Unlocking Patient Safety: The Power of Autodetection in Healthcare

By Chris Emerson, PharmD, Vice President of Clinical Services

At VigiLanz, we believe the key to preventing safety events and reducing harm is not about what you know is happening, but what you don’t know. As the only offering on the market with the ability to autodetect safety events, our safety surveillance software can dramatically increase your organization’s event capture by augmenting voluntary event reporting with events that are automatically detected. Not only does this create greater awareness of potential harm, it provides a more complete understanding of patient safety inside your institution so that you can put more effective measures in place to prevent future events. Let’s explore this a little more deeply.

The True State of Patient Safety 

Event reporting is a well-known practice for establishing a strong culture of safety. Designed to improve quality of care, an effective event reporting system helps health systems learn from mistakes by providing insights into the root causes of harm. Traditionally, events are captured through a voluntary process that requires staff to be aware that an event has occurred, and then take the initiative to manually report the incident using the institution’s event reporting process.

According to survey data collected by the AHRQ, there is an overall perception in healthcare that this approach is working. Eighty-three percent of survey respondents believe safety events are always reported when a mistake reaches the patient, and 65 percent believe they are always reported when a mistake is caught and corrected before causing harm. The reality, however, is much different.

A study released by the U.S Department of Health and Human Services estimates that roughly 86 percent of patient safety incidents occurring in healthcare organizations go unreported. Other studies have published varying percentages, but what’s clear is that we are dramatically underreporting safety incidents in healthcare. As a result, organizations are left with only a portion of the data they need to fully understand what is happening inside their facilities. 

Why does this matter? Without these insights, threats to safety can go unresolved and cause significant preventable damage to patients’ physical, mental, and financial health. Another recent study found that nearly one in four patients experience an adverse event, and of that number, nearly one-quarter of the events were preventable. These numbers are far too high. We must work more effectively to prevent harm – and increasing the reporting frequency of both safety events and near-misses is an important first step.

Overcoming Common Event Reporting Barriers

One of the key reasons why so many events go unreported is due to a lack of understanding about what should be reported. Near misses and lower-level harm events are often overlooked, yet they are so important for understanding where processes failed, or almost failed. If you know about these events, you can do a better job of getting out in front of them before the same set of circumstances happen again.

There are many other barriers to voluntary event reporting that we read about in the literature or hear about when working with hospitals, such as:

• “There’s no feedback or follow-up on the incident, so why should I bother reporting it? It’s just going into a black hole anyway.” 
• “The form is too long.”
• “I don’t have time to do it – I’m too busy and we’re short-staffed.” 
• “The form is too complicated to fill out.” 
• “I forgot to go in and report the incident.” 
• “I’m not sure who’s responsible to make the report.” 
• “I’m afraid of getting my co-worker in trouble.” 
• “I’m not sure what qualifies as an incident or a near-miss.” 
• “Where do I even go to report an event in the first place?” 

If a few of these sound familiar to you, we have good news – increasing your institution’s event capture through autodetection can help you overcome many of these barriers. 

The Power of Autodetection: A CHRISTUS Health Study

Autodetection is a groundbreaking technology that uses the VigiLanz rules engine to continuously monitor data from the electronic health record (EHR) for specific scenarios that have occurred. When a scenario does occur, a safety event is automatically populated into the event reporting system. Since the rules engine runs every five to ten minutes, this happens in near-real time. Then, based on the event type or location, the event is automatically routed to the appropriate staff member for investigation, just like a voluntarily reported event would be. 

A good example of this in practice is CHRISTUS Health, who recently partnered with us to standardize all aspects of their event reporting process. After identifying 21 scenarios around adverse drug events (ADEs) that they wanted to autodetect, we created rules based on those scenarios and ran them across 19 hospitals. 

A retrospective study was then performed over 18 months, directly comparing and analyzing ADEs that were manually reported versus those that were autodetected. The results were astounding:

• VigiLanz autodetection captured an average of 19 additional events per month per facility. When comparing these numbers to their voluntary event reporting data during the same period, there was a 400 percent increase in ADEs via autodetection as compared to voluntary reporting. 
• Seventy-seven percent of these autodetected events led to an investigation, leaving only 23 percent that were closed as not actual events or closed as duplicates that had also been reported manually. 
• Additionally, there was a 66 percent increase in ADEs that resulted in harm to a patient – a significant amount of harm that would have otherwise gone unreported.

Preventing Sentinel Events

Autodetection can be used to detect more than just ADEs. After reviewing the Joint Commission’s list of the top 10 leading sentinel event types in 2022, we realized there were additional opportunities to detect safety events in the background. These are very serious events and lead to significant morbidity and mortality for patients – 20 percent are associated with patient death and 44 percent with severe temporary harm to a patient.

VigiLanz set up 17 autodetection rules around sentinel events and hospital-acquired conditions for 56 days at 32 different sites. On average, the rules identified more than three events per day. Most of the events identified were in the hospital-acquired conditions category, but two sentinel events were identified as well. DVT/PE, CAUTI, and Iatrogenic Pneumothorax were the most frequently detected events in this short observation period. This effort further solidifies the value of this tool to enhance safety event capture in an automated way.

Improve Patient Safety at Your Institution 

Let’s bring this full circle. The VigiLanz platform can provide identification and early detection of safety events so that your organization can make more informed decisions to prevent harm and lower the incidence of safety events. It’s been said that you can’t manage what you can’t measure, and that’s where autodetection can make a big difference.

VigiLanz, an Inovalon solution, is the only offering on the market currently leveraging both voluntarily reported and automatically detected safety incidents to help healthcare leaders gain visibility into the true state of patient safety inside their institutions. At the end of the day, it’s all about the patient – and we are committed to empowering your teams to provide the best possible care to patients when they need it most. 

For more information about our safety surveillance solution, connect with our experts today.