Congratulations 2022 Awardees
This year’s awardees made advancements related to medical errors in health information technology (IT), significantly reduced rates of critical events related to anesthesia, and connected mothers with important postpartum care. They are:
Individual Achievement
Jason S. Adelman, MD, MS, chief patient safety officer and associate chief quality officer; executive director, Center for Patient Safety Research; director, Patient Safety Research Fellowship, Columbia University Irving Medical Center and NewYork-Presbyterian; associate professor of medicine (in biomedical informatics) and vice chair for quality and patient safety, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons
Dr. Jason S. Adelman is a leader and innovator in the medical errors field and has developed novel methods to measure and prevent errors in health IT systems. Among Dr. Adelman’s key accomplishments is the development of the Wrong-Patient Retract-and-Reorder (RAR) Measure that detects wrong patient orders in electronic health record data. The RAR Measure has subsequently facilitated a large body of patient safety research, including medication errors and wrong-patient orders in neonatal intensive care units (NICUs).
As executive director and founder of the Center for Patient Safety Research, a multi-disciplinary collaboration between Columbia University Irving Medical Center, Weill Cornell Medicine, and NewYork-Presbyterian, Dr. Adelman has led several National Institutes of Health (NIH) and AHRQ funded projects to test safety interventions across the interventions’ lifespans. His far-reaching impact has contributed to national and international safety recommendations, including from The Joint Commission and NQF.
National Level Innovation in Patient Safety and Quality
Anesthesia Risk Alerts Program – North American Partners in Anesthesia (NAPA)
North American Partners in Anesthesia is honored for its Anesthesia Risk Alerts Program, which was implemented across 500 hospitals and ambulatory surgery centers (ASCs) in March 2019. The program implemented specific mitigation strategies targeting five high-risk clinical scenarios: known or suspected difficult airway, a body mass index (BMI) greater than or equal to 45, pulmonary hypertension, American Society of Anesthesiologists (ASA) status 4 or 5, and operating room (OR) fire risk. Each patient is assessed by the anesthesia clinician, and if a risk is identified, the specific mitigation strategy for that scenario is advised to prevent harm.
After implementation of the program, which reached greater than 95% compliance, the incidence rate of relevant critical adverse events for patients with a BMI greater than or equal to 45 and under general anesthesia decreased significantly.
Local Level Innovation in Patient Safety and Quality
Improving Maternal Safety and Quality Through Extending Maternal Care After Pregnancy in Dallas County – Parkland Health
Parkland Health is recognized for its Extending Maternal Care After Pregnancy (eMCAP) program in Dallas County, initiated in October 2020. The eMCAP program provides postpartum access to care for 12 months after birth for women with the highest social needs and limited access to physician clinic locations, mostly minority women. The program utilizes advance practice providers, community health workers, nurse home visits, virtual visits, and a mobile van deployed to locations in Dallas County to address patient health concerns including hypertension, diabetes, and behavioral health.
Compared to matched controls:
- Attendance for eMCAP patients with chronic hypertension was significantly better up to 12 months after birth.
- Up to three months after birth, patients with diabetes management had significantly better follow up, resulting in significantly lower HbA1c values.
- Patients with abnormal mental health screening scores were successfully referred for behavioral therapy, completed sessions with licensed mental health counselors, and accepted therapeutic intervention.
Launched in 2002, the awards honor the late John M. Eisenberg, MD, MBA, former administrator of the Agency for Healthcare Research and Quality (AHRQ). An impassioned advocate for healthcare quality improvement, Dr. Eisenberg was a founding member of NQF’s board of directors.
Additional details on the strategies used and improvements implemented by this year’s recognized initiatives can be found within the awardee summaries.