Fostering safe patient care environments is largely dependent on the ability to precisely detect, prevent and report adverse events. Nationwide estimates of inpatient harms are often underreported and rely on self-reported events, the use of administrative data or internal hospital incident reporting systems. A new study by Adventist Health System and Pascal Metrics, published in the Joint Commission Journal on Quality and Patient Safety, shows that these current safety reporting systems greatly underestimate cases of harm, whereas an all-cause automated electronic harm identification solution more broadly and efficiently detects and reports adverse events.
The study, "Developing and Evaluating an Automated All-Cause Harm Trigger System," shows how the Risk Trigger Monitoring system enabled the capture of more harm, provided a broader scope of harm and led to a deeper understanding of patient safety vulnerabilities. Piloted at two large hospitals over the course of 11 consecutive months, the automated system identified far more instances of harm than a manual review process did over similar time periods. The automated system, which used 41 automated triggers to detect and report harm in real time, was also able to detect events that transpired outside the hospital.
"We are extremely encouraged by the automated system's ability to give us a more accurate picture of the frequency and severity of harms that may occur," said Christine Sammer, DrPH, RN, director of corporate patient safety for Adventist Health System and lead author of the study. "Implementing a process that gives us greater understanding of harm enables us to take steps to reduce and prevent occurrences, and provide safer, more efficient care to patients."
Adventist Health System's intentional focus on harm reporting and reduction has led the organization to develop what it refers to as "Clinical Patient Safety Communications." The communications, which are based on some of the top 10 harm findings and/or patterns of harm, are distributed broadly across the system. They are also accompanied by recommendations for improvement.
"The safety of patients is of the utmost importance, and this latest report shows that IT solutions like the automated trigger system can create safer environments and ultimately contribute to better outcomes," said Loran Hauck, M.D., chief clinical officer for Adventist Health System. "This is a huge step in the right direction, and hopefully our research and focus can advance the patient safety conversation within the industry and encourage the adoption of solutions that prevent even more instances of harm."
Pascal Metrics, a leader in measuring and improving patient safety through advanced analytics, collaborated with Adventist Health System on the study and the development of the automated harm identification system.
"The results of this study serve as an example of how health systems can leverage automated trigger systems to alleviate certain types of harm, and as the industry broadens the use of these types of solutions, the resulting mitigation of harm will enhance safety for the benefit of patients inside and outside of the hospital setting," said David Classen, M.D., chief medical information officer for Pascal Metrics.