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Communication Training, Adverse Events, and Quality Measures: 2 Retrospective Database Analyses in Washington State Hospitals

Slade, Ian R. MD; Beck, Sara J. MS; Kramer, C. Bradley MPP; Symons, Rebecca G. MPH; Cusumano, Michael PharmD; Flum, David R. MD, MPH; Gallagher, Thomas H. MD; Devine, Emily Beth PhD, PharmD, MBA
Journal of Patient Safety: Post Author Corrections: June 30, 2017
doi: 10.1097/PTS.0000000000000348
Original Article: PDF Only


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).


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.


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.


Interprofessional communication training is an area of intense activity nationwide. A broad-based training initiative may play a role in mitigating AEs.

Correspondence: Emily Beth Devine, PhD, PharmD, MBA Pharmaceutical Outcomes Research and Policy Program, University of Washington, Box 357630 Seattle, WA (e-mail:

Funding: AHRQ 1R18 HS019531 (PI: T.H.G.).

The authors disclose no conflict of interest.

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