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.
Longstanding Patient Safety Hazards Remain, ‘Lateral Violence’ Emerges
In Q2 2024, hospitals reported longstanding patient safety hazards, including falls, ineffective communication, care transition failures, patient-directed discharges, and lateral violence.
More specifically, falls remain a critical focus, with an uptick in incidents occurring when patients are left unsupervised for privacy during toileting. Alarming trends in inter- and intra-hospital “patient dumping” surfaced, with nurses finding patients placed in rooms without receiving any report or treatment plan. Finally, visitor compliance issues increased; hospitals reported private caregivers secretly administering unapproved medications and smuggling contraband into the facility.
Lateral violence emerged as a top signal, highlighted by incidents of staff exhibiting aggressive behavior toward peers and physically hiding to avoid their duties, and providers publicly berating team members.
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.
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 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.
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.