Patient Safety Indicators Events Research Articles

Characteristics of Patients Hospitalized to Community Hospitals With Malignant Brain Tumors and Factors Associated With Discharge Destination.

Our main objective was to compare the characteristics and hospital outcomes of patients with primary and metastatic brain malignancies and to investigate the associated factors related to hospital outcomes. We conducted a retrospective, cross-sectional study of 1628 patients with brain malignancies from 8 community hospitals between 2017 and 2022 who were identified using International Classification of Disease codes. A stepwise logistic regression was used to identify demographics and clinical characteristics associated with in-hospital mortality and home discharge. The median age was 65 years old, with 72.5% of patients having metastatic brain malignancies. After 7.2 days of hospital stay, 49.2% were discharged home, and 102 patients expired during hospitalization. Increased age, medical coverage by Medicare, hemiplegia or paraplegia, lower initial hemoglobin level, increased length of stay, and the use of electrolyte replacement, antibiotics, laxatives, heparin, and anticonvulsants were associated with a decreased likelihood of discharge to home. No medical insurance, Medicaid insurance coverage, comorbidities of cerebrovascular disorder, the need to stay in the intensive care unit, patient safety indicator events, and the use of antibiotics, oral analgesics, and ipratropium-albuterol were associated with increased odds of in-hospital mortality. We identified several predictor variables that delineate differences between both mortality risk and home discharge in patients with primary and metastatic brain tumors. Understanding these predictor variables can be helpful in improving the acute and post-acute care of this population.

Patient Safety Indicators at an Academic Veterans Affairs Hospital: Addressing Dual Goals of Clinical Care and Validity

Hospital-acquired complications add to patient morbidity and mortality, costs, length of stay, and negative patient experience. Patient Safety Indicators (PSIs) are a validated and widely used metric to evaluate hospital administrative data on preventing these events. Although many studies have addressed PSI validity, few have aimed to reduce PSI through clinical care. The authors aimed to reduce PSI events by addressing both validity and clinical care. Frontline clinicians used a deep dive template to provide input on all PSI cases, which were then reviewed by a PSI task force to identify performance gaps. After analyzing the frequency of gaps and cost-vs.-impact of potential solutions, five interventions were implemented to address the three most common, highly weighted PSIs: pressure ulcers, postoperative venous thromboembolism (VTE), and postoperative sepsis. Clinical care interventions included increasing patient mobility by creating a specialized mobility technician position, skin care audits to prevent pressure ulcers, and increasing use of pharmacologic VTE prophylaxis. Administrative interventions addressed improving clinician-coding concordance for sepsis and increasing documentation of comorbidities. After interventions, the number of PSI events for composite PSI, VTE, and sepsis decreased by 41.3% (p = 0.039), 85.2% (p = 0.0091), and 51.5% (p = 0.063), respectively, relative to the preintervention period. Pressure ulcers increased by 33.3% (p = 0.0091). Hospital complications cause substantial burden to hospitals, patients, and caregivers. Addressing administrative and clinical factors with targeted interventions led to reduction in composite PSI. Further efforts are needed locally to reduce the pressure ulcer PSI.

330 Accuracy and Clinical Significance of Neurosurgical Patient Safety Indicator Events Reported by Centers for Medicare Services

INTRODUCTION: Data on patient safety indicator (PSI) events are used by Center for Medicare Services (CMS) for determining reimbursement to hospitals, and public quality reporting. It is unclear whether the process used by CMS to detect PSI events is accurate, and whether PSI events affect clinical outcomes in neurosurgical patients. METHODS: We reviewed CMS reported PSI events in neurosurgical patients at our hospital from July 1, 2018, through December 31, 2019. Discharge billing codes were reviewed in order to assess whether CMS criteria for PSI were met. Charts were reviewed by experienced clinicians in order to assess the accuracy and clinical significance of CMS reported PSI events. For deep venous thrombosis/pulmonary embolism (DVT/PE) PSI events, chart reviews were performed in order to assess whether standard of care prophylaxis was administered. RESULTS: 14 PSI events were reported in 11 patients, representing 1.3% of neurosurgical procedures in fee for service medicare patients. 7 patients underwent spinal surgery and 4 underwent cranial surgery. PSI events included DVT/PE (n = 6), postoperative hematoma (n = 2), postoperative respiratory failure (n = 5), and iatrogenic pneumothorax (n = 1). Only 10/14 PSI events (71%) met CMS criteria based on discharge billing codes, and only 8/14 PSI events (57%) met CMS criteria based on chart review. All PSI events that were confirmed based on chart review required specific medical or surgical treatment, but only 5 (63%) led to increased length of stay, and no patients had residual adverse effects at hospital discharge. 5/6 patients with chart confirmed DVT/PE (83%) received standard of care DVT prophylaxis. CONCLUSIONS: CMS-reported PSI events have significant rates of inaccuracy. PSI events may not correlate with meaningful adverse clinical outcomes. DVT/PE PSI events were not associated with breaches in standard of care.

Relationship between patient safety indicator events and hospital location for inpatient hysterectomy.

Previous studies suggest surgical quality outcomes are similar between rural and urban hospitals, but data about gynecology in rural hospitals is sparse. This was a retrospective cohort study utilizing the National Inpatient Sample database from the Agency of Healthcare Research and Quality. Patients who underwent benign hysterectomy for non-prolapse indications between 2012-2016 were identified using ICD-9 and 10 codes. Patients were stratified into rural or urban non-teaching groups; urban teaching hospitals were the referent group. The primary outcome was the rate of patient safety indicator (PSI) events. PSI events were identified using ICD-9 and 10 codes. Statistical analysis was performed using analysis of variance and uni- and multivariate Poisson regressions. 154,810 patients met all inclusion criteria. The cumulative rate of PSI events was 11.9% at rural hospitals, 13.9% at urban non-teaching hospitals and 16.9% at urban teaching hospitals, P<0.001. The most common PSI events were postoperative metabolic derangement, hemorrhage, and accidental puncture. The rate of transfusion was highest in urban teaching hospitals (6.7%) and similar for rural (5.1%) and urban non-teaching hospitals (5.5%), P<0.001. The rate of genitourinary tract injury was between 1.4-1.6%, and similar across sites, P=0.89. After adjusting for confounders, the risk of PSI events was similar across locations. The risk of transfusion was lower at rural hospitals (aRR=0.84, 95% CI: 0.74-0.94). Hysterectomy performed at rural hospitals, typically thought of as having low surgical volume compared to urban hospitals, is associated with similar risk of PSI events and lower risk of transfusion.

Novel Application of a Dynamic, In-room Survey Platform to Measure Surgical Team Satisfaction.

To elucidate the potential usage of continuous feedback regarding team satisfaction and correlations with operative performance and patient outcomes. Continuous, actionable assessment of teamwork quality in the operating room (OR) is challenging. This work introduces a novel, data-driven approach to prospectively and dynamically assess health care provider satisfaction with teamwork in the OR. Satisfaction with teamwork quality for each case was assessed utilizing a validated prompt displayed on HappyOrNot Terminals placed in all ORs, with separate panels for circulators, scrub nurses, surgeons, and anesthesia providers. Responses were cross-referenced with OR log data, team familiarity indicators, efficiency parameters, and patient safety indicator events through continuous, semiautomated data marts. Deidentified responses were analyzed through logistic regression modeling. Over a 24-week period, 4123 responses from 2107 cases were recorded. The overall response rate per case was 32.5%. Greater scrub nurse specialty experience was strongly associated with satisfaction (odds ratio: 2.15, 95% CI: 1.53-3.03, P < 0.001). Worse satisfaction was associated with longer than expected procedure time (odds ratio: 0.91, 95% CI: 0.82-1.00, P = 0.047), nighttime (0.67, 95% CI: 0.55-0.82, P < 0.001), and add-on cases (0.72, 95% CI: 0.60-0.86, P < 0.001). Higher material costs (22%, 95% CI: 6-37, P = 0.006) were associated with greater team satisfaction. Cases with superior teamwork ratings were associated with a 15% shorter length of hospital stay (95% CI: 4-25, P = 0.006). This study demonstrates the feasibility of a dynamic survey platform to report actionable health care provider satisfaction metrics in real-time. Team satisfaction is associated with modifiable team variables and some key operational outcomes. Leveraging qualitative measurements of teamwork as operational indicators may augment staff engagement and measures of performance.

Impact of Facility Volume on Patient Safety Indicator Events After Transsphenoidal Pituitary Surgery.

To investigate the impact of facility volume on Patient Safety Indicator (PSI) events following transsphenoidal pituitary surgery (TSPS). Retrospective database review. National Inpatient Sample database (2003-2011). The National Inpatient Sample was queried for TSPS cases from 2003 to 2011. Facility volume was defined by tertile of average annual number of TSPS procedures performed. PSIs, based on in-hospital complications identified by the Agency of Healthcare Research and Quality, and poor outcomes, such as mortality and tracheostomy, were analyzed. An overall 16,039 cases were included: 804 had ≥1 PSI and 15,235 had none. A greater proportion of male to female (5.8% vs 4.3%) and Black to White (7.0% vs 4.5%) patients experienced PSIs. There was an increased likelihood of poor outcome (odds ratio [OR], 3.1 [95% CI, 2.5-3.7]; P < .001) and mortality (OR, 30.1 [95% CI, 18.5-48.8]; P < .001) with a PSI. The incidence rates of PSIs at low-, intermediate-, and high-volume facilities were 5.7%, 5.1%, and 4.2%, respectively. Odds of poor outcome with PSIs were greater at low-volume facilities (OR, 3.3 [95% CI, 2.4-4.4]; P < .001) vs intermediate (OR, 3.1 [95% CI, 2.1-4.2]; P < .001) and high (OR, 2.5 [95% CI, 1.7-3.8]; P < .001). Odds of mortality with PSIs were greater at high-volume facilities (OR, 43.0 [95% CI, 14.3-129.4]; P < .001) vs intermediate (OR, 40.0 [95% CI, 18.5-86.4]; P < .001) and low (OR, 17.3 [95% CI, 8.0-37.7]; P < .001). PSIs were associated with a higher likelihood of poor outcome and mortality following TSPS. Patients who experienced PSIs had a lower risk of poor outcome but increased mortality at higher-volume facilities.

A retrospective study of the effects of minimally invasive colorectal surgery on Patient Safety Indicators across a five-hospital system.

The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals. A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13. There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15. Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes.

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns. Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital. The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death. Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers. Therapeutic, III.

Adverse Events and Hospital-Acquired Conditions Associated With Potential Low-Value Care in Medicare Beneficiaries

There has been insufficient research on the patient harms and costs associated with potential low-value procedures in the US Medicare population. To report the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. This is a retrospective cohort study using Medicare fee-for-service claims between January 2016 to December 2018. Participants were aged 65 years or older. Procedures were selected if they had previously published indicators of low-value care, including knee arthroscopy, spinal fusion, vertebroplasty, percutaneous coronary intervention (PCI), carotid endarterectomy, renal stenting, and hysterectomy for benign conditions. Analysis was conducted from July to December, 2020. For inpatient procedures, the number and rate of admissions with a hospital-acquired condition (HAC) or patient safety indicator event (PSIs), as well as the unadjusted and adjusted difference in mean LOS and Medicare costs between admissions with and without a HAC/PSI. For outpatient procedures, we report the number of claims where the beneficiary had an unplanned hospital admission within seven days and the number of these admissions with a HAC/PSI. There were 573 351 patients included in the study, with 617 264 procedures; the mean (SD) age was 74.2 (6.7) years, with 320 637 women (55.9%), and mostly White patients (520 735; 90.8%). Among the 197 755 claims for the inpatient procedures, 231 had an HAC and 1764 had a PSI. Spinal fusion was associated with the most HACs (123 admissions) and PSIs (1015 admissions). Overall, HACs during a PCI admission were associated with the highest adjusted additional mean LOS (17.5 days; 95% CI, 10.3-23.6), with also the highest adjusted additional mean cost ($22 000; 95% CI, $9100-$32 600). There were 419 509 included outpatient procedures, and 7514 (1.8%) had an unplanned admission within 7 days. A total of 17 HACs and PSIs occurred in these admissions. In this cross-sectional cohort study of Medicare fee-for-service claims, patients receiving potential low-value care were exposed to risk of unnecessary harm associated with higher cost and LOS.

01 Relationship between patient safety indicator events and hospital location for inpatient hysterectomy

01 Relationship between patient safety indicator events and hospital location for inpatient hysterectomy

Patient safety indicator events and complications in shoulder arthroplasty

BackgroundAn estimated 70,000 patients undergo anatomic or reverse total shoulder arthroplasty (ATSA or RTSA) in the United States every year. This study examines the relative safety of primary RTSA to ATSA and the influence of patient- and hospital-level characteristics on perioperative and prosthetic joint complications. MethodsAll patients in the Nationwide Inpatient Sample (NIS) undergoing primary ATSA or RTSA from 2012-2014 were identified using ICD-9-CM codes. We quantified the incidence of Patient Safety Indicators (PSI), as developed by the Agency for Healthcare Research and Quality (AHRQ), and mechanical complications. The association of RTSA with PSI or mechanical complications was determined by logistic regression. ResultsWe identified 27,540 patients receiving either an ATSA or RTSA. The overall PSI incidence and mechanical complication rates were 3.3% and 0.34%, respectively. RTSA (OR = 1.63, 95% CI 1.42-1.88), age ≥ 69 years (OR = 1.04, 95% CI 1.03-1.04), medium hospital size (OR = 1.26, 95% CI 1.03-1.55), and large hospital size (OR = 1.32, 95% CI 1.10-1.58) were significantly associated with increased odds of experiencing a PSI event. RTSA (OR = 4.47, 95% CI 2.74-7.28) and age ≥ 69 years (OR = 0.97, 95% CI 0.95-0.99) were significantly associated with increased and decreased odds of experiencing a mechanical complication, respectively. ConclusionsWhile the national incidence of PSI events and mechanical complications among patients receiving shoulder arthroplasty is relatively low, we found that older patients undergoing RTSA were more likely to experience a PSI event and younger patients to experience a mechanical complication. Level of evidenceLevel III.

Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter?

Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

545 The Association of Plastic Surgery Facility Volume with Inpatient Burn Outcomes

Abstract Introduction Acute burn care involves a spectrum of physicians, nurses, and allied health professionals. Similarly, burn surgeons have variable training backgrounds that originate from different specialties. Plastic surgery was founded on the core principles of reconstruction and offers the full spectrum of acute burn care and reconstructive surgery. Previous work has shown that variations in practice within burn surgery are partially driven by training background. We hypothesize that plastic surgery involvement and access to the full reconstructive paradigm will improve inpatient outcomes in the treatment of burn injuries. Methods Acute burn patients with known percent total body surface area (%TBSA) were extracted from the National Inpatient Sample (NIS) from 2012–2014 based on International Classification of Disease 9th Edition codes. Plastic surgery volume per facility for the entire NIS was determined based on ICD-9 codes for flap procedures, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators (venous thromboembolic event, sepsis, surgical bleeding, pneumonia, wound complications) and mortality. Regression models included the following variables: age, %TBSA, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status. Results The weighted sample included 99,510 burn admissions with a mean age of 37.2 years (standard deviation [SD] 24.3) and mean %TBSA of 12.4% (SD 12.4%). The weighted median plastic surgery volume by facility was 245 cases per year (Interquartile range 115, 495). Compared to the lowest quartile, the upper three quartiles of plastic surgery volume were associated with an increased likelihood of undergoing a flap procedure during admission (p&amp;lt; 0.05). Plastic surgery volume was also associated with decreased likelihood of patient safety indicator events, whereby the highest quartile showed an OR of 0.71 (95% confidence interval 0.59–0.85, p&amp;lt; 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death. Conclusions Burn patients treated at high volume plastic surgery facilities were more likely to undergo flap procedures during their admission compared to low volume centers. High volume plastic surgery facilities were associated with lower likelihood of inpatient complications, although there were no differences in mortality. Applicability of Research to Practice Inform health systems design in the delivery of burn care to provide the best outcomes for burn survivors.

The association of burn patient volume with patient safety indicators and mortality in the US

IntroductionClinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes. MethodsAll burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002–2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models. ResultsOf the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99–0.99, p < 0.001) and PSIs (OR 0.99, 95% CI 0.99–0.99, p = 0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p < 0.05). ConclusionThere was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

Impact of hospital volume on patient safety indicators and failure to rescue following open aortic aneurysm repair

ObjectiveFailure to rescue (FTR), a patient safety indicator (PSI) defined, codified, and adjudicated by the Agency for Healthcare Research and Quality, is classified as a preventable inpatient death following major complications. FTR has been reported to be a significant driver of postoperative mortality after open abdominal aortic aneurysm (OAAA) repair. The association between hospital volume (HV) and mortality is well known; however, the mechanisms responsible for these improved outcomes and relative contribution to observed interhospital variation is poorly understood. Similarly, HV influence on specific complications predictive of FTR is unknown; therefore, we sought to determine how HV influences risk and contributes to interhospital variation in PSI events leading to FTR and/or in-hospital mortality after OAAA repair. MethodsThe Vizient database (174 academic/nonacademic hospitals) was queried for all OAAA repairs (elective, n = 2827; nonelective, n = 1622) completed from 2012 to 2014. The primary endpoint was combined FTR and/or in-hospital 30-day mortality. Risk-adjusted rates of complications, Agency for Healthcare Research and Quality-designated PSIs, and FTR were determined. Additional modeling identified PSIs associated with FTR, whereas HV effects on PSIs and FTR were evaluated using mixed-effect models accounting for interhospital variation. Proportion of variation attributable to HV was estimated by contrasting hospital random effect variances in the presence/absence of volume effects. ResultsThe combined overall FTR/in-hospital 30-day mortality rate was 9.3% (n = 414). For elective and nonelective cases, the overall FTR and 30-day mortality rates were: FTR, 1.6%, 4.9%; and 30-day in-hospital mortality, 3.4%, 17.5%, respectively. HV significantly influenced FTR/30-day in-hospital mortality (P < .0001). FTR/30-day mortality odds for hospitals with 3-year volumes of 50, 100, 150, and 200 cases were 1.4, 2.0, 2.7, and 3.0 times lower, respectively, than hospitals performing ≤25 cases/3 years. The proportion of interhospital variation attributed to HV was greatest for FTR/30-day mortality (62%). Procedural volume accounted for 41% and 38% of interhospital variation in postoperative bleeding and myocardial infarction, respectively. Preoperative predictors of FTR included coagulopathy, arrhythmia (nonelective cases); congestive heart failure, obesity (elective cases); and age, neurological disease, hypertension, and valvular disease (all cases). ConclusionsOAAA FTR/30-day in-hospital mortality strongly correlated with annual case volume with higher volume centers having the lowest risk. Notably, HV accounted for a significant proportion of the observed variation in FTR and specific complications providing direct evidence for how the volume-outcome relationship may influence perioperative mortality. These findings can inform stakeholders to strategically enable them to implement processes of care directed at the most vulnerable patients that are designed to reduce the likelihood of preventable adverse events and death after OAAA repair. Furthermore, these results underscore the need to regionalize OAAA repair and potentially other complex operations, to HV centers because of their improved ability to rescue patients experiencing complications associated with postoperative mortality.

Increasing Numbers and Reported Adverse Events in Patients with Lung Cancer Undergoing Inpatient Lung Biopsies: A Population-Based Analysis.

The use of molecular biomarkers to guide lung cancer management has led to increasing frequency and amounts of tissue required for repeat lung biopsies. While patient safety and reporting of adverse events has been increasingly emphasized in recent decades, the safety of lung biopsies in patients with lung cancer has only been studied in small cohorts. We therefore analyzed adverse events in patients with lung cancer undergoing lung biopsies in the National Hospital Discharge Survey (NHDS) database. Data were abstracted using ICD-9 lung cancer diagnosis (162.X) and lung biopsy procedure codes (33.20, 33.24, 33.25, 33.26, 33.27, 33.28) from 2001 to 2010. Agency for Healthcare Research and Quality (AHRQ) Patient-Safety Indicators (PSI) were used to identify hospital-acquired adverse events. Weighted analyses were performed using SAS version 9.4. A total of 540,747 patients were included for analysis. The number of biopsies increased over time, from 51,221 in 2001, to 63,239 in 2010 (P < 0.001). Overall, 159,683 (30%) patients suffered ≥ 1-PSI event during their hospitalization. Incidence of PSI varied by biopsy type: bronchoscopic (26%), percutaneous (34%), surgical (39%). The proportion of patients with ≥ 1 PSI event increased from 24% in 2001 to 38% in 2010 (P < 0.001). Patients with ≥ 1 PSI had longer length of stay (mean, 11.6 vs 8.1days; P < 0.001) and higher in-hospital mortality (adjusted odds ratio, 5.9, 95% CI 3.9-8.9; P < 0.001). The frequency of lung biopsies performed and rate of documented adverse events in hospitalized lung cancer patients have increased. These findings have policy, funding, research, and practice implications.

Impact of Patient Safety Indicators on readmission after abdominal aortic surgery

Patient safety is a critical component of health-care quality and measures created by the Agency for Healthcare Research and Quality (AHRQ) to identify hospitalizations with potentially preventable adverse events. This analysis evaluated whether Patient Safety Indicator (PSI) events after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) were associated with increased risk of readmission. Patients undergoing elective repair of nonruptured AAA from 2009 to 2012 were selected in the Medicare Provider Analysis and Review files using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. To identify PSI events, we used the AHRQ PSI International Classification of Diseases, Ninth Revision, Clinical Modification numerator codes. Chi-square test, multivariable logistic regression analysis, nonparametric Wilcoxon rank sum test, and Kaplan-Meier survival analysis were used for statistics. A total of 66,923 patients undergoing elective AAA repair were evaluated: (1) 9,315 with OSR and (2) 57,608 with EVAR. The most frequent PSI events after OSR versus EVAR were postoperative respiratory failure (PSI, 11; 17.7% vs 1.8%; P<.0001); perioperative hemorrhage/hematoma (PSI, 9; 3.6% vs 2.6%; P<.0001); postoperative sepsis (PSI, 13; 3.5% vs 0.4%; P<.0001); accidental puncture or laceration (PSI, 15; 2.1% vs 0.6%; P<.0001); and postoperative acute kidney injury requiring dialysis (PSI, 10; 1.4% vs 0.2%; P<.0001). The overall 30-day readmission rate was 10.5%. The occurrence of any PSI event overall significantly increased 30-day readmission compared with no event cases (odds ratio [OR]=1.71; 95% confidence interval [CI], 1.57-1.86). Likelihood of 30-day readmission was greater for postoperative acute kidney injury requiring dialysis (OR=1.66; 95% CI, 1.28-2.15), postoperative respiratory failure (OR=1.36; 95% CI, 1.22-1.52), perioperative hemorrhage (OR=1.34; 95% CI, 1.18-1.52), and postoperative pressure ulcer (OR = 2.88; 95% CI, 1.99-4.17). Occurrence of any PSI event was associated with an increased total hospital and intensive care unit length of stay and total hospital charges (all P<.001). In conclusion, AHRQ PSI events may be used to identify patients at the greatest risk for readmission after AAA repair. The risk for 30-day readmission was 71% higher when a PSI event occurred and was not associated with the type of repair. Minimizing preventable PSI events may be beneficial to reducing hospital readmissions after open and endovascular AAA repair and to improving hospital resource utilization.

Improved hospital safety performance and reduced medicolegal risk: an ecological study using 2 Canadian databases.

Few empirical studies have validated the relation between medicolegal risk and hospital patient safety performance. We sought to determine whether there was a relation between in-hospital patient safety events and medicolegal cases involving Canadian physicians. In this ecological study, we used Poisson regression to compare data from the Canadian Institute for Health Information's Discharge Abstract Database and the database of the Canadian Medical Protective Association (CMPA) of medicolegal cases over 10 years (2005/06 to 2014/15). We identified incidents and cases based on 15 Agency for Healthcare Research and Quality patient safety indicators within the Canadian Institute for Health Information and CMPA data sets. We performed subgroup analyses for obstetrical and surgical cases. We found a statistically significant positive association between volume changes in patient safety indicator events (n = 339 741) and medicolegal cases (n = 15 180) (parameter estimate 1.15, 95% confidence interval [CI] 0.4 to 1.9). This association suggests that, on average, a 10% decrease in events would correspond to a decrease of 11% in medicolegal cases. The degree of positive association varied by practice type, with obstetrics (97 982 patient safety indicator events, 865 cases) showing a 25% decrease in medicolegal cases for every 10% decrease in events (parameter estimate 2.9, 95% CI 0.5 to 5.3) and surgery (168 886 patient safety indicator events, 4568 cases) showing a decrease of 9% for every 10% decrease in events (parameter estimate 0.9, 95% CI 0.2 to 1.7). The statistically significant positive association between patient safety indicator events and medicolegal cases quantifies a relation between patient safety and physician medicolegal risk in Canadian hospitals. This suggests new, practical uses for both medicolegal and patient safety indicator data in system-level quality-improvement efforts.

Surgeon-Reported Complications vs AHRQ Patient Safety Indicators: A Comparison of Two Approaches to Identifying Adverse Events

Traditionally, clinicians present complications at surgical morbidity and mortality (M&M) conferences, and the AHRQ Patient Safety Indicators (PSIs) use inpatient administrative data to identify certain adverse outcomes. Although both methods are used to identify adverse events and inform quality improvement efforts, these 2 methods might not overlap. This is a retrospective observational study of all hospitalizations at a single academic department of surgery (including subspecialties) in 2016 involving a PSI-defined event (PSIs 03, 05 to 15) identified by surgery faculty and residents for review by departmental M&M conference or administrative data (according to AHRQ, version 6.0). Pediatric cases were excluded. We analyzed the degree to which these 2 processes captured PSI-defined events and reasons for exclusion by each process. Among 6,563 surgical hospitalizations, 647 hospitalizations (9.9%) had at least 1 complication identified by the M&M process or the PSIs (or both). Of these hospitalizations, 116 had at least 1 PSI-defined event (for a total of 149 PSI-defined events) captured by either M&M or the PSIs. Most complications (n= 82 [88.2%]) identified by M&M alone were excluded by PSI criteria (as intended), but 11 true PSI events (ie false negatives) were identified by M&M only. In contrast, pressure ulcers and central venous catheter-related bloodstream infections were detected exclusively by the PSIs and not reported via M&M. There was limited overlap, with 18 events (12.1%) captured by both processes. Surgical M&M and the PSIs are complementary approaches to identifying complications. Both case-finding processes should be used to inform quality improvement efforts.

Relationship between patient safety indicator events and comprehensive stroke center volume status in the treatment of unruptured cerebral aneurysms.

OBJECTIVE The Agency of Healthcare Research and Quality (AHRQ) has defined Patient Safety Indicators (PSIs) for assessments in quality of inpatient care. The hypothesis of this study is that, in the treatment of unruptured cerebral aneurysms (UCAs), PSI events are less likely to occur in hospitals meeting the volume thresholds defined by The Joint Commission for Comprehensive Stroke Center (CSC) certification. METHODS Using the 2002-2011 National (Nationwide) Inpatient Sample, patients treated electively for a nonruptured cerebral aneurysm were selected. Patients were evaluated for PSI events (e.g., pressure ulcers, retained surgical item, perioperative hemorrhage, pulmonary embolism, sepsis) defined by AHRQ-specified ICD-9 codes. Hospitals were categorized by treatment volume into CSC or non-CSC volume status based on The Joint Commission's annual volume thresholds of at least 20 patients with subarachnoid hemorrhage and performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms. RESULTS A total of 65,824 patients underwent treatment for an unruptured cerebral aneurysm. There were 4818 patients (7.3%) in whom at least 1 PSI event occurred. The overall inpatient mortality rate was 0.7%. In patients with a PSI event, this rate increased to 7% compared with 0.2% in patients without a PSI event (p < 0.0001). The overall rate of poor outcome was 3.8%. In patients with a PSI event, this rate increased to 23.3% compared with 2.3% in patients without a PSI event (p < 0.0001). There were significant differences in PSI event, poor outcome, and mortality rates between non-CSC and CSC volume-status hospitals (PSI event, 8.4% vs 7.2%; poor outcome, 5.1% vs 3.6%; and mortality, 1% vs 0.6%). In multivariate analysis, all patients treated at a non-CSC volume-status hospital were more likely to suffer a PSI event with an OR of 1.2 (1.1-1.3). In patients who underwent surgery, this relationship was more substantial, with an OR of 1.4 (1.2-1.6). The relationship was not significant in the endovascularly treated patients. CONCLUSIONS In the treatment of unruptured cerebral aneurysms, PSI events occur relatively frequently and are associated with significant increases in morbidity and mortality. In patients treated at institutions achieving the volume thresholds for CSC certification, the likelihood of having a PSI event, and therefore the likelihood of poor outcome and mortality, was significantly decreased. These improvements are being driven by the improved outcomes in surgical patients, whereas outcomes and mortality in patients treated endovascularly were not sensitive to the CSC volume status of the hospital and showed no significant relationship with treatment volumes.