Peer Review of a Report on Strategies to Improve Patient Safety (2021) / Chapter Skim
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Review of the AHRQ Report
Review of the AHRQ Report
Pages 7-24
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From page 7... ...
, facilitating the use of Common Formats or models for that data, using artificial intelligence to derive insights from the aggregate data, and clarifying the legal protections surrounding the submission of data to PSOs.
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From page 8... ...
The network of databases shall have the capacity to accept, aggregate across the network, and analyze nonidentifiable patient safety work product voluntarily reported by patient safety organizations, providers, or other entities. The Secretary shall assess the feasibility of providing for a single point of access to the network for qualified researchers for information aggregated across the network and, if feasible, provide for implementation.
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issued a report titled Patient Safety Organizations: Hospital Participation, Value and Challenges, which provides a summary of the important relationships among health care providers, PSOs, and the NPSD, depicted in Figure 1. Only the first step of submitting patient safety work product (PSWP)
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From page 10... ...
The committee believes there are multiple strategies to break the logjam that could be addressed in the AHRQ report, such as interfacing with EHRs, applying artificial intelligence methods to harvest learnings from the aggregate data, and clarifying the legal protections surrounding the submission of data. EHRs The widespread availability of EHR systems and clinical databases offers new opportunities to use electronically captured data to reduce medical errors and improve patient safety.
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The draft report could better respond to the confusion by developing strategies to clarify the legal protections for data submitted to PSOs. Where the protections are insufficient to convince health care organizations to participate, further strategies to address those concerns may require regulatory or legislative action.
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The committee suggests that the AHRQ report to Congress include an assessment of the degree to which these functions have been achieved, areas in which they have not, and steps that could be taken to address any barriers that are identified. Much of this information is contained in the 2019 OIG report previously referenced.
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From page 13... ...
The AHRQ report could also examine other national patient safety programs, such as those highlighted in the following sections, for strategies they employ to learn from aggregate data analysis. NCPS The VA created the NCPS in 1998 as a system-oriented approach to reducing AEs and close calls.
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FDA Methods FDA provides another example of sophisticated methods of using voluntarily reported safety data effectively and making them accessible to the broader community to improve safety. FDA Adverse Event Reporting System FAERS contains voluntarily submitted reports of AEs, medication errors, and product quality problems.
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Balancing the CUSP Review with Additional Evidence While AHRQ's draft report focuses heavily on CUSP and its successes, review of its weaknesses as well as its strengths would be helpful to the reader as the literature on CUSP is more nuanced than the draft report implies. The draft report presents CUSP as a clear success, but it should include examples where it has been less effective as well.
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. Discussion of these additional assessments and provision of approaches to help hospitals with higher infection rates would be useful to include in the AHRQ report.
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The AHRQ report should explore strategies for communicating the value of PSOs for organizations and reporting individuals to increase participation in the existing programs. A strategy should target all of the stakeholders who would benefit from PSOs' aggregate data functions, including health systems executives, patient safety executives, medical group leadership, and frontline clinicians.
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To participate in such an incentive effort, these specific PSO programs should be certified to accept data using Common Formats and to transmit relevant data to the NPSD using Common Formats. SECTION 4 Technical comments and corrections to the AHRQ draft report.
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From page 19... ...
Are there collaboration or partnership opportunities for the use of multi-organizational aggregate data? Consider Including Additional High-Profile National Patient Safety Programs and Initiatives • The CDC Epicenter Program, a research program in which CDC collaborates closely with academic investigators, has provided the basis for many of the evidence based practices currently used to prevent health care–associated infection, including CLABSIs (CDC, 2015)
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From page 20... ...
updated the evidence for these initially identified practices and also included evidence summaries of additional patient safety practices. The draft AHRQ report effectively uses Tables 1 to 28 to concisely summarize this enormous amount of work spanning nearly two decades.
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• Provide evidence-based guidance to the end user for prioritizing recommendations based on demonstrated impact beyond the developer's organization. Although the AHRQ draft report provides the rationale for moving away from providing single determinations of the strength of evidence for the patient safety programs covered, the key takeaways in the summary table ES.2 from MHS III could provide concise direction and guidance.
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. • China The National Patient Safety Incidents Reporting System (NPSIRS)
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These include automating EHR data collection, facilitating use of Common Formats for that data, and using artificial intelligence to derive insights from the aggregate data. Additional evidence regarding effectiveness that could be considered for discussion in the AHRQ draft include up-to-date assessments of PSOs and the NPSD and examples of data aggregation successes in other national patient-safety programs, such as the VHA.
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From page 24... ...
• Explore high visibility implementation strategies from other national patient-safety initiatives -- such as the VHA NCPS, FAERS, the FDA Sentinel Initiative, VAERS, the CDC Epicenters Program, IHI, and The Joint Commission -- and appropriate international examples. • Update AHRQ's responses to the OIG report recommendations with any subsequent results.
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