Patient Safety Indicators Events Research Articles

Patient Safety Indicators for Judging Hospital Performance.

Patient Safety Indicators (PSIs) were originally intended for use as a screen for quality of care but are now being used to rank hospitals and to modify hospital reimbursement. PSI data are dependent on accuracy of clinical documentation and coding. Information on whether a PSI event is inherent to the nature of the operation or posed a significant impact on the outcome is lacking. Cases for one year at a single academic center were queried. Cases with target PSIs were included (n = 136). Cases were evaluated for both the inherent nature and significance of injury. Both patient safety officers agreed that the PSI event was inherent to the disease process, and thus, the procedure and was not a marker of patient safety (false positive) in 11.8% to 33.3% of cases. Both reviewers agreed that the events were not clinically significant in 11.8% to 30.4% of cases. This study found high false-positive rates and only moderate interrater reliability for 3 PSIs. PSIs as currently reported are not reliable enough to be utilized for ranking.

Do patient safety indicators explain increased weekend mortality?

BackgroundWe sought to determine the differential role of patient safety indicator (PSI) events on mortality after weekend as compared with weekday admission. Materials and methodsWe evaluated Agency for Healthcare Research and Quality PSI events within a cohort of patients with nonelective admissions. First, we identified all patients with a PSI based on day of admission (weekend versus weekday). Then, we evaluated the outcome of mortality after each PSI event. Finally, we entered age, sex, race, median household income, payer information, and Charlson comorbidity scores in regression models to develop risk ratios of weekend to weekday PSI events and mortality. ResultsThere were 28,236,749 patients evaluated with 428,685 (1.5%) experiencing one or more PSI events. The rate of PSI was the same for patients admitted on weekends as compared to weekdays (1.5%). However, the risk of mortality was 7% higher if a PSI event occurred to a patient admitted on a weekend as compared with a weekday. In addition, compared to patients admitted on weekdays, patients admitted on weekends had a 36% higher risk of postoperative wound dehiscence, 19% greater risk of death in a low-mortality diagnostic-related group, 19% increased risk of postoperative hip fracture, and 8% elevated risk of surgical inpatient death. ConclusionsRisk adjusted data reveal that PSI events are substantially higher among patients admitted on weekends. The considerable differences in death after PSI events in patients admitted on weekends as compared with weekdays indicate that responses to adverse events may be less effective on weekends.

Laparoscopic appendectomy is safer than open appendectomy in an elderly population.

Background and Objectives:This study describes perioperative patient safety outcomes comparing laparoscopic appendectomy with open appendectomy in the elderly population (defined as age ≥65 years) during the diffusion of laparoscopic appendectomy into widespread clinical practice.Methods:We performed a cross-sectional analysis of patients undergoing open or laparoscopic appendectomy in the US Nationwide Inpatient Sample, a 20% sample of inpatient discharges from 1056 hospitals, from 1998 to 2009, and used weighted sampling to estimate national trends. Multivariate logistic regression modeling was used to examine the association of laparoscopy with perioperative outcomes.Results:Patients who met the inclusion criteria totaled 257 484. Of these, 87 209 (34%) underwent laparoscopic appendectomy. These patients were younger (P < .001); had lower Charlson comorbidity scores (P < .001); were more likely to be white (P < .001), to be privately insured (P = .005), and to undergo surgery in urban hospitals (P < .001); and were less likely to have appendiceal rupture (P < .001). Laparoscopic appendectomy was associated with a decreased length of stay (4.44 days vs 7.86 days, P < .001), fewer total patient safety indicator events (1.8% vs 3.5%, P < .001), and a decreased mortality rate (0.9% vs 2.8%, P < .001). On multivariate analyses, we observed a 32% (odds ratio, 0.68) decreased probability of patient safety events occurring in laparoscopic appendectomy cases versus open appendectomy cases as measured by patient safety indicators.Conclusion:The data suggest that laparoscopic appendectomy is associated with improved clinical outcomes in the elderly and that diffusion of laparoscopic appendectomy is not associated with adverse patient safety events in this population.

The prevalence of patient safety indicators and hospital-acquired conditions in patients with ruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database

The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are publicly reported metrics used to gauge the quality of health care provided by health care institutions. To better understand the prevalence of these events in hospitalized patients treated for ruptured cerebral aneurysms, the authors determined the incidence rates of PSIs and HACs among patients with a diagnosis of subarachnoid hemorrhage and procedure codes for either coiling or clipping in the Nationwide Inpatient Sample database. The authors queried the Nationwide Inpatient Sample database, part of the AHRQ's Healthcare Cost and Utilization Project, for all hospitalizations between 2002 and 2010 involving coiling or clipping of ruptured cerebral aneurysms. The incidence rate of each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The authors used the SAS statistical software package to calculate incidence rates and perform multivariate analyses to determine the effects of patient variables on the probability of developing each indicator. There were 62,972 patient admissions with a diagnosis code of subarachnoid hemorrhage between the years 2002 and 2010; 10,274 (16.3%) underwent clipping and 8248 (13.1%) underwent endovascular coiling. A total of 6547 PSI and HAC events occurred within the 10,274 patients treated with clipping; at least 1 PSI or HAC occurred in 47.9% of these patients. There were 5623 total PSI and HAC events among the 8248 patients treated with coils; at least 1 PSI or HAC occurred in 51.0% of coil-treated patients. Age, sex, comorbidities, hospital size, and hospital type had statistically significant associations with indicator occurrence. Compared with patients without events, those treated by either clipping or coiling and had at least 1 PSI during their hospitalization had significantly longer lengths of stay (p < 0.001), higher hospital costs (p < 0.001), and higher in-hospital mortality rates (p < 0.001). These results estimate baseline national rates of PSIs and HACs in patients treated for ruptured cerebral aneurysms. These data may be used to gauge individual institutional quality of care and patient safety metrics in comparison with national data.

Using AHRQ Patient Safety Indicators to Detect Postdischarge Adverse Events in the Veterans Health Administration

Patient safety indicators (PSIs) use inpatient administrative data to flag cases with potentially preventable adverse events (AEs) attributable to hospital care. This study explored how many AEs the PSIs identified in the 30 days post discharge. PSI software was run on Veterans Health Administration 2003-2007 administrative data for 10 recently validated PSIs. Among PSI-eligible index hospitalizations not flagged with an AE, this study evaluated how many AEs occurred within 1 to 14 and 15 to 30 days post discharge using inpatient and outpatient administrative data. Considering all PSI-eligible index hospitalizations, 11 141 postdischarge AEs were identified, compared with 40 578 inpatient-flagged AEs. More than 60% of postdischarge AEs were detected within 14 days of discharge. The majority of postdischarge AEs were decubitus ulcers and postoperative pulmonary embolisms or deep vein thromboses. Extending PSI algorithms to the postdischarge period may provide a more complete picture of hospital quality. Future work should use chart review to validate postdischarge PSI events.

Prevalence of patient safety indicators and hospital-acquired conditions in those treated for unruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database

The Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are metrics used to gauge the quality of health care provided by health care institutions. The PSIs and HACs are publicly reported metrics and are directly linked to reimbursement for services. To better understand the prevalence of these adverse events in hospitalized patients treated for unruptured cerebral aneurysms, the authors determined the incidence rates of PSIs and HACs among patients with a diagnosis of unruptured aneurysm in the Nationwide Inpatient Sample (NIS) database. The NIS, part of the AHRQ's Healthcare Cost and Utilization Project, was queried for all hospitalizations between 2002 and 2010 involving coiling or clipping of unruptured cerebral aneurysms. The incidence rate for each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The SAS statistical software package was used to calculate incidences and perform multivariate analyses to determine the effects of patient variables on the probability of each indicator developing. There were 54,589 hospitalizations involving unruptured cerebral aneurysms in the NIS database for the years 2002-2010; 8314 patients (15.2%) underwent surgical clipping and 9916 (18.2%) were treated with endovascular coiling. One thousand four hundred ninety-two PSI and HAC events occurred among the 8314 patients treated with clipping; at least 1 PSI or HAC occurred in 14.6% of these patients. There were 1353 PSI and HAC events among the 9916 patients treated with coiling; at least 1 PSI or HAC occurred in 10.9% of these patients. Age, sex, and comorbidities had statistically significant associations with an adverse event. Compared with the patients having no adverse event, those having at least 1 PSI during their hospitalizations had significantly longer hospital stays (p < 0.0001), higher hospital costs (p < 0.0001), and higher mortality rates (p < 0.0001). These results estimate baseline national rates of PSIs and HACs in patients with unruptured cerebral aneurysms. These data may be used to gauge individual institutional quality of care and patient safety metrics in comparison with national data.

National trends in hospital-acquired preventable adverse events after major cancer surgery in the USA

ObjectivesWhile multiple studies have demonstrated variations in the quality of cancer care in the USA, payers are increasingly assessing structure-level and process-level measures to promote quality improvement. Hospital-acquired adverse events...

퇴원손상심층자료를 이용한 환자안전지표의 적용

목적: 본 연구의 목적은 국내 환자안전지표 산출 가능성을 확인하는 것이다. 조사방법: 환자안전지표의 정의는 OECD에서 AHRQ에 근거하여 작성한 보건기술문서 19의 기준을 이용하였고, 이에 따라 2004-2008년 퇴원손상심층조사 875,622건에서 환자안전지표(PSIs)를 산출하였다. 로지스틱 회귀분석을 이용하여 환자안전지표별 비율의 변이요인을 확인하였다. 분석결과: 2004-2008년간 약 80만 건의 퇴원 중에서 8개의 환자안전지표에 해당하는 위해사건은 3,084건이었다. 욕창(PSI3, 4.88), 시술 중 이물질 체내 잔류(PSI5, 0.05), 수술 후 패혈증(PSI13, 1.32), 출생손상-신생아(PSI17, 7.92), 산과적 외상-도구를 이용한 질식 분만(PSI18, 32.81)의 퇴원 1,000건당 비율은 모두 OECD 환자안전지표 비율의 최소-최대 범위 내에 포함되었다. 그러나 내과적 치료에 의한 감염(PSI7, 0.22), 수술 후 폐색전증 또는 심부정맥혈전증(PSI12, 0.90), 우발적 천공 또는 열상(PSI15, 0.71)의 퇴원 1,000건당 비율은 OECD 환자안전지표 최소값에 못 미쳤다. PSI 18을 제외한 7개의 지표값 모두 부진단명의 개수와 유의한 상관관계가 있는 것으로 나타났다. 또한 환자안전지표 비율은 환자특성을 보정했을 때, 병상규모 및 병원소재지 등 병원특성에 따른 유의한 차이를 보였다. 결론: 본 연구는 국가적인 행정자료를 이용하여 위해사고를 스크리닝 하는 환자안전지표를 산출한 최초의 실증적 연구이다. 본 연구의 결과는 자료의 질, 임상 관련 변수 등의 결과에 영향을 미치는 요소가 여전히 있지만, 환자안전에 대한 국가적인 통계를 추계하는 기초자료를 제공하였다는데 의의가 있다. 향후 본 연구결과를 바탕으로 위해사건으로 인한 사망 규모 산출 등의 결과연구가 필요하다. 【Objective: This study aims to determine whether national patient safety indicators (PSIs) can be calculated. Methods: Using PSI criteria from Organization for Economic Co-Operation and Development (OECD) Health Technical Papers 19 based on the Agency for Healthcare Research and Quality (AHRQ), PSIs were identified in the Korean National Hospital Discharge In-depth Injury Survey (KNHDIIS) database for 875,622 inpatient admissions between 2004 and 2008. Logistic regression was used to estimate factors of variations for PSIs. Results: From 2004 to 2008, 3,084 PSI events of 8 PSIs occurred for over 80 thousands discharges. Rates per 1,000 events for decubitus ulcer (PSI3, 4.88), foreign body left during procedure (PSI5, 0.05), postoperative sepsis (PSI13, 1.32), birth trauma-injury to neonate (PSI17, 7.92) and obstetric trauma-vaginal delivery (PSI18, 32.81) are all identified between ranges from maximum to minimum of OECD rates, respectively. However, rates per 1,000 events for selected infections due to medical care (PSI7, 0.22), postoperative pulmonary embolism or deep vein thrombosis (PSI12, 0.90) and accidental puncture or laceration (PSI15, 0.71) are below the minimum of OECD range. 7 PSIs except PSI 18 showed statistically significant relationship with number of secondary diagnoses. When adjusting patient characteristics, there are statistically significant different rates according to bed size or location of hospitals. Conclusion: This is the first empirical study to identify nationally number of adverse events and PSIs using administrative database. While many factors influencing these results such as quality of data, clinical data and so on are remain, the results indicate opportunities for estimate national statistics for patient safety. Furthermore outcome research such as mortality related to adverse events is needed based on results of this study.】

Examining the Impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration

By focusing primarily on outcomes in the inpatient setting one may overlook serious adverse events that may occur after discharge (eg, readmissions, mortality) as well as opportunities for improving outpatient care. Our overall objective was to examine whether experiencing an Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) event in an index medical or surgical hospitalization increased the likelihood of readmission. We applied the Agency for Healthcare Research and Quality PSI software (version 4.1.a) to 2003-2007 Veterans Health Administration inpatient discharge data to generate risk-adjusted PSI rates for 9 individual PSIs and 4 aggregate PSI measures: any PSI event and composite PSIs reflecting "Technical Care," "Continuity of Care," and both surgical and medical care (Mixed). We estimated separate logistic regression models to predict the likelihood of 30-day readmission for individual PSIs, any PSI event, and the 3 composites, adjusting for age, sex, comorbidities, and the occurrence of other PSI(s). The odds of readmission were 23% higher for index hospitalizations with any PSI event compared with those with no event [confidence interval (CI), 1.19-1.26], and ranged from 22% higher for Iatrogenic Pneumothorax (CI, 1.03-1.45) to 61% higher for Postoperative Wound Dehiscence (CI, 1.27-2.05). For the composites, the odds of readmission ranged from 15% higher for the Technical Care composite (CI, 1.08-1.22) to 37% higher for the Continuity of Care composite (CI, 1.26-1.50). Our results suggest that interventions that focus on minimizing preventable inpatient safety events as well as improving coordination of care between and across settings may decrease the likelihood of readmission.

Thirty-Day, All-cause Readmissions for Elderly Patients Who Have an Injury-related Inpatient Stay

Policymakers are exploring ways to reduce readmission rates. Much attention has been given to readmissions for conditions such as heart failure, acute myocardial infarction, and pneumonia, but little attention has been given to readmissions of patients with injury-related index admissions. This analysis is a retrospective cohort study of elderly persons who are admitted to a community hospital for a principal diagnosis of injury. We use 2006 Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from 11 States. With logistic regression we identify factors associated with a 30-day, all-cause inpatient readmission. Factors include: patient characteristics, injury characteristics, clinical experiences during the hospital stay, and hospital characteristics. About 1 in 7 elderly patients with an injury-related admission were readmitted in 30 days (13.7%). We found that severe injuries had higher predicted readmission rates. Patients receiving transfusions, experiencing a Patient Safety Indicator event, and with infections had higher readmission rates. Patients discharged to nursing homes or home health care had higher readmission rates compared with patients discharged to the community. This study expands evidence for the influence of injury characteristics on readmission rates. It also provides evidence about hospital experiences that affect readmissions. These findings suggest that a focus on preventing complications during the hospital stay may help reduce hospital-specific readmissions for patients with injury-related conditions. It also suggests that a strategy to reduce readmission rates should not only focus on hospitals but also nursing homes and home health care.

The Association Between Sepsis and Potential Medical Injury Among Hospitalized Patients

Patient safety remains a national priority, but the role of disease-specific characteristics in safety is not well characterized. We identified potentially preventable medical injuries using patient safety indicators (PSIs) and annual data from the Nationwide Inpatient Sample between 2003 and 2007. We compared the rate of selected PSIs among patients hospitalized with and without sepsis. Among patients with sepsis, we also compared PSI rates across severity strata. Using multivariable case-control matching and regression analyses, we estimated the excess adverse outcomes associated with PSI events in patients with sepsis. Patients hospitalized with sepsis accounted for 2% to 4% of hospital discharges; however, they accounted for 9% to 26% of all potential medical injuries. PSI rates varied considerably; among patients hospitalized for sepsis, they were lowest for accidental puncture or laceration and highest for postoperative respiratory failure. Nearly all PSI rates were higher among patients with sepsis compared with patients without sepsis. Among those with sepsis, most PSI rates increased as sepsis severity increased. Compared with matched sepsis control subjects, increased length of stay and hospital charges were associated with PSI events in sepsis cases. However, only decubitus ulcer, iatrogenic pneumothorax, and postoperative metabolic and physiologic derangement or respiratory failure were associated with excess mortality. Patients hospitalized for sepsis, compared with the general hospital population, were at a substantially increased risk of potential medical injury; their risk rose as disease severity increased. Future patient safety efforts may benefit from focusing on medically vulnerable populations.

Is patient safety improving? National trends in patient safety indicators: 1998-2007.

Emphasis has been placed on quality and patient safety in medicine; however, little is known about whether quality over time has actually improved in areas such as patient safety indicators (PSIs). To determine whether national trends for hospital PSIs have improved from 1998 to 2007. Using PSI criteria from the Agency for Healthcare Research and Quality, PSIs were identified in the Nationwide Inpatient Sample (NIS) for all eligible inpatient admissions between 1998 and 2007. Joinpoint regression was used to estimate annual percentage changes (APCs) for PSIs. Annual percent change for PSIs. From 1998 to 2007, 7.6million PSI events occurred for over 69million hospitalizations. A total of 14 PSIs showed statistically significant trends. Seven PSIs had increasing APC: postoperative pulmonary embolism or deep vein thrombosis (8.94), postoperative physiological or metabolic derangement (7.67), postoperative sepsis (7.17), selected infections due to medical care (4.05), decubitus ulcer (3.05), accidental puncture or laceration (2.64), and postoperative respiratory failure (1.46). Seven PSIs showed decreasing APCs: birth trauma injury to neonate (-17.79), failure to rescue (-6.05), postoperative hip fracture (-5.86), obstetric trauma-vaginal without instrument (-5.69), obstetric trauma-vaginal with instrument (-4.11), iatrogenic pneumothorax (-2.5), and postoperative wound dehiscence (-1.8). This is the first study to establish national trends of PSIs during the past decade indicating areas for potential quality improvement prioritization. While many factors influence these trends, the results indicate opportunities for either emulation or elimination of current patient safety trends.

Testing the Association Between Patient Safety Indicators and Hospital Structural Characteristics in VA and Nonfederal Hospitals

This study tested the association between hospital structural characteristics-teaching status, bedsize, and nurse staffing-and potentially preventable adverse events. The authors calculated 14 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) and a PSI composite, using discharge databases from VA and nonfederal hospitals. This study compared the likelihood of PSI events in hospitals, controlling for structural and other characteristics, including patients' case-mix. Additional controls were employed to account for differences in VA versus nonfederal patients and data. The study found some associations, most notably a positive (unfavorable) association between status as a major teaching hospital and six PSIs. However, for most PSIs, the authors found no association between the structural characteristics tested and likelihood of PSI events. The study's findings extend previous research showing a lack of consistent relationship between structural characteristics and patient safety. However, the results also suggest continued need for examination of the relationship between teaching status and potentially preventable adverse events.

Effects of Resident Duty Hour Reform on Surgical and Procedural Patient Safety Indicators Among Hospitalized Veterans Health Administration and Medicare Patients

Improving patient safety was a strong motivation behind duty hour regulations implemented by Accreditation Council for Graduate Medical Education on July 1, 2003. We investigated whether rates of patient safety indicators (PSIs) changed after these reforms. Observational study of patients admitted to Veterans Health Administration (VA) (N = 826,047) and Medicare (N = 13,367,273) acute-care hospitals from July 1, 2000 to June 30, 2005. We examined changes in patient safety events in more versus less teaching-intensive hospitals before (2000-2003) and after (2003-2005) duty hour reform, using conditional logistic regression, adjusting for patient age, gender, comorbidities, secular trends, baseline severity, and hospital site. Ten PSIs were aggregated into 3 composite measures based on factor analyses: "Continuity of Care," "Technical Care," and "Other" composites. Continuity of Care composite rates showed no significant changes postreform in hospitals of different teaching intensity in either VA or Medicare. In the VA, there were no significant changes postreform for the technical care composite. In Medicare, the odds of a Technical Care PSI event in more versus less teaching-intensive hospitals in postreform year 1 were 1.12 (95% CI; 1.01-1.25); there were no significant relative changes in postreform year 2. Other composite rates increased in VA in postreform year 2 in more versus less teaching-intensive hospitals (odds ratio, 1.63; 95% CI; 1.10-2.41), but not in Medicare in either postreform year. Duty hour reform had no systematic impact on PSI rates. In the few cases where there were statistically significant increases in the relative odds of developing a PSI, the magnitude of the absolute increases were too small to be clinically meaningful.

The Occurrence of Potential Patient Safety Events Among Trauma Patients

The Patient Safety Indicators (PSIs) from the Agency for Healthcare Research and Quality are validated measures of quality of care. The pattern of PSIs among adult trauma patients is unknown. The occurrence of PSI events should be random and have no identifiable pattern across age, gender, and racial groups in trauma, because trauma services are designed to be an equal-access system. : Retrospective analysis of a nationally representative dataset. Nationwide Inpatient Sample (representative 20% sample from 37 states) for 5 years (2000 through 2004). Patients aged > or =18 admitted primarily for trauma. Occurrence of at least one of the applicable PSIs on multiple logistic regression analysis, with confirmation by sensitivity analysis. A total of 1.35 million trauma patients were identified, with 19,338 patients (1.43%) experiencing at least one of the applicable PSIs. On multivariate analysis, controlling for injury severity and disease comorbidity, the adjusted odds ratios (ORs) for occurrence of at least 1 applicable PSI were noted to increase for patients who are 1) above age 35, 2) male gender (OR 1.25, 95% CI 1.19-1.31), and 3) black (OR 1.20 vs. whites, 95% CI 1.10-1.30) but not for any other racial groups. These results did not change significantly on sensitivity analysis. Patients who are above age 35, male gender, and black are associated with increased likelihood of experiencing a patient safety event in trauma care. When all else is equal, black patients are approximately 20% more likely than any other racial groups to experience a patient safety event, even after controlling for injury severity and disease comorbidity. These findings can help institutions prioritize chart review-based investigations to determine potential targets of systems improvement.

Evaluating the Patient Safety Indicators

The Patient Safety Indicators (PSIs), an administrative data-based tool developed by the Agency for Healthcare Research and Quality, are increasingly being used to screen for potential in-hospital patient safety problems. Although the Veterans Health Administration (VA) is a national leader in patient safety, accurate information on the epidemiology of patient safety events in the VA is still unavailable. Our objectives were to: (1) apply the AHRQ PSI software to VA administrative data to identify potential instances of compromised patient safety; (2) determine occurrence rates of PSI events in the VA; and (3) examine the construct validity of the PSIs. We examined differences between observed and risk-adjusted PSI rates in the VA, compared VA and non-VA PSI rates, and investigated the construct validity of the PSIs by examining correlations of the PSIs with other outcomes of VA hospitalizations. We identified 11,411 PSI events in the VA nationwide in FY'01. Observed PSI rates per 1000 discharges ranged from 0.007 for "transfusion reaction" to 155.5 for "failure to rescue." There were significant, although small, differences between VA and non-VA risk-adjusted PSI rates. Hospitalizations with PSI events had longer lengths of stay, higher mortality, and higher costs than those without PSI events. Our results suggest that the PSIs may be useful as a patient safety screening tool in the VA. Our PSI rates were consistent with the national incidence of low rates; however, differences between VA and non-VA rates suggest that inadequate case-mix adjustment may be contributing to these findings.

Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for Children's Hospitals

Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality. Our objectives were (1) to apply these algorithms to the National Association of Children's Hospitals and Related Institutions (NACHRI) Aggregate Case Mix Comparative Database for 1999-2002, (2) to establish mean rates for each of the PSI events in children's hospitals, (3) to investigate the inadequacies of PSIs in relation to pediatric diagnoses, and (4) to express the data in such a way that children's hospitals could use the PSIs determined to be appropriate for pediatric use for comparison with their own data. In addition, we wanted to use the data to set priorities for ongoing clinical investigations and to propose interventions if the indicators demonstrated preventable errors. The Agency for Healthcare Research and Quality PSI algorithms (version 2.1, revision 1) were applied to children's hospital administrative data (1.92 million discharges) from the NACHRI Aggregate Case Mix Comparative Database for 1999-2002. Rates were measured for the following events: complications of anesthesia, death in low-mortality diagnosis-related groups (DRGs), decubitus ulcer, failure to rescue (ie, death resulting from a complication, rather than the primary diagnosis), foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care (ie, infections related to surgery or device placement), postoperative hemorrhage or hematoma, postoperative pulmonary embolism or venous thrombosis, postoperative wound dehiscence, and accidental puncture/laceration. Across the 4 years of data, the mean risk-adjusted rates of PSI events ranged from 0.01% (0.1 event per 1000 discharges) for a foreign body left in during a procedure to 14.0% (140 events per 1000 discharges) for failure to rescue. Review of International Classification of Diseases, Ninth Revision, Clinical Modification codes associated with each PSI category showed that the failure to rescue and death in low-mortality DRG indicators involved very complex cases and did not predict preventable events in the majority of cases. The PSI for infection attributable to medical care appeared to be accurate the majority of the time. Incident risk-adjusted rates of infections attributable to medical care averaged 0.35% (3.5 events per 1000 discharges) and varied up to fivefold from the lowest rate to the highest rate. The highest rates were up to 1.8 times the average. PSIs derived from administrative data are indicators of patient safety concerns and can be relevant as screening tools for children's hospitals; however, cases identified by these indicators do not always represent preventable events. Some, such as a foreign body left in during a procedure, iatrogenic pneumothorax, infection attributable to medical care, decubitus ulcer, and venous thrombosis, seem to be appropriate for pediatric care and may be directly amenable to system changes. Evidence-based practices regarding those particular indicators that have been reported in the adult literature need to be investigated in the pediatric population. In their present form, 2 of the indicators, namely, failure to rescue and death in low-mortality DRGs, are inaccurate for the pediatric population, do not represent preventable errors in the majority of pediatric cases, and should not be used to estimate quality of care or preventable deaths in children's hospitals. The PSIs can assist institutions in prioritizing chart review-based investigations; if clusters of validated events emerge in reviews, then improvement activities can be initiated. Large aggregate databases, such as the NACHRI Case Mix Database, can help establish mean rates of potential pediatric events, giving children's hospitals a context within which to examine their own data.

Pediatric patient safety in hospitals: a national picture in 2000.

To describe potential patient safety events for hospitalized children, examine associated factors, and explore impacts of safety events. The newly released Patient Safety Indicators (PSIs), developed by researchers at the Agency for Healthcare Research and Quality to identify potential in-hospital patient safety problems using administrative data, were applied to hospital discharge data. All 5.7 million discharge records for children younger than 19 years from 27 states in the 2000 Healthcare Cost and Utilization Project were analyzed for PSI events. Prevalence of PSI events and associations with patient-level and hospital-level characteristics were examined. Multivariate regression adjusting for patient severity of illness was used to estimate impacts of safety events in terms of excess length of stay, charges, and in-hospital mortality. The prevalence of pediatric patient safety events is significant. PSI events occurred more frequently in the very young and those on Medicaid insurance, some of the most vulnerable hospitalized children. Regression analysis found that almost all PSIs are associated with significant and substantial increases in length of stay, charges, and in-hospital death. Using the estimates derived here and the actual number of cases identified in the 2000 data, we estimate that patient safety events incurred >1 billion dollars in excess charges for children alone in 2000. Patient safety problems for hospitalized children occur frequently and with substantial impacts to our health care industry. Unmeasurable by this study are the additional "costs" and "burdens" of safety events that our patients are forced to handle. Additional work to describe and quantify better these outcomes in addition to ones measured here can help solidify the "business case" for patient safety efforts.

Medical injuries can increase mortality risk and incur additional costs

Question What is the effect of medical injury on risk of mortality, length of stay in hospital and associated costs? Study design Outcomes analysis: hospital discharge data. Main results The increased length of stay following patient safety indicator events ranged from 0 days (injury to neonate) to 10.89 days (postoperative sepsis). Additional costs ranged from $0 (obstetric trauma without vaginal instrumentation) to $57,727 (postoperative sepsis). Increased mortality ranged from 0% (obstetric trauma) to 21.9% (postoperative sepsis). Twelve of the 18 patient safety indicator events generated significant increases to mortality rate (see Table 1). Table 1 Outcomes for Patient Safety Indicator events occurring at a rate ≥1 per 1000 discharges. Patient Safety Indicator Event Rate per 1000 discharges at risk Excess mortality, % ( p value) * Excess length of hospital stay, days ( p value) * Excess cost, US $ ( p value) * Obstetric trauma, vaginal birth with instrumentation 224.21 0 (0.32) 0.07 (<0.001) 220 (0.3) Obstetric trauma, vaginal birth without instrumentation 86.61 0 (>0.99) 0.05 (0.01) −93 (0.16) Decubitus ulcer 21.51 7.23 (<0.001) 3.98 (0.10) 10,845 (<0.001) Sepsis (postoperative) 11.25 21.92 (<0.001) 10.89 (<0.001) 57,727 (<0.001) Pulmonary embolism or DVT (postoperative) 9.34 6.56 (<0.001) 5.36 (0.15) 21,709 (<0.001) Obstetric trauma, caesarean birth 6.97 −0.02 (0.32) 0.43 (0.003) 2718 (<0.001) Birth trauma, injury to neonate 6.53 −0.08 (0.27) −0.09 (0.27) 298 (0.32) Respiratory failure (postoperative) 3.58 21.84 (<0.001) 9.08 (<0.001) 53,502 (<0.001) Puncture or laceration, accidental 3.32 2.16 (<0.001) 1.34 (<0.001) 8271 (<0.001) Haemorrhage or haematoma (postoperative) 2.06 3.01 (<0.001) 3.94 (<0.001) 21,431 (<0.001) Wound dehiscence 2.05 9.63 (<0.001) 9.42 (<0.001) 40,323 (<0.001) Infection due to medical care 1.99 4.31 (<0.001) 9.58 (<0.001) 38,656 (<0.001) Physiologic and metabolic derangement (postoperative) 1 19.81 (<0.001) 19.81 (<0.001) 54,818 (<0.001) *Data are mean values. Excess length of stay, mortality and costs are the difference between a case and matching controls. Paired t test used to test if mean excess differed significantly from zero. Authors’ conclusions The effect of injuries experienced while in hospital varies enormously, which can result in significant increases to risk of mortality, length of hospital stay and cost.