Quality Improvement

Reports on patient safety indicate progress, challenges and a need to focus on pediatric mental health

Hospital-based quality measures have improved in key areas, but clinician and staff feedback and statistics on disparities suggest much work remains.

March 29, 2023 4:28 pm

Recent reports add context to the issue of patient safety in hospitals and health systems.

ECRI released a report that ranks the pediatric mental health crisis as the No. 1 patient safety issue in healthcare. The report cites a JAMA study that found increases of 29% in anxiety and 27% in depression between 2016 and 2020 among children ages 3 to 17.

The report also notes that the number of adolescent visits to the emergency department for suspected suicide attempts increased by 39% between early 2019 and early 2021, according to the CDC.

ECRI and its affiliate, the Institute for Safe Medication Practices (ISMP), analyzed “a wide scope of data to identify the most pressing threats to patient safety, including scientific literature, patient safety events, concerns reported to or investigated by ECRI and ISMP, client research requests and queries, and other internal and external data sources,” according to the report.

The rest of the top five patient safety issues are:

  • Physical and verbal violence against healthcare staff
  • Clinician needs in times of uncertainty surrounding maternal-fetal medicine
  • Impact on clinicians expected to work outside their scope of practice and competencies
  • Delayed identification and treatment of sepsis

Among those issues and others listed in the report, ECRI notes that several are aggravated by ongoing staffing shortages.

Changes in quality performance

The federal Agency for Healthcare Research and Quality (AHRQ) this month released an updated version of its Chartbook on Patient Safety, including a look at progress in the agency’s healthcare quality measures between 2000 and 2020.

In the patient safety domain, 17 of 29 measures improved, while 11 remained the same. One got worse: “Adults who reported a home healthcare provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home healthcare.”

When looking at specific settings, nine hospital-based quality measures improved, while five stayed the same. Of two ambulatory-based measures, both improved.

Among the hospital-based measures that improved were key outcome measures:

  • Postoperative measures on:
    • Sepsis
    • Pulmonary embolism or deep vein thrombosis
    • Respiratory failure, prolonged mechanical ventilation or reintubation
    • Acute kidney injury
  • Deaths per 1,000 elective-surgery admissions who developed serious treatable complications of care during hospitalization, ages 18-89 or obstetric admissions
  • Deaths per 1,000 hospital admissions with expected low mortality, ages 18 and over or obstetric admissions

The measure with the largest rate of improvement was postoperative respiratory failure, prolonged mechanical ventilation or reintubation per 1,000 elective-surgery admissions.

Across settings, the 64% share of patient safety measures that improved was better than for the other broad domains tracked by AHRQ, including person-centered care (36%), healthy living (50%), effective treatment (30%) and care coordination (30%).

Hospital staff views on patient safety

An AHRQ survey on patient safety culture spanned November 2020 to July 2022 and drew responses from 206,410 clinicians and staff at 400 hospitals. Among 10 composite measures, teamwork (82%) and supervisor, manager or clinical leader support for patient safety (80%) were most likely to be viewed positively.

Staffing and work pace (51%) was least likely to be viewed positively and most likely to be viewed negatively (27%). Hospital management support for patient safety also drew a relatively high share of negative responses (20%).

By averaging the rate of positive responses across the 10 measures, the survey could gauge a hospital’s overall patient safety score. Hospitals in the top quartile had a score of 75%-85%, compared with 39%-65% for those in the lowest quartile.

A supplemental survey examined workplace safety and featured responses from 11,710 clinicians and staff at 40 hospitals between May 2021 and July 2022. Among the six categories, protection from workplace hazards (90%) had an overwhelmingly positive response. However, performance on addressing workplace aggression by patients or visitors was viewed positively by only 56% of respondents and negatively by 25%.

Striving for more equitable care

Both reports highlight room for improvement in health equity.

Referring to the pediatric mental health crisis, Dheerendra Kommala, MD, chief medical officer at ECRI, noted those affected are “disproportionately” in “historically marginalized communities.”

“Structural barriers and bias block access to high-quality mental healthcare for youth of color and LGBTQ youth despite the fact they are more likely to experience depression and anxiety and attempt suicide at higher rates,” Kommala said in a news release.

And when breaking down changes in quality measures by demographic, the AHRQ report found some notable disparities across healthcare settings.

For example, compared with high-income patients, poor patients fared worse on five quality measures (among them postoperative measures involving sepsis, respiratory failure and acute kidney injury, and deaths per 1,000 hospital admissions with expected low mortality) and better on none.

Black patients fared worse than white patients on 10 measures (including several involving postoperative complications), although they also fared better on five (including birth trauma and measures pertaining to nursing homes and home healthcare).

Hispanic patients fared worse on five measures (including postoperative sepsis and respiratory failure) and better on six (including birth trauma).

“No patient safety measure had worsening disparities over time,” the report notes.


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