Preventing Adverse Events Post-Discharge through Proactive Identification, Multidisciplinary Communication, and Technology
Background & Goals
Decrease adverse events (AEs) for patients discharged from BWFH who are at risk for preventable harm and hospital readmission
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).
Categories of Hospital Acquired Conditions (HACs) and Preventable Harms
Patient Safety Dashboard
Proactively identify hospitalized patients at risk for preventable harm and suboptimal discharge preparation
The Patient Safety Dashboard has implemented many technical improvements. PREDICT aims to emphasize a Systems Engineering and Human Factors approach to operationalize the dashboard across Brigham Health. The dashboard is currently live at Brigham and Women’s Faulkner Hospital.
The dashboard can be used to quickly identify at risk patients and institute appropriate care, while reducing provider cognitive load and improve decision-making. Using the Discharge Safety dashboard column and Patient Discharge Preparation Checklist from our PDTK study, providers have continual updates on patient readiness for discharge. The dashboard data is updated in real-time to reflect patient’s status.
The dashboard can be pinned to both the top menu and the left-hand side navigator of the EHR. Members of a patient’s care team can review red/yellow flags, click quick links to take recommended actions, and defer actions as appropriate. Relevant documentations such as orders can also be updated as pertinent.