Please see attached file Assignment Review the following document and identify 1 topic that includes a chart or graph to answer the following ques

Please see attached file

Assignment

Review the following document and identify 1 topic that includes a chart or graph to answer the following question: How can healthcare be improved?

National Healthcare Quality and Disparities Report Chartbook on Patient Safety

Assignment:You will be writing an SBAR with an executive summary using a table or figure. It should be 1-2 pages long, double-spaced, and adhere to the structure outlined below.

Instructions: Review the attached document above and choose one of the tables or graphs to answer the question “How can healthcare be improved”. Focus on one specific trend or finding and use the SBAR format to analyze the data available.
Important note: For full credit, you will need to copy the table or graph from the Chartbook and add it to your SBAR. You will need to cite the image and refer to it in your SBAR.

Use this Structure:

Executive summary statement (put this at the beginning):Write a 2-3 sentencesummary of the most important points/topicsyou wrote about in the analysis. Include details that are critical to understanding these topics.

Situation:Give a description of the problem or situation – describe the problem that the table or chart is attempting to display.

Background:Describe any context or background to the problem – use information from the Chartbook or add personal experience or research background facts to understand the problem.

Analysis:Give a detailed and thoughtful analysis of the question/situation.
Use the table or date to identify a trend and propose a root cause.

Recommendation:Based on the available data and root cause, offer a specific solution or recommendation to improve this problem NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORT

Chartbook on
Patient Safety

e

This document is in the public domain and may be used and reprinted without permission.
Citation of the source is appreciated. Suggested citation: National Healthcare Quality and
Disparities Report Chartbook on Patient Safety. Rockville, MD: Agency for Healthcare Research
and Quality; March 2023. AHRQ Pub. No. 23-0032.

NATIONAL HEALTHCARE QUALITY AND
DISPARITIES REPORT
CHARTBOOK ON PATIENT SAFETY

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
www.ahrq.gov

AHRQ Publication No. 23-0032
Updates 21-0012
March 2023
www.ahrq.gov/research/findings/nhqrdr/index.html

https://www.ahrq.gov/

https://www.ahrq.gov/research/findings/nhqrdr/index.html

ACKNOWLEDGMENTS

The National Healthcare Quality and Disparities Report (NHQDR) is the product of collaboration among
agencies across the U.S. Department of Health and Human Services (HHS). Many individuals guided and
contributed to this effort. Without their magnanimous support, this chartbook would not have been possible.
Specifically, we thank:

Authors:

AHRQ: Barbara Barton, Darryl Gray, and Cecilia Hahn.
Cormac Corporation: Pam Phojanakong, Morgan Cappa, Naizam Kamookagath.
Mathematica Inc. Xiaohong (Sharon) Zhao.

Primary AHRQ Staff: Robert Otto Valdez, David Meyers, Erin Grace, Margie Shofer, Karen Chaves,
Barbara Barton, Doreen Bonnett, Darryl Gray, Romsai (Tony) Boonyasai, Cecilia Hahn, Lan Liang, Pradip
Muhuri, Caren Ginsberg, and Elma Chowdhury.

AHRQ Patient Safety Team Reviewers: Cindy Brach, Emily Chew, Caren Ginsberg, Monika Haugstetter,
Lawrence Reid, Margie Shofer, Tselote Tilahun, Andrea Timashenka.

HHS Interagency Workgroup (IWG) for the NHQDR: Girma Alemu (HRSA), Andreea Balan-Cohen
(IMPAQ), Barbara Barton (AHRQ), Doreen Bonnett (AHRQ), Deron Burton (CDC), Victoria Chau
(SAMHSA), Karen Chaves (AHRQ), Xiuhua Chen (Atlas Research), Deborah Duran (NIH-NIMHD),
Melissa Evans (CMS), Darryl Gray (AHRQ), Kirk Greenway (IHS), Sarah Heppner (HRSA), Ed Huff
(CMS), DeLoris Hunter (NIH-NIMHD), Susan Jenkins (ACL), Christine Lee (FDA), Doris Lefkowitz
(AHRQ), Jesse Lichstein (HRSA), Lan Liang (AHRQ), Shari Ling (CMS), Iris Mabry-Hernandez (AHRQ),
Marlene Matosky (HRSA), Tracy Matthews (HRSA), Christine Merenda (FDA), Kamila Mistry (AHRQ),
Ernest Moy (VHA), Samia Noursi (NIH-NIDA), Kathy OConnor (CDC), Dianne Rucinski (OASH), Asel
Ryskulova (CDC), Yahtyng Sheu (HRSA), Adelle Simmons (ASPE), Loida Tamayo (CMS), Caroline
Taplin (ASPE), Emmanuel Taylor (NIH-NCI), Michelle Washko (HRSA), and Ying Zhang (IHS).

Data Support Contractors:

Cormac Corporation: Pam Phojanakong, Morgan Cappa, Naizam Kamookagath
Mathematica: Xiaohong (Sharon) Zhao
Atlas: Xiuhua Chen
Westat: Theresa Famolaro, Naomi Yount

CONTENTS

INTRODUCTION ……………………………………………………………………………………………………. 1
CHARTBOOK ORGANIZATION AND BACKGROUND ……………………………………………… 1

Priority 1: Making Care Safer by Reducing Harm Caused in the Delivery of Care ……………. 1
Patient Safety Origins in the United States ……………………………………………………………….. 2
Key Definitions …………………………………………………………………………………………………… 2
Patient Safety Research Landscape …………………………………………………………………………. 2

CHARTBOOK CONTENT ………………………………………………………………………………………… 3
TRENDS ACROSS NHQDR PRIORITIES……………………………………………………………………. 4

Trends in Patient Safety ………………………………………………………………………………………… 5
Summary of Patient Safety Trends ………………………………………………………………………… 13

DISPARITIES IN PATIENT SAFETY ……………………………………………………………………….. 15
Overall Disparities …………………………………………………………………………………………….. 15
Trends in Disparities ………………………………………………………………………………………….. 22

MEASURES OF PATIENT SAFETY…………………………………………………………………………. 22
Patient Safety in the Hospital Setting …………………………………………………………………….. 22
Patient Safety in the Ambulatory Setting ………………………………………………………………… 55
Patient Safety in the Nursing Home Setting …………………………………………………………….. 58
Patient Safety in the Home Health Setting ………………………………………………………………. 66

PATIENT SAFETY, HEALTH LITERACY, AND COMMUNICATION …………………………. 71
Health Literacy………………………………………………………………………………………………….. 71
Measures of Communication………………………………………………………………………………… 71
Tools for Improving Patient Safety and Communication With Patients and Families ……….. 81

PATIENT SAFETY TOOLS, RESOURCES, AND PROGRAMS ACROSS
MULTIPLE SETTINGS ………………………………………………………………………………………….. 81

Surveys on Patient Safety Culture Ambulatory Surgery Center Survey …………………………. 82
Surveys on Patient Safety Culture Hospital Survey 2.0………………………………………………. 84
Surveys on Patient Safety Culture Medical Office Survey ………………………………………….. 91
Patient Safety Organization Program ……………………………………………………………………… 95
Network of Patient Safety Databases and the National Learning System ……………………….. 99

REFERENCES …………………………………………………………………………………………………….. 101
APPENDIX A: DATA METHODS AND ANALYSIS …………………………………………………. 107

e Quality and Disparities Report Patient Safety Chartbook | 1

INTRODUCTION

This Patient Safety Chartbook is part of a family of documents and tools that support the
National Healthcare Quality and Disparities Report (NHQDR). The NHQDR is an annual report
to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). The
NHQDR provides a comprehensive overview of the quality of healthcare received by the general
U.S. population and disparities in care experienced by different racial and socioeconomic groups.

The purpose of the reports is to assess the performance of our healthcare system and to identify
areas of strengths and weaknesses in the healthcare system along three main axes: the portrait of
American healthcare, special emphasis topics, and quality and disparities tables.

The reports are based on more than 440 measures of quality and disparities covering a broad
array of healthcare services and settings. Data generally cover 2000 through 2022. The reports
are produced with the help of a Federal Interagency Work Group led by the Agency for
Healthcare Research and Quality (AHRQ) and submitted to Congress on behalf of the Secretary
of the U.S. Department of Health and Human Services (HHS). To access the most recent
NHQDR, including methodologies and measure lists, go to https://www.ahrq.gov/research/
findings/nhqrdr/nhqdr22/index.html.

CHARTBOOK ORGANIZATION AND BACKGROUND

The chartbooks are organized around six priority areas:

1. Making care safer by reducing harm caused in the delivery of care.
2. Ensuring that each person and family is engaged as partners in their care.
3. Promoting effective communication and coordination of care.
4. Promoting the most effective prevention and treatment practices for the leading causes of

mortality, such as cardiovascular disease.
5. Working with communities to promote wide use of best practices to enable healthy living.
6. Making quality care more affordable for individuals, families, employers, and

governments by developing and spreading new healthcare delivery models.

Patient Safety is one of the six national priorities identified by the NHQDR. These priority areas
are interrelated and work to support all priority areas and can support necessary and critical
improvements in making care safer. Readers can access the latest NHQDR chartbooks at
https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/index.html.

Priority 1: Making Care Safer by Reducing Harm Caused in the
Delivery of Care
AHRQ has identified three long-term goals related to patient safety: reduce preventable hospital
admissions and readmissions, reduce the incidence of adverse healthcare-associated conditions,
and reduce harm from inappropriate or unnecessary care. This chartbook focuses on adverse
healthcare-associated conditions and harm from inappropriate or unnecessary care.

https://www.govinfo.gov/content/pkg/PLAW-106publ129/html/PLAW-106publ129.htm

https://www.ahrq.gov/research/findings/nhqrdr/nhqdr22/index.html

https://www.ahrq.gov/research/findings/nhqrdr/nhqdr22/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/personcentered/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/effectivetreatment/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/healthyliving/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/careaffordability/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/index.html

Patient Safety Chartbook

2 | 2022 National Healthcare Quality and Disparities Report

Preventable admissions and readmissions can result from problems with patient safety or
problems with care coordination. We have chosen to include most measures of preventable
admissions and readmissions in the Care Coordination chartbook. To access the most recent Care
Coordination chartbook, go to https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/
carecoordination/index.html.

Patient Safety Origins in the United States
Patient safety is the freedom from accidental or preventable injuries produced by medical care
(Kohn, et al., 2000). Patient safety research examines systems-based gaps to improve safety and
patient outcomes.

Medical error and other patient safety issues can be deadly:

One estimate of the number of hospital-acquired conditions in U.S. hospitals in 2017 was
approximately 2,550,000 cases (AHRQ, 2019a).

One estimate of the age-standardized mortality rate due to adverse effects of medical
treatment was 1.15 per 100,000 population in 2016 (Sunshine, et al., 2019).

AHRQ is one of the lead federal agencies for patient safety research. AHRQ partners with many
federal agencies to support patient safety and quality improvement work. These agencies include
the Centers for Medicare & Medicaid Services, Centers for Disease Control and Prevention,
Food and Drug Administration, Health Resources and Services Administration, and other
agencies within and outside HHS.

Key Definitions
The patient safety field uses terms including adverse event and patient safety event to describe
incidents in which patient harm may occur as a result of healthcare (rather than from an
underlying disease). Among other terms used by organizations such as The Joint Commission are
sentinel events. These patient safety events result in death, permanent harm, or serious
temporary harm to a patient.

Some events pose hazards to patients but do not result in harm. These patient safety events are
called near-misses. Patients experience a near-miss when they are exposed to a hazardous
situation but do not experience harm (either through luck or early detection).

These definitions are detailed on AHRQs PSNet website (https://psnet.ahrq.gov/primer/
patient-safety-101). More information on sentinel events is available at The Joint Commission
website, https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/.

Patient Safety Research Landscape
Since 1999, the patient safety field has made advances such as the reduction of select healthcare-
associated infections and medication-related events. These advances have been made through
novel strategies, such as clinical decision support, surveillance, treatment protocols, and
education and training through simulation. Advancements in safety research and implementation
are further described on AHRQs PSNet.

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/index.html

https://www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/index.html

https://psnet.ahrq.gov/primer/patient-safety-101

https://psnet.ahrq.gov/primer/patient-safety-101

https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/

https://psnet.ahrq.gov/

https://psnet.ahrq.gov/

Patient Safety Chartbook

2022 National Healthcare Quality and Disparities Report | 3

In April 2020, AHRQ published Making Healthcare Safer III, the third compendium of existing
and emerging patient safety best practices. In September 2020, AHRQ and the Institute for
Healthcare Improvement copublished the National Action Plan to Advance Patient Safety.
AHRQ and several organizations committed to patient safety developed this plan. It focuses on
culture, leadership, and governance; patient and family engagement; workforce safety; and
learning systemsall foundational needs for safe care.

The body of research examining disparities in patient safety continues to evolve in the United
States and abroad (Metersky, et al., 2011; Piccardi, et al., 2018; Noursi, et al., 2020; Fasano, et
al., 2020; Thomas, et al., 2020).

CHARTBOOK CONTENT

This chartbook includes:

Summaries of trends across measures of patient safety from the NHQDR.
Figures illustrating select measures of patient safety.
Supplemental descriptions and data on patient safety measures from several outside

sources.

References:

Introduction and Methods contains information about methods used in the chartbook.
A Data Query tool provides access to most NHQDR data tables

(https://datatools.ahrq.gov/nhqdr).

Data Sources:

Agency for Healthcare Research and Quality (AHRQ):

Healthcare Cost and Utilization Project (HCUP)
Medical Expenditure Panel Survey (MEPS)
Quality and Safety Review System (QSRS)

Centers for Disease Control and Prevention (CDC):

National Vital Statistics System Natality (NVSS-N)

Centers for Medicare & Medicaid Services (CMS):

Home Health Care Consumer Assessment of Healthcare Providers and Systems
(HHCAHPS)

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Hospital Inpatient Quality Reporting (HIQR) (formerly the Quality Improvement

Organization)
Outcome and Assessment Information Set (OASIS)
Minimum Data Set (MDS)

https://www.ahrq.gov/research/findings/making-healthcare-safer/mhs3/index.html

http://www.ihi.org/Engage/Initiatives/National-Steering-Committee-Patient-Safety/Pages/National-Action-Plan-to-Advance-Patient-Safety.aspx

https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2022qdr-intro.pdf

NHQDR Data Tools

Patient Safety Chartbook

Previous patient safety chartbooks reported data from the Medicare Patient Safety Monitoring
System (MPSMS). As of October 2020, however, MPSMS has been replaced by QSRS. Due to
the COVID-19 pandemic, QSRS data were not collected from January to August 2020. QSRS is
an improved patient safety surveillance system that is expected to have an expanded list of
adverse event measures.

QSRS data are collected through retrospective manual abstraction of inpatient records. QSRS
uses standardized definitions and algorithms consistent with the AHRQ Common Formats for
Surveillance. Therefore, analysis of some events originally included in previous chartbooks has
been removed entirely or changed for one of the following reasons:

The data are not available from QSRS.
The data do not meet the criteria for statistical reliability, data quality, or confidentiality.

More information on the departure from MPSMS is available at AHRQs QSRS web page.

TRENDS ACROSSNHQDR PRIORITIES
Number and percentage of quality measures improving, not changing, or worsening from 2000 to
2020, total and by priority area

Improving Not Changing Worsening
100%

80%

60%

40%

20%

0%
Total (n=176) Person- Patient Healthy Effective Care Affordable

Centered Safety Living Treatment Coordination Care
Care (n=25) (n=29) (n=55) (n=38) (n=27) (n=2)

13

86

77

16

9

1

11

17

2

23

30

5

21

12

5

13

9

2

Key: n = number of measures.
Note: This graph is limited to those measures that have the minimum four data points that AHRQ requires to
conduct a trend analysis. For each measure with at least four estimates over time, unweighted log-linear regression is
used to calculate average annual percentage change (AAPC) and to assess the statistical significance of the rate of
change (p <0.10). Rates are aligned so that negative change indicates improved care. The model used is ln(M) = 0 + 1Y, where ln(M) is the natural logarithm of the aligned rate, 0 is the intercept or constant, and 1 is the coefficient corresponding to year Y (e.g., the average annual percentage change = 100 (exp()-1)). Improving = Average annual percentage change >1% per year in a favorable direction and p <0.10. Not Changing = Average annualpercentagechange 1% per year or p 0.10. Worsening = Average annual percentage change >1% per year in an unfavorable direction and p <0.10. 4 | 2022 National Healthcare Quality and Disparities Report https://www.ahrq.gov/patient-safety/quality-measures/qsrs/index.html Patient Safety Chartbook 2022 National Healthcare Quality and Disparities Report | 5 Through 2020, across a broad spectrum of healthcare quality measures, less than half (44%) showed improvement. Person-Centered Care: 36% of person-centered care measures were improving overall. Patient Safety: More than half of patient safety measures were improving overall. The one measure with worsening results was Adults who reported a home health care provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care. Healthy Living: More than 50% of healthy living measures were improving overall. Effective Treatment: More than 30% of effective treatment measures were improving overall. Care Coordination: More than 30% of care coordination measures were improving overall. Affordable Care: No affordable care measures showed improvement overall. Access measures are not represented on this graph. For more information, refer to the 2022 National Healthcare Quality and Disparities Report. Trends in Patient Safety Trends by Setting of Care Number and percentage of patient safety measures improving, not changing, or worsening from 2002 to 2020, by setting of care 2 2 9 4 5 5 1 1 0% 20% 40% 60% 80% 100% Ambulatory (n=2) Home Health (n=8) Hospital (n=14) Nursing Home (n=5) Improving Not Changing Worsening Key: n = number of measures. Importance: The chartbook is organized around setting of care; stratifying trends by care setting provides insight into which settings are exhibiting more or fewer measures improving. Findings: Both ambulatory care measures, 25% of home health measures, 64% of hospital measures, and 80% of nursing home measures were improving overall. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr22/index.html https://www.ahrq.gov/research/findings/nhqrdr/nhqdr22/index.html Patient Safety Chartbook 6 | 2022 National Healthcare Quality and Disparities Report The home health measure that is worsening is Adults who reported a home health care provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care, which declined from 78.8% in 2012 to 74.5% in 2020. Ambulatory Measures: Improving: 1. Adults age 65 and over who received in the calendar year at least 1 of 11 prescription medications that should be avoided in older adults 2. Adults age 65 and over who received in the calendar year at least 1 of 33 potentially inappropriate prescription medications for older adults Home Health Measures: Improving: 1. Home health care patients whose surgical wound improved 2. Home health care patients whose management of oral medications improved Not Changing: 1. Adults who reported a home health care provider talking with them about how to set up their home so they can move around safely when they first started getting home health care 2. Adults who reported a home health care provider talking with them about all the prescription and over-the-counter medicines they were taking when they first started getting home health care 3. Adults who reported that home health care providers talked with them about the purpose of taking their new or changed prescription medicines in the last 2 months of care 4. Adults who reported that home health care providers talked with them about when to take medicines in the last 2 months of care 5. Adults who reported that home health care providers talked with them about the side effects of medicines in the last 2 months of care Worsening: 1. Adults who reported a home health care provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care Patient Safety Chartbook 2022 National Healthcare Quality and Disparities Report | 7 Hospital Measures: Improving: 1. Postoperative sepsis per 1,000 elective-surgery admissions, age 18 and over 2. Hospital admissions with central venous catheter-related bloodstream infection per 1,000 medical and surgical discharges of length 2 or more days, age 18 and over or obstetric admissions 3. Postoperative pulmonary embolism or deep vein thrombosis per 1,000 surgical admissions, age 18 and over 4. Postoperative respiratory failure, prolonged mechanical ventilation, or reintubation per 1,000 elective-surgery admissions, age 18 and over 5. Postoperative acute kidney injury requiring dialysis per 1,000 elective-surgery admissions, age 18 and over 6. Accidental puncture or laceration during a procedure per 1,000 medical and surgical admissions, age less than 18 years 7. Hospital admissions with iatrogenic pneumothorax per 1,000 medical and surgical admissions, age 18 and over 8. Deaths per 1,000 elective-surgery admissions who developed serious treatable complications of care during hospitalization, ages 18-89 or obstetric admissions 9. Deaths per 1,000 hospital admissions with expected low mortality, age 18 and over or obstetric admissions Not Changing: 1. Perioperative hemorrhage or hematoma with surgical drainage or evacuation per 1,000 surgical admissions, age 18 and over 2. Postoperative hip fracture per 1,000 surgical admissions who were not susceptible to falling, age 18 and over 3. Reclosure of postoperative abdominal wound dehiscence per 1,000 abdominopelvic- surgery admissions of length 2 or more days, age 18 and over 4. Accidental puncture or laceration during a procedure per 1,000 medical and surgical admissions, age 18 and over 5. Birth trauma - injury to neonate per 1,000 live births Nursing Home Measures: Improving: 1. High-risk, long-stay nursing home residents with pressure ulcer 2. Long-stay nursing home residents with a urinary tract infection 3. Low-risk, long-stay nursing home residents with a catheter inserted and left in the bladder 4. Short-stay nursing home patients with pressure ulcers that are new or worsened Not Changing: 1. Long-stay nursing home residents experiencing one or more falls with major injury Patient Safety Chartbook 8 | 2022 National Healthcare Quality and Disparities Report Trends by Type of Measure Number and percentage of patient safety measures improving, not changing, or worsening from 2002 to 2020, by type of measure 14 3 6 5 1 0% 20% 40% 60% 80% 100% Outcome (n=20) Process (n=9) Improving Not Changing Worsening Key: n = number of measures. Importance: The ultimate goal of quality improvement is to produce better patient outcomes. Improvements in processes may or may not lead to improved patient outcomes. Findings: Most (70%) outcome measures improved, while 33% of process measures improved. Type of measure and setting of care are related; 14 of 20 outcome measures are hospital measures, while no process measures are hospital measures. The process measure that is worsening is Adults who reported a home health care provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care, which declined from 78.8% in 2012 to 74.5% in 2020. Outcome Measures: Improving: 1. Postoperative sepsis per 1,000 elective-surgery admissions, age 18 and over 2. Hospital admissions with central venous catheter-related bloodstream infection per 1,000 medical and surgical discharges of length 2 or more days, age 18 and over or obstetric admissions 3. Postoperative pulmonary embolism or deep vein thrombosis per 1,000 surgical admissions, age 18 and over 4. Postoperative respiratory failure, prolonged mechanical ventilation, or reintubation per 1,000 elective-surgery admissions, age 18 and over Patient Safety Chartbook 2022 National Healthcare Quality and Disparities Report | 9 5. Postoperative acute kidney injury requiring dialysis per 1,000 elective-surgery admissions, age 18 and over 6. Home health care patients whose surgical wound improved 7. Accidental puncture or laceration during a procedure per 1,000 medical and surgical admissions, age less than 18 years 8. Hospital admissions with iatrogenic pneumothorax per 1,000 medical and surgical admissions, age 18 and over 9. Deaths per 1,000 elective-surgery admissions who developed serious treatable complications of care during hospitalization, ages 18-89 or obstetric admissions 10. Deaths per 1,000 hospital admissions with expected low mortality, age 18 and over or obstetric admissions 11. Home health care patients whose management of oral medications improved 12. High-risk, long-stay nursing home residents with pressure ulcer 13. Long-stay nursing home residents with a urinary tract infection 14. Short-stay nursing home patients with pressure ulcers that are new or worsened Not Changing: 1. Perioperative hemorrhage or hematoma with surgical drainage or evacuation per 1,000 surgical admissions, age 18 and over 2. Postoperative hip fracture per 1,000 surgical admissions who were not susceptible to falling, age 18 and over 3. Reclosure of postoperative abdominal wound dehiscence per 1,000 abdominopelvic- surgery admissions of length 2 or more days, age 18 and over 4. Accidental puncture or laceration during a procedure per 1,000 medical and surgical admissions, age 18 and over 5. Birth trauma - injury to neonate per 1,000 live births 6. Long-stay nursing home residents experiencing one or more falls with major injury Process Measures: Improving: 1. Adults age 65 and over who received in the calendar year at least 1 of 11 prescription medications that should be avoided in older adults 2. Adults age 65 and over who received in the calendar year at least 1 of 33 potentially inappropriate prescription medications for older adults 3. Low-risk, long-stay nursing home residents with a catheter inserted and left in the bladder Not Changing: 1. Adults who reported a home health care provider talking with them about how to set up their home so they can move around safely when they first started getting home health care 2. Adults who reported a home health care provider talking with them about all the prescription and over-the-counter medicines they were taking when they first started getting home health care Patient Safety Chartbook 10 | 2022 National Healthcare Quality and Disparities Report 3. Adults who reported that home health care providers talked with them about the purpose of taking their new or changed prescription medicines in the last 2 months of care 4. Adults who reported that home health care providers talked with them about when to take medicines in the last 2 months of care 5. Adults who reported that home health care providers talked with them about the side effects of medicines in the last 2 months of care Worsening: 1. Adults who reported a home health care provider asking to see all the prescription and over-the-counter medicines they were taking when they first started getting home health care Trends by Sub-Area Number and percentage of patient safety measures improving, not changing, or worsening from 2002 to 2020, by sub-area 1 4 4 8 3 5 1 21 0% 20% 40% 60% 80% 100% Complications of Medication (n=1) Surgical Care (n=7) Home Health Communication (n=6) Supportive and Palliative Care (n=5) Key: n = number of measures. Note: Among the list of surgical care measures, the chartbook lists a home health care measure in the surgical care area due to its scope. All other surgical care measures are specific to the inpatient setting. Importance: Improvement is not concentrated in one aspect of care but is spread over multiple aspects of care. Findings: Four of five (80%) Supportive and Palliative Care measures were improving, as were 8 of 10 (80%) Other Patient Safety measures and the one Complications of Medication measure. Four of 7 (57%) Surgical Care measures and no Home Health Communication measures were improving. Other Patient Safety (n=10) Improving Not Changing Worsening Patient Safety Chartbook 2022 National Healthcare Quality and Disparities Report | 11 Home Health Communication is the only area in which any measure was