Q1 2024 Collaborative Healthcare and Patient Safety Organization (CHPSO)
About HQI’s Sentinel Signal Detection System Report
HQI’s sentinel signal detection system automatically detects abnormal changes (i.e., signals) in the incidence of terms detected in CHPSO patient safety reports. Every quarter, HQI aggregates these signals across reporting hospitals to provide a statewide perspective.
Falls, Patient Directed Leaves and Healthy Work Environment Challenges Emerge
In Q1 2024, workplace violence continued to disrupt safe and effective patient care, with hospitals reporting an increase in combative patients, staff on staff bullying and harassment (lateral violence), and visitor altercations. Hospitals saw an increase in patient falls, life-threatening safety events such as ectopic pregnancies, and patients leaving against medical advice (patient directed leave). Ineffective communication among team members signaled resulting in missed care, procedures performed despite contraindications, and delays in imaging studies. Additionally, patient safety events related to medication errors and device issues signaled, particularly in outpatient care areas, perioperative and laboratory settings.
HQIP provides hospital leaders with the capability to review the latest signals for their organization each quarter. In this report, these signals are aggregated across reporting hospitals and provided as counts representing a statewide signal.
As an example, consider these results for the term “intimidate”:
The Term indicates the word or word grouping reported. Natural Language Processing techniques are implemented to capture as much context as possible. For example, the words “intimidate,” “intimidates,” and “intimidated” would all be counted as “intimidate.” Pairs of words which appear will always be shown in alphabetical order. For example, “used a hoyer lift” and “lifted with hoyer” would both be shown as “hoyer lift” in this report.
The Positive column gives the number of reporting hospitals that had a statistically significant increase in the count of uses of this term for this quarter (i.e., the count of positive signals).
The Negative column gives the number of reporting hospitals that had a statistically significant decrease in the count of uses of this term for this quarter (i.e., the count of negative signals).
The Neutral column gives the number of reporting hospitals that did not see a statistically significant change in the count of uses of this term this quarter.
The Net Signal Value provided is the absolute difference between the number of Positive and Negative signals. The absolute difference is the difference between the two with a positive sign; a Positive Signal count of 20 and a Negative Signal count of 12 would lead to a Net Signal Value of 8 (as would a Positive Signal count of 12 and a Negative Signal count of 20).
The Most Correlated Term gives the term which most commonly occurs with the signaling term in the patient safety records.
The # category provides a bar chart with the quarterly counts of uses of this term among reporting hospitals. Hovering over each bar with a mouse cursor will provide a tooltip with the quarterly counts. Some reporting hospitals are excluded from this report if the most recent quarter’s report volume is much higher or much lower than typical for those hospitals.