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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†‡

doi: 10.1097/PTS.0000000000000348
Original Article: PDF Only

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.

From the *Department of Anesthesiology and Pain Medicine, †Surgical Outcomes Research Center, ‡Pharmaceutical Outcomes Research and Policy Program, and §Department of Medicine, University of Washington, Seattle, Washington.

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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