- The Agency for Healthcare Research and Quality (AHRQ) is developing an improved patient safety surveillance system aimed at reducing the number of medical errors at U.S. hospitals.
- The Quality and Safety Review System will replace the 15-year-old Medicare Patient Safety Monitoring System, whose usefulness has “reached its limits,” Jeffrey Brady, director of AHRQ’s Center for Quality Improvement and Patient Safety, said in a blog post Tuesday.
- CMS created the MPSMS following a 1999 Institute of Medicine report that found a high rate of medical mishaps and adverse events at U.S. hospitals.
While the rate of medical errors has declined since the "To Err Is Human" report, it is still too high with about 120 events per 1,000 hospital stays, Brady writes. The ECRI Institute reported last month providers regularly misidentify patients "during procedures and processes, including but not limited to patient registration, electronic data entry and transfer, medication administration, medical and surgical interventions, blood transfusions, diagnostic testing, patient monitoring, and emergency care."
Yet more than 251,000 deaths are related to medical errors each year, according to researchers at Johns Hopkins School of Medicine. And the annual cost of preventable medication errors can range between $4.2 billion and $16.4 billion, the National Priorities Partnership estimated.
The new QSRS will draw on clinical information in electronic patient records and is designed to capture structured data, such as prescriptions and lab results, according to an overview of the system. It will also have more adverse event measures than the 21 tracked by the MPSMS, which was transferred to AHRQ in 2009, as well as an “all-cause harm” measure to help hospitals target areas for improvement. Other features include more detailed information on the most frequently occurring events and algorithms to match events across different hospitals.
AHRQ has awarded contracts to Johns Hopkins University and the MedStar Health Research Institute to pilot the QSRS in hospitals. “The science of adverse event monitoring and measurement is complex, but the ultimate goal is simple: making patient care safer,” Brady writes. “AHRQ will continue to develop the tools and resources, including the QSRS, to ensure that this goal moves within our reach.”