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 Collaborative Healthcare and Patient Safety Organization (CHPSO) patient safety reports. Every quarter, HQI aggregates these signals across reporting hospitals to provide a statewide perspective.
Q1 2025 CHPSOData Patient Safety Signals
In the first quarter of 2025, CHPSO reported signals related to provider disputes, unhealthy workplace culture, unexpected clinical events, and electronic health record (EHR) inconsistencies across departments.
Staff qualifications — and more specifically, training gaps — emerged as the most frequently reported contributing factor in each of these areas, particularly with respect to EHRs.
Provider Disputes and Incomplete Orders
- Incomplete medication orders and disputes between providers about the patient’s level of care contribute to missed care, as well as delays in transfers and discharges.
- Actionable Insight: Clear escalation pathways and standardized EHR order sets may reduce ambiguity and prevent care delays.
Unprofessional Conduct Undermines Patient Trust
- Staff members making rude, disparaging remarks in front of patients erodes patient confidence.
- Actionable Insight: Swift and consistent enforcement of professional conduct standards protects both staff morale and patient trust.
Uncommon Medication Reactions Expose Knowledge Gaps
- Staff members encountered challenges managing less common adverse events, including ceftriaxone-induced thrombocytopenia, amiodarone infiltration, and heat sensations during chemotherapy infusions.
- Actionable Insight: Provide clear, accessible point-of-care guidance for infusion-related reactions and vesicants to support timely and appropriate clinical response.
Environmental, EHR Failures Impact Safety
- Reports included unsecured wall-mounted items, ineffective signage, and EHR inaccuracies that misrepresented both patient location and procedure schedules.
- Actionable Insight: Implement regular environment-of-care and health information technology audits to identify safety hazards and prevent workflow disruptions.
Tackle Training Gaps
Hospitals often adopt a single EHR across the entire facility or health system, but worker interfaces and access pathways will vary by care area or department.
Actionable insights: Hospitals must provide ongoing EHR support to prevent care delays. Support should include searchable help topics, quick one-minute tutorials, and access to EHR superusers on every shift. EHR training — especially in teaching hospitals — must ensure that medical residents, newly licensed nurses, traveling nurses, and float staff receive role-appropriate instruction on these nuances.
The interactive table below shows aggregate signals from all hospitals that contribute to CHPSOData; to interact with hospital-specific data, log in to CHPSOData.
The Hospital Quality Improvement Platform (HQIP) provides hospital leaders with the ability 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.
View Definitions
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 that appear will always be shown in alphabetical order.
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 that most commonly occurs with the signaling term in the patient safety records.