On World Patient Safety Day, AHRQ Highlights the Urgent Need to Address Diagnostic Safety

Robert Otto Valdez, Ph.D., M.H.S.

As the healthcare community prepares to recognize World Patient Safety Day 2024 on Tuesday, we look forward to joining Department of Health and Human Services (HHS) Secretary Xavier Becerra and other healthcare leaders at the White House to commemorate the observance and affirm our commitment to safe care everywhere and zero preventable harm for all.

AHRQ is a federal leader in efforts to advance patient and healthcare worker safety, and we are proud that the National Action Alliance for Patient and Workforce Safety - an initiative led by AHRQ on behalf of HHS-will be highlighted at the event as a cornerstone of supporting national efforts to ensure that patients and healthcare workers are protected from avoidable harms.

This year's World Patient Safety Day theme is "Improving Diagnosis for Patient Safety." Over the last five years, AHRQ has been fortunate to have dedicated funds to support safe and timely diagnosis. The resources resulting from these investments will be featured tomorrow on World Patient Safety Day in this month's National Action Alliance webinar, where experts will share recently developed tools and strategies for reducing diagnostic errors. (Note: registration remains open!)

The need to reduce diagnostic errors is urgent. Some estimate that up to 795,000 Americans die or are permanently disabled each year due to misdiagnosis. These errors disproportionately affect the most vulnerable in our country. In primary care, delayed or missed diagnoses of cancer commonly allow the disease to progress to a less treatable stage, worsening prognosis and decreasing survival.

AHRQ's efforts to tackle this challenge are wide-ranging:

• Four toolkits-MeasureDx, CalibrateDx, TeamSTEPPS, and the Toolkit for Engaging Patients to Improve Diagnostic Safety-provide clinical teams and patients with resources to recognize risks, avoid errors, learn from mistakes that occur, and improve team training.
• Twenty-two diagnostic safety issue briefs summarize the state of science or identify calls to action on topics ranging from the impact of cognitive load to the value of nurses in diagnostic safety to accessing patient experiences as a strategy for understanding the origin of errors.
• Ten Diagnostic Safety Centers of Excellence are working to develop systems, measures, and technology solutions to improve diagnostic safety.
• Looking ahead, an AHRQ-supported special supplement in Academic Emergency Medicine will highlight research findings that provide fresh insights into improving diagnostic safety in emergency departments.

Craig A. Umscheid, M.D., M.S.

While these and other resources and activities underscore AHRQ's commitment to improving diagnosis, the agency continues to tackle safety in many other ways. A notable example is the recent release of Adverse Events Among In-Hospital Medicare Patients in 2021 and 2022 (PDF, 2 MB). This report suggests we're making some progress since the pandemic's peak, with a 13-to-15 percent reduction in adverse events in 2022 compared to 2021.

Developed with our partners at the Centers for Medicare & Medicaid Services, the report is based on data from AHRQ's Quality and Safety Review System (QSRS). The QSRS is a new one-of-a-kind national repository that includes data on 41 types of adverse events experienced by hospitalized Medicare patients and creates a baseline to assess the national impact of ongoing patient safety improvement initiatives. Among the report highlights:

• In 2021, 7.1 percent of Medicare patients experienced at least one adverse event per hospital stay, with 83.6 adverse events per 1,000 discharges. These rates improved in 2022, decreasing to 6.2 percent of patients and 71.1 adverse events per 1,000 discharges.
• In both 2021 and 2022, the three most common individual adverse events for populations with sufficient size for analysis were: 1) worsening pressure injuries that were present on admission (2021: 4.9 percent, 2022: 6.0 percent), 2) hypoglycemic events (4.7 percent for both years), and 3) adverse events related to intravenous unfractionated heparin (2021: 4.2 percent, 2022: 3.0 percent).

On World Patient Safety Day and every day, AHRQ is working to advance patient and healthcare worker safety research and is developing tools and other resources to help healthcare systems and clinicians deliver the safest care possible, including correct and timely diagnoses.

Through research investments and work with our public and private partners, we will continue to prioritize patient and healthcare worker safety, advancing our collective vision of safe care everywhere and zero preventable harm for all. Please visit our National Action Alliance for Patient and Workforce Safety website to see how we can help you in this effort.

Dr. Valdez is director of AHRQ. Dr. Umscheid is director of AHRQ's Center for Quality Improvement and Patient Safety.

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