Broadening the definition of patient-safety events: lessons from a multicentre learning health system collaborative

Abstract

Background: Improving safety in healthcare has been paramount for decades, yet despite major attention and investment, improvement has remained incremental. Patient safety is a major concern in US healthcare, leading to significant harm and economic losses annually. Accurately identifying safety events remains difficult due to methodological discrepancies and lack of standardisation. This study evaluated the feasibility of implementing a standardised case-review methodology and safety-event taxonomy across diverse hospital settings to assess opportunities for improvement (OFIs) and compare findings with traditional definitions.

Methods: This multicentre retrospective cohort study reports data from 103 hospitals across the USA and Canada between 2016 and 2023. A multivariable logistic regression was performed to test case reviews for differences in the presence of one or more OFIs across several hospital types (bed size, academic status, urban setting, trauma level and Centres for Medicare and Medicaid Services overall star rating) and patient characteristics (age, gender, length of stay, admission and discharge code status and mortality).

Results: 19 181 cases were reviewed across the Learning Health System Collaborative, with a median of 107 reviews per hospital. Mortality was the most common cohort selection, studied by 91 hospitals (88%). At least one OFI was identified in 12 714 cases (66.3%). The logistic regression analysis found that all hospital characteristics and patient age, length of stay, code status and discharge disposition were significantly associated with at least one OFI. Of the 46 444 OFIs identified, 41 439 (89%) were from categories focused on omissions of care. The categories of end-of-life, documentation and treatment/care alone accounted for 25 980 OFIs (56%).

Conclusion: The highest volumes of safety-related OFIs were associated with omissions of care, as opposed to the traditional definition of patient safety, which primarily includes outcomes from acts of commission.

Keywords: Adverse events, epidemiology and detection; Chart review methodologies; Healthcare quality improvement; Incident reporting; Patient safety.

Figure 1. High-level case-review life cycle. Workflow used by all members of the LHSC to perform case reviews. Sequential or randomly selected cases within a cohort are assigned to at least two case reviewers from different disciplines (eg, a nurse and a physician). Each independent review is shared among a multidisciplinary, multispecialty committee where a facilitated discussion occurs to reach consensus regarding whether the issues identified by the reviewers are counted as OFIs. Selected cases are shared with clinical areas to ‘CTL’ and promote the generalisation of knowledge learnt from that case via case-based education opportunity. After the chosen case reviews are completed, the cohort data are aggregated, analysed and shared broadly across clinical practice, quality and leadership stakeholders. CTL, close the loop; LHSC, Learning Health System Collaborative; OFIs, opportunities for improvement.

Figure 2. Percentage of hospitals studying common cohorts by category. Cohorts were grouped into common categories. The percentage of all hospitals participating in the LHSC with at least one case review from each cohort category is presented here. The specific cohorts studied could be more targeted (ie, 30-day sepsis mortality or pneumonia readmissions) and could be included in more than one of the broader categories. ICU, intensive care unit; LHSC, Learning Health System Collaborative.

Figure 3. Pareto of OFI categories. The categories of OFIs identified across all case reviews are visualised in this Pareto chart with bars for category counts and the green line for the cumulative percentage. To reflect our expanded definition of patient safety, category bars were coloured by whether they were included in the traditional definition of patient-safety events using the IHI global trigger tool as a reference. The names of the OFI categories here have been shortened for visual clarity. For full names, definitions and examples, refer to table 1. OFI, opportunity for improvement.