Quality Quarterly

Uncovering the True Impact of ‘No Harm’ in Patient Safety Events

Key Points: 

  • The Collaborative Healthcare Patient Safety Organization (CHPSO) has seen dramatic improvement in reducing unclassified events on its platform, dropping from 16.8% in 2022 to just 6.9% in 2024. 
  • Even when patients experience additional suffering, extended recovery, or psychological trauma, these impacts are frequently mislabeled as “no harm” if they do not result in catastrophic outcomes. 
  • Harm misclassification skews safety data and masks the true burden of harm.  

    • CMS Patient Safety Structural Measure Reporting Begins This Year — HQI Can Help

    Key Points:  

  • The Centers for Medicare & Medicaid Services’ (CMS) new Patient Safety Structural Measure is intended to improve hospital safety by focusing on structural elements that support a culture of safety. 
  • PSSM reporting begins in calendar year (CY) 2025. 
  • The Hospital Quality Institute’s (HQI’s) program HQI Cares: Implementing BETA HEART® helps hospitals meet this new requirement.  

    • Analysis Paper: How Methodological Choices Affect California’s 30-Day Hospital Readmission Rates

    Key Points: 

  • The calculation of 30-day hospital-wide all-cause readmission rates varies significantly across organizations due to differences in inclusion/exclusion criteria, data sources, and operational definitions. For example, the Centers for Medicare & Medicaid Services (CMS) uses both encounter and claims data, while the California Department of Health Care Access and Information (HCAI) and the Hospital Quality Institute (HQI) rely on patient-level encounter data only.  
  • HQI’s adherence to CMS methodologies results in higher alignment with national benchmarks, whereas HCAI’s broader criteria — such as counting all readmissions within 30 days and crediting readmitting facilities — lead to inflated statewide rates and potential inconsistencies for benchmarking.  
  • HQI’s methodology, closely mirroring CMS standards, supports standardized benchmarking and state-level policy decisions, whereas HCAI’s approach, while operationally useful, lacks consistency for broader comparative analyses.  

    • Analysis Paper: Using HQI’s Hospital Similarity Clusters Improves Quality Comparisons

    Key Points:  

  • Evaluating a hospital’s performance against its peers by comparing hospital quality metrics is important, but identifying appropriate peers can be complex.  
  • Clustering hospitals based on their similarity across multiple characteristics — such as inpatient admission volume and hospital type — can help identify more comparable peers.  
  • The Hospital Quality Institute’s (HQI’s) Hospital Similarity Clusters allow for comparisons and provide insights, as demonstrated in a recent article on sepsis mortality rates. 

    • HQIP Update: Hospital Enrollment, Utilization Trends, and Platform Enhancements

    Executive Summary

    The Hospital Quality Improvement Platform (HQIP) is a secure, web-based platform that provides quality measures for conditions significantly affected by hospital quality initiatives. HQIP offers hospitals access to clinically detailed, timely reports to help identify opportunities for improvement and areas for focus. It is available at no cost to all California Hospital Association members, does not connect to hospitals’ electronic health records systems, and utilizes data that hospitals already report to the California Department of Health Care Access and Information (HCAI), the National Healthcare Safety Network (NHSN), the Centers for Medicare & Medicaid Services (CMS), and the California Maternal Quality Care Collaborative.   

    Anaphylactic Shock Highlights the Crisis in Medication Safety

    Key Takeaways 

  • Cases of anaphylaxis have risen by 33% 
  • Anaphylaxis is especially dangerous in perioperative settings where sterile drapes hide visible skin reactions, and sedated patients cannot report their symptoms 
  • Chlorhexidine has emerged as an increasingly frequent trigger 

    • The Relationship Between Hospital Sepsis Bundle Compliance and Sepsis Mortality

    Key Points 

  • Statewide SEP-1 Sepsis Bundle compliance has increased over time. Sepsis mortality declined overall but spiked during the COVID-19 pandemic, indicating challenges in sustaining improvements. 
  • Higher hospital SEP-1 Sepsis Bundle compliance is associated with lower mortality rates, but the correlation weakened over time (from r = -.31 in 2017 to r = -.17 in 2022) and varied significantly by hospital characteristics such as ownership type and transfer volume. 
  • Investor-owned hospitals and those with smaller sample sizes exhibited weaker or negligible relationships between compliance and mortality, highlighting the role of contextual factors and the need for hospital-specific strategies. 

    • Ozempic and Wegovy: Are These Popular Diabetes and Weight Loss Drugs Associated with Increases in Serious Side Effects?

    Key Points:

  • Prescriptions for semaglutide, marketed under the names Ozempic and Wegovy, surged almost 3,000% in the U.S. from 2018 to 2022. 
  • Encounters of gallbladder inflammation in California hospitals surged by 492% during the study period, potentially linked to the slowed digestion caused by long-term semaglutide use. 
  • Hospital encounters in California related to acute kidney injuries rose by 18% and cases of low blood sugar (hypoglycemia) increased by 27%, suggesting these may be emerging areas of concern for semaglutide users.