million HACs and saving 87,000 lives and nearly $20 billion in health care costs.

According to researchers in an article in the Journal of Patient Safety, while the MPSMS has advanced the science of patient safety measurement, the current system’s usefulness has approached its limits. These limitations include the system’s reliance on an outdated software tool and potentially obsolete specifications for some types of adverse events that have become better understood in recent years.

“MPSMS also cannot identify rare or unusual events, such as wrong-site surgeries; nor can it be used to measure any type of adverse event not defined as one of its 21 measures,” according to Brady in the blog post.

The patient safety surveillance system is being redeveloped as QSRS, which relies on clinical information recorded in medical records, and the system has been designed to make use of structured data where it is or may become available, according to AHRQ. “The use of reliable structured data, such as medication prescriptions and laboratory test results that are relevant to patient safety events, offers opportunities to further enhance the efficiency of QSRS by automatically drawing this information from an electronic health record. Overall, the QSRS will generate adverse event rates, trend performance over time and unlike MPSMS, QSRS was designed to serve as a local hospital and health system tool to identify and measure adverse events,” agency officials wrote in a fact sheet.

In addition to the eventual use of electronic data, an important goal of the transition from MPSMS to QSRS is to capture an “all-cause harm” measurement that hospitals and clinicians can use to better target and measure their quality improvement efforts, Brady wrote in the blog post, and he noted that unlike MPSMS, QSRS has been designed to allow voluntary use at individual hospitals and systems.

The QSRS also will offer an expanded array of adverse event measures, including ones related to opioid use/misuse, surgical site infections and other surgical and anesthesia-related adverse events, as well as obstetric and neonatal adverse events. And, the new patient safety monitoring system will provide additional detail for the most frequently occurring events, e.g., not just fall rates over a given time, but also the percentage of falls that resulted in injury and the rates of each specific type of injury.

Additionally, the QSRS will use standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event Reporting, and other measures such as those associated with the CDC's National Healthcare Safety Network, which will help to ensure that an event identified at one institution is the same as one identified elsewhere.


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