AHRQ Developing New Tool To Update Monitoring of Patient Safety

A new online patient safety tool being developed by AHRQ is intended to track adverse events in hospitals by capturing data from Medicare patients’ electronic health records. The Quality and Safety Review System (QSRS) will be tested by Johns Hopkins University and MedStar Health Research Institute as a replacement for the current Medicare Patient Safety Monitoring System (MPSMS). While substantial progress has been made in monitoring and measuring patient harms, MPSMS has approached its useful limits because it relies on outdated software, can’t identify rare or unusual events and is unable to measure adverse events not currently defined by one of the system’s 21 measures, according to a recent article in the Journal of Patient Safety. The AHRQ-funded article, “Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future),” reviewed the strengths and limitations of MPSMS and other methods for measuring patient safety. Authors also explored expected future directions in patient safety measurement while focusing on issues that are informing the development and implementation of QSRS. Access the abstract and a new AHRQ Views blog post, "New System Aims To Improve Patient Safety Monitoring."

AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

AHRQ Quality and Safety Review System

Improved patient safety monitoring

Background

The Institute of Medicine report, To Err Is Human, revealed more than 15 years ago the extent of medical errors that occur in U.S. hospitals. Safety experts -- including AHRQ, the Centers for Medicare & Medicaid Services (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 Medicare Patient Safety Monitoring System (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 now in its 15th year. This chart review-based surveillance system determines national rates for 21 types of adverse events, including certain hospital-acquired conditions (HACs), such as post-surgical complications and pressure ulcers, but has some limitations that AHRQ is addressing with a new surveillance system.

Current Project

AHRQ is developing and testing an improved patient safety surveillance system to replace MPSMS that is known as the Quality and Safety Review System (QSRS). The QSRS 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. 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.

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.
Capture an “all-cause harm” measurement that hospitals and clinicians can use to better target and measure quality improvement efforts.
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.
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. This will ensure that an event identified at one institution is the same as one identified elsewhere.

Pilot Testing

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

Page last reviewed October 2016

Internet Citation: AHRQ Quality and Safety Review System. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/qsrs/index.html

2016 Oct 20. [Epub ahead of print]

Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future).

Classen DC1, Munier W, Verzier N, Eldridge N, Hunt D, Metersky M, Richards C, Wang Y, Brady PJ, Helwig A, Battles J.

Author information

Abstract

The explicit declaration in the landmark 1999 Institute of Medicine report "To Err Is Human" that, in the United States, 44,000 to 98,000 patients die each year as a consequence of "medical errors" gave widespread validation to the magnitude of the patient safetyproblem and catalyzed a number of U.S. federal government programs to measure and improve the safety of the national healthcare system. After more than 10 years, one of those federal programs, the Medicare Patient Safety Monitoring System (MPSMS), has reached a level of maturity and stability that has made it useful for the consistent measurement of the safety of inpatient care. The MPSMS is a chart review-based national patient safety surveillance system that provides rates of 21 specific hospital inpatient adverse event measures, which have been divided into 4 clinical domains (general, hospital-acquired infections, postprocedure adverse events, and adverse drug events) for analysis. The 2014 MPSMS national sample was drawn from 1109 hospitals and includes approximately 20,000 medical records of patients admitted to the hospital (all payors) for at least 1 of the 4 conditions of congestive heart failure, acute myocardial infarction, pneumonia, and major surgical procedures as defined by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. The MPSMS is now going through a major transformation to capture additional types of adverse events and is being redeveloped as the Quality and Safety Review System (QSRS). As an example of this transformation, QSRS will electronically import electronic data, which are standardized according to the Centers for Medicare and Medicaid Services billing definitions and will be updated and evolve over time to incorporate expanded standardized data available from electronic health records. This article reviews the development of MPSMS, the strengths and limitations of MPSMS, and expected future directions in patient safety measurement, focusing on those issues that are informing the development and implementation of QSRS.