Get Full Government Meeting Transcripts, Videos, & Alerts Forever!
Get email alerts on the AHRQ Gap Analysis topic
No spam. Unsubscribe anytime.
AHRQ summary: diagnostic safety, adverse drug events and ambulatory gaps in patient safety indicators
Summary
AHRQ presented a gap analysis recommending review of existing PSIs to reduce overlap and expansion of indicators into diagnostic safety, adverse drug events, maternal/neonatal measures and ambulatory/perioperative settings; AHRQ and CMS are coordinating measure development and testing.
Commander Karen Chavez, director of the Division of Quality Measurement and Improvement at the Agency for Healthcare Research and Quality, summarized a gap analysis of the AHRQ Patient Safety Indicators (PSIs) that identified multiple measurement shortfalls and recommended targeted expansion.
Chavez told PTEC that the PSI module currently lacks specific diagnostic‑safety measures and that the study flagged missed labs, imaging and delayed follow‑up as opportunities for measurement. "Currently, the PSI module does not have measures that specifically address diagnostic safety," she said, noting work underway on cancer screening follow‑up measures.
The analysis also identified adverse drug events (ADEs) as the most common form of patient harm and noted the PSI module does not include ADE measures. Chavez said stakeholders recommended focusing on serious ADEs and high‑alert medications such as opioids, anticoagulants and insulin and exploring patient‑reported data as a supplementary source.
Healthcare‑associated infections and healthcare‑associated conditions were discussed as areas for potential refinement; Chavez said AHRQ is cautious about duplicating CDC NHSN efforts and is considering retiring some existing PSIs while expanding others. The study also highlighted gaps for maternal and neonatal safety beyond hospital settings and for ambulatory and perioperative care.
Chavez closed with four recommendations: review existing PSIs to eliminate overlap with other federal measures; expand PSIs into ambulatory surgical centers and perioperative care; broaden maternal and neonatal indicators to settings beyond hospitals; and continue identifying data sources to measure diagnostic errors.
