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Patient Safety Learning Laboratory

Preventing Adverse Events Post-Discharge through Proactive Identification, Multidisciplinary Communication, and Technology

Background

Adverse events (AEs) occur in 19-23% of hospitalized patients in the 30 days after discharge. The most common AEs occurring after discharge include: adverse drug events (72%), therapeutic errors (16%) and hospital acquired infections (11%).

Evidence suggests the risk of post-discharge AEs and the unanticipated utilization of healthcare resources such as readmission are higher for patients with Hospital Acquired Conditions (HACs).

Study Goals

The aim of the AHRQ-funded PREDICT I study was to utilize the Patient Safety Dashboard, a health information technology tool integrated in the institution’s electronic health record (EHR) system, to decrease adverse events (AEs) for patients discharged from BWFH who are at risk for preventable harm and hospital readmission.

Methods

Data from various administrative clinical sources, including the Enterprise Data Warehouse and a rigorous two-person EHR chart review process, were aggregated, cleaned, and analyzed. Data on key hospital process measures was also collected and analyzed. A total of 268 patients (125 pre- and 143 post-intervention) were enrolled.

Results

Our unadjusted analyses showed an insignificant decrease in adverse events in the pre- and post-intervention cohort.

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