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Objective: Washington State's HealthPact program was launched in 2011 as part of AHRQ's Patient Safety and Medical Liability Reform initiative. HealthPact delivered interdisciplinary communication training to health-care professionals with the goal of enhancing safety. We conducted 2 exploratory, retrospective database analyses to investigate training impact on the frequency of adverse events (AEs) and select quality measures across 3 time frames: pretraining (2009-2011), transition (2012), and posttraining (2013).Methods: Using administrative data from Washington State's Comprehensive Hospital Abstract Reporting System (CHARS) and clinical registry data from the Surgical Care and Outcomes Assessment Program (SCOAP), we compared proportions of AEs and quality measures between HealthPact (n = 4) and non-HealthPact (n = 93-CHARS; n = 48-SCOAP) participating hospitals. Risk ratios enabled comparisons between the 2 groups. Multivariable logistic regression enabled investigation of the association between training and the frequency of AEs.Results: Approximately 9.4% (CHARS) and 7.7% (SCOAP) of unique patients experienced 1 AE or greater. In CHARS, the odds of a patient experiencing an AE in a HealthPact hospital were initially (pretraining) higher than in a non-HealthPact hospital (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.10-1.17), lower in transition (OR, 0.80; 95% CI, 0.76-0.83) and posttraining (OR, 0.72; 95% CI, 0.69-0.75) periods. In SCOAP, ORs were consistently lower in HealthPact hospitals: pretraining (OR, 0.87; 95% CI, 0.80-0.95), transition (OR, 0.75; 95% CI, 0.70-0.81), and posttraining (OR, 0.63; 95% CI, 0.58-0.68). The proportion of at-risk patients that experienced each individual AE was low (<1%) throughout. Adherence to quality measures was high. Conclusions:Interprofessional communication training is an area of intense activity nationwide. A broad-based training initiative may play a role in mitigating AEs.

Background: Understanding quality improvement (QI) reporting patterns is important for practice-based improvement and for prioritizing QI initiatives. The aim of this project was to identify major domains of neuroanesthesiology QI reports at a single academic institution with 2 hospital-based practice sites.Methods: We retrospectively reviewed institutional QI databases to identify reports from neuroanesthesia cases between 2013 and 2021. Each report was categorized into one of the 16 primary predefined QI domains; the QI report domains were ranked by frequency. Descriptive statistics are used to present the analysis.Results: Seven hundred three QI reports (3.2% of all cases) were submitted for the 22,248 neurosurgical and neuroradiology procedures during the study period. Most of the QI reports across the institution were in the domain of communication/ documentation (28.4%). Both hospitals shared the same 6 top QI report domains, although the relative frequency of each domain differed between the 2 hospitals. Drug error was the top QI report domain at one hospital, representing 19.3% of that site's neuroanesthesia QI reports. Communication/documentation was the top domain at the other hospital, representing 34.7% of that site's reports. The other 4 shared top domains were equipment/ device failure, oropharyngeal injury, skin injury, and vascular catheter dislodgement. Conclusions:The majority of neuroanesthesiology QI reports fell into 6 domains: drug error, communication/documentation, equipment/device failure, oropharyngeal injury, skin injury, and vascular catheter dislodgement. Similar analyses from other centers can guide generalizability and potential utility of using QI reporting domains to inform the development of neuroanesthesiology quality measures and reporting frameworks.

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PurposeThe number of patients with diabetic peripheral neuropathy is increasing in Wahkiakum County, Washington. Nationwide, estimates of the lifetime incidence of diabetic foot ulcers are as high as 25%, and as many as 30% of patients with ulcers eventually undergo amputation. With such morbidity and treatment costs in thousands of dollars per ulcer, prevention is important; patient education about foot self-care is part of this pursuit. A community medicine project was undertaken by the author in July 2005 to create clear, concise patient reference materials to help clinicians provide consistent education to all diabetics about the benefits of following a foot care plan. The materials target patients at Wahkiakum Family Practice Clinic (WFPC) in Cathlamet, Washington, the only medical clinic in Wahkiakum County.MethodsCurrent foot care recommendations were compiled from NIH, American Diabetes Association, and local care providers. Topics include routine diabetes management, daily foot inspection, skin and nail care, and footwear selection. The material was organized under subheadings that can be used to guide a clinician/patient discussion. There was agreement among local clinicians that the information was accurate and would be useful in patient education efforts.ResultsThe content was adapted to a brochure format for use at WFPC. The illustrations, level of detail, and simple language allow the brochure to stand alone, although it is intended to be initially reviewed during an office visit. A clinician may use this resource in providing individualized instruction relevant to each patient's risk of complications, level of understanding, and motivation for self-care activities.ConclusionPrinted reference materials may be useful in delivering consistent patient education. Providing this guidance is an important component of prevention endeavors.

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