Key Methods for Measuring Patient Safety, Adverse Events

Chart review

Chart review is considered the “gold standard” in patient safety reporting and detection, according to AHRQ. During chart review, the reviewer will look at whether a medical error or patient safety event may have occurred.

“Patient charts contain detailed clinical data including information about patient safety events and complications,” per AHRQ. “Prior to the widespread implementation of electronic medical records (EMRs), organizations typically relied on clinicians to abstract data from paper-based charts. Reviewing charts is a resource-intensive and cumbersome process typically completed months after care was provided to a patient.”

In more recent years, healthcare organizations have utilized triggers, or electronic tools that will alert patient safety staff to an adverse patient safety event. For example, a trigger might identify the use of the anti-overdose drug naloxone. Use of naloxone might indicate the administration of a harmful dose of an opioid, which constitutes an adverse patient safety event, according to AHRQ.

Triggers digitize the manual process of scanning the medical record for medical errors or patient safety events, meaning triggers still provide a retrospective look at patient safety. The benefit of triggers is the automation, cutting down on the time and expense it takes to review a chart.

There are many different chart review triggers available, but AHRQ said the Global Trigger Tool from the Institute for Healthcare Improvement is one of the most widely used. The GTT includes 53 different triggers that can apply to all patients or populations in specific disease states.

AHRQ and IHI caution against using GTT to make judgments about whether an adverse event was preventable. Additionally, they acknowledge that the reliability of the trigger is usually dependent on the individual reviewing the chart in response to the trigger.

Notably, most triggers apply to inpatient acute care. There is little data outlining the efficacy of triggers in ambulatory care, AHRQ states on its website.

Spotlight on Prospective Automated Surveillance

AHRQ says automated surveillance is a form of patient safety assessment. Triggers, described above, fall into the bucket of automated surveillance. However, as noted, triggers are an automated form of chart review and usually look at charts retrospectively.

But it is also possible to use automated surveillance prospectively. Researchers have described using machine learning to flag electronic records for patients who are at risk for but have not yet experienced an adverse patient safety event. That flag should prompt review from a patient safety expert who can assess the true odds of that event arising.

In that way, healthcare professionals can take preventive steps to stave off the chance of an adverse patient safety event.

This system, although effective for mitigating patient safety events before they even happen, can lead to false positives, which AHRQ said is one of the pitfalls of automated surveillance.

Voluntary error reporting systems

AHRQ says that voluntary error reporting systems have become foundational to healthcare organizations’ patient safety efforts. These systems allow the people involved in a patient’s care to report an error or event in detail, prompting a chain reaction of reporting to hospital or clinic management and patient safety team members.

According to AHRQ, an effective voluntary error reporting system hinges on four key factors, including

• Institution must have a supportive environment for event reporting that protects the privacy of staff who report occurrences.
• Reports should be received from a broad range of personnel.
• Summaries of reported events must be disseminated in a timely fashion.
• A structured mechanism must be in place for reviewing reports and developing action plans.

Fundamentally, these systems almost entirely rely on frontline staff reports, AHRQ says. Folks who usually file reports initially are the frontline staff who provide direct care to the patient: the nurse, pharmacist, or physician.

“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,” according to AHRQ.

To that end, voluntary error reporting systems can have some pitfalls, mostly in that they can sometimes fail to capture certain adverse patient safety events. A separate AHRQ webpage noted that these systems usually receive responses primarily from nurses, indicating some response bias. Moreover, they only offer a retrospective look at a patient safety event.

Key barriers to using voluntary error reporting systems include limited feedback on incident follow-up, system forms that are too long, perceptions that the incident was trivial, ward or department busyness, and lack of clarity regarding the party responsible for reporting, AQHR says.

Still, these systems can be effective for looking more deeply at the processes that can lead to—or prevent—adverse patient safety events, most experts agree. In a perspective piece published in PSNet (Patient Safety Network), experts discuss how organizations can use error reporting systems to support a larger quality improvement plan.

Foremost, organizations need to show frontline providers how these tools can spark patient safety improvements. This can increase provider motivation to use these reporting tools. From there, organizations should encourage providers to write detailed reports to accommodate better report investigation and quality improvement.

The final leg of that plan is engaging physicians in event reporting. As noted above, physicians use error reporting systems less than other providers. But most adverse hospital events involve interdisciplinary teams, including the physician, so getting all perspectives will be key.

Administrative/claims data review

Claims data review is a strategy for gaining a retrospective view of adverse patient safety events. Patient safety experts—or, in recent times, an algorithm—will scan administrative and claims data to flag the incidence of adverse patient safety events. This can help organizations better understand patient safety rates and steer quality improvement initiatives.

This strategy is effective because it is low-cost, and the data is readily available. Healthcare experts can also use claims data reviews to track patient safety events across time as part of a population health analysis.

But there are some pitfalls to leveraging administrative and claims data for patient safety assessment. Notably, claims data is retrospective, meaning any insights it can provide are reactive rather than proactive. Moreover, AHRQ points out that claims data can be variable or inaccurate across health systems.

Patient reports

Patient reporting is a burgeoning field in patient safety detection. These reports hinge on patients and family members reporting adverse patient safety events to hospitals for investigation. According to AHRQ, this can be beneficial because it captures events that may have otherwise been missed by hospital staff, but tools to facilitate patient reporting are limited.

But data shows that when hospitals do make tools for patients to report safety events available, the data the tools provide is fruitful. In 2022, researchers assessed the rollout of the MySafeCare tool—a portal to facilitate patient-reported safety concerns anonymously and in real-time—in six acute care units over an 18-month timeline.

The portal didn’t yield very many complaints, the researchers acknowledged—just 0.6 submissions per 1,000 patient-days—and was considerably lower than the number of submissions to the organizations’ Patient Family Relations group.

However, the team did say the content in that limited number of submissions was important; themes included unmet care needs and preferences, inadequate communication, and concerns about the safety of care.

The World Health Organization echoes this sentiment, asserting that involving patients and families in the reporting of adverse patient safety events underscores the weight of the event.

“It is often only the patient, family member or carer who has a complete view of the entire journey of care surrounding an event; this emphasizes the value of involving patients, families and carers in investigating and understanding what happened and the circumstances surrounding an incident,” WHO said in a report on patient safety reporting. “The best reporting systems also include and encourage patient-generated reports.”

As healthcare organizations continue their work toward zero harm, it will be essential to understand the best practices for assessing the state of patient safety within their own four walls. Tapping the right systems and tools, ranging from electronic chart review to patient and family engagement, will be key to building a path toward quality improvement.