Project Details

Challenge:

Since the Institute of Medicine (IOM) released a report in 1999 entitled “To Err is Human: Building a Safer Health System ” that showed errors cause between 44 000 and 98 000 deaths and over one million injuries annually among hospitalized patients, acute care providers have become increasingly committed to improving patient safety. The first step towards improving patient safety was to create a comprehensive, robust and standardized national patient safety surveillance system in MPSMS. With increasing adoption of electronic health records (EHR) the current challenge is to leverage information captured within these records to provide real time data to drive improvement.

Solution:

In 2001 Qualidigm worked on a team with CMS leadership to create the Medicare Patient Safety Monitoring System (MPSMS). Under the leadership of AHRQ we have been maintaining it for over seventeen years. MPSMS identifies the national rates of specific medical adverse events occurring within the hospitalized adult population, focusing on patient harm rather than medical error. The data is used to produce the National Hospital Acquired Conditions rate used to evaluate the Department of Health and Human Services’ Partnership for Patients initiative. In 2018 Qualidigm received a contract from AHRQ to transition MPSMS to the Quality and Safety Review System (QSRS) allowing electronic capture of data where available.

Benefit:

MPSMS is now the largest and most robust national patient safety-focused data source of medical record-abstracted, clinical data available today. Data is available to researchers for discharges from 2002-2007 and 2009-2017. MPSMS data can be used for the identification, aggregation and trending of condition-specific and measure-specific harm experienced by adult hospitalized patients. Since 2004 it has sourced both the National Healthcare Quality and Disparities Reports, and the Partnership for Patients initiative. QSRS is poised to become the future of patient safety-focused data and will ultimately allow hospitals to capture real time data and provide opportunities for benchmarking and best practice sharing.