Patient Safety Indicators

Patient Safety IndicatorsA way to improve health care

Serviço de Bioestatística e Informática Médica – Introdução à Medicina II

Patient Safety Indicators: A way to Improve Healthcare

According to the Institute of Medicine, Patient Safety is:

“freedom from accidental injury due to medical care, or medical errors.”


Key words

Patient safety indicators

Quality indicators

Health status indicators

Provider-level indicators

Area-level indicators

What are Patient Safety Indicators (PSIs)?


•Subset of quality indicators;

•Ways of measuring the quality of health care services during or after hospitalization;

•Concerned only about preventable situations.


PSI’s

Provider-level indicators

The problem occurs within

the same hospitalization.

Area-level indicators

The problem occurs

within a given area.

PSI’s • Patient Safety Indicators - Provider PSI

Number

▫ Complications of Anesthesia 1 ▫ Death in Low-Mortality DRGs 2 ▫ Decubitus Ulcer 3 ▫ Failure to Rescue 4 ▫ Foreign Body Left During Procedure 5 ▫ Iatrogenic Pneumothorax 6 ▫ Selected Infections Due to Medical Care 7 ▫ Postoperative Hip Fracture 8 ▫ Postoperative Hemorrhage or Hematoma 9 ▫ Postoperative Physiologic and Metabolic Derangements 10 ▫ Postoperative Respiratory Failure 11 ▫ Postoperative Pulmonary Embolism or Deep Vein Thrombosis 12 ▫ Postoperative Sepsis 13 ▫ Postoperative Wound Dehiscence 14 ▫ Accidental Puncture or Laceration 15 ▫ Transfusion Reaction 16 ▫ Birth Trauma – Injury to Neonate 17 ▫ Obstetric Trauma – Vaginal with Instrument 18 ▫ Obstetric Trauma – Vaginal without Instrument 19 ▫ Obstetric Trauma – Cesarean Delivery 20


• Patient Safety Indicators - Area PSI Number

▫ Foreign Body Left During Procedure 21

▫ Iatrogenic Pneumothorax 22

▫ Selected Infections Due to Medical Care 23

▫ Postoperative Wound Dehiscence 24

▫ Accidental Puncture or Laceration 25

▫ Transfusion Reaction 26

▫ Postoperative Hemorrhage or Hematoma 27


Types of Data

• Administrative data from the National System of Health

▫ Data from

hospitalizations

Diagnoses

Procedures

Age

Gender

Admission source

Hospital classification


Concerning all these items and the data we will have access to, our work is divided in…

•Analysis of hospitals, organized in groups

•Comparative analysis between groups of hospitals

•Analysis of data per year, from 2000 to 2005

• Comparison between Provider-level indicators and Area-level indicators, in the cases of the ones which appear in both groups.


Type C – administrative groups

1 Central hospital

2 County* Hospital

3 County* Hospital level 1

Type A – economical groups [in group I are included the most complex, specialized and

technologically advanced hospitals]

Group I

Group II

Group III

Group IV

Hospital divisions we used

*meaning the portuguese administrative division “distrito”


Objectives

• To conclude about the most prevalent PSI’s

• To identify the safety characteristics of each group of

hospitals

• To evaluate the evolution of the PSI’s in the various groups of

hospitals


Key questions

• What are the main differences between the various groups of

hospitals?

• Which are the most safety hospitals?

• Which group of hospitals suffered the biggest evolution?

• Which are the most prevalent PSI’s?


Participants and methods

Target population:

inpatient episodes from public Portuguese hospitals, with discharges

between years 2000 and 2005

Sample:

no sample (we will use all the

data)Inclusion criteria:

having attended the National Service of Health

Unity of analysis:

each group of hospitals


Data withdrawn from the AHRQ website


PSI 5 – Foreign Body Left During Procedure, Secondary Diagnosis FieldNumerator• ICD-9-CM codes for foreign body left in during procedure in any secondary

diagnosis

Denominator• All surgical and medical discharges 18 years and older or MDC 14 defined by

Surgical and Medical Discharge DRGs. Exclude patients with ICD-9-CM codes for foreign body left in during procedure in the principal diagnosis field or

secondary diagnosis present on admission.

General result:

PSI 5 = 0,0625 (Rate per 1000 cases)


PSI 5 - Gender per year

0

0,02

0,04

0,06

0,08

0,1

0,12

2000 2001 2002 2003 2004 2005

Year

Rate

per

1000 c

ases

Male Female

PSI 5 - Economic Groups per year

0

0,05

0,1

0,15

0,2

0,25

0,3

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s

Group I Group II Group III Group IV


Male = 0,077

Female = 0,052

AHRQ Rates:

Male = 0,084

Female = 0,086

I = 0,1435

II = 0,0602

III = 0,0474

IV = 0,0508

PSI 5 - Administrative Groups per year

0

0,02

0,04

0,06

0,08

0,1

0,12

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s

Central Hospital County Hospital County Hospital Level 1

Central Hospital = 0,0773

County Hospital = 0,0522

County Hospital Level 1 = 0,0474


PSI 6 – Iatrogenic Pneumothorax, Secondary DiagnosisNumerator• Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field

Denominator• Include all surgical and medical discharges 18 years and older or MDC 14 defined

by Surgical and Medical Discharge DRGs. • Exclude cases with:• ICD-9-CM code of 512.1 in the principal diagnosis field or secondary diagnosis,• MDC 14• diagnosis code of chest trauma or pleural effusion • ICD-9-CM procedure code of diaphragmatic surgery repair • any code indicating thoracic surgery, lung or pleural biopsy, or assigned to cardiac

surgery DRGs

General resultsPSI 6 = 0,297 (Rate per 1000 cases)



0

0,05

0,1

0,15

0,2

0,25

0,3

0,35

0,4

0,45

2000 2001 2002 2003 2004 2005

Year

Ra

te p

er

10

00

ca

se

s

Male Female


0

0,1

0,2

0,3

0,4

0,5

0,6

0,7

0,8

0,9

2000 2001 2002 2003 2004 2005

Year

Ra

te p

er

10

00

ca

se

s


I = 0,5195

II = 0,4110

III = 0,0344

IV = 0,2093

Male = 0,3573

Female = 0,2413


AHRQ Rates:

Male = 0,506

Female = 0,622

PSI 6 - Administrative Group per year

0

0,1

0,2

0,3

0,4

0,5

0,6

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s






PSI 7 – Selected Infections due to Medical Care, Secondary Diagnosis Field

Numerator• Discharges with ICD-9-CM code of 999.3 or 996.62 in any secondary

diagnosis field Denominator• All surgical and medical discharges 18 years and older or MDC 14

defined by Surgical and Medical Discharge DRGs.• Exclude cases with:

▫ with ICD-9-CM code of 999.3 or 996.62 in the principal diagnosis field or secondary diagnosis present on admission, if known

▫ length of stay less than 2 days ▫ any code for immunocompromised state or cancer ▫ cancer DRG

General resultsPSI 7 = 0,671 (Rate per 1000 cases)



0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s



0

0,2

0,4

0,6

0,8

1

1,2

1,4

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s

Male Female


Male = 0,9877

Female = 0,4686

I = 1,1944

II = 1,1194

III = 0,2002

IV = 0,4375

AHRQ Rates:

Male = 2,716

Female = 1,744


0

0,2

0,4

0,6

0,8

1

1,2

1,4

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s






PSI 14 – Postoperative Wound DehiscenceNumerator• Discharges with ICD-9-CM code for reclosure of postoperative disruption of

abdominal wall

Denominator• Include all abdominopelvic surgical discharges age 18 and older.• Exclude case:

▫ where length of stay is less than 2 days ▫ with immunocompromised state ▫ MDC 14

General results




0

2

4

6

8

10

12

14

16

2000 2001 2002 2003 2004 2005

Year

Ra

te p

er

10

00

ca

se

s

Male Female


0

2

4

6

8

10

12

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s


I = 6,0885

II = 8,0627

III = 1,9741

IV = 7,4808

Male = 9,3522

Female = 5,3288


AHRQ Rates:

Male = 4,311

Female = 0,995

PSI 14 - Administrative Group per year

0

2

4

6

8

10

12

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s






PSI 15 – Accidental Puncture or Laceration, Secondary Diagnosis Field

Numerator• Discharges with ICD-9-CM code denoting accidental cut, puncture,

perforation or laceration during a procedure.

Denominator• All surgical and medical discharges 18 years and older or MDC 14 defined

by Surgical and Medical Discharge DRGs.• Exclude cases with

▫ ICD-9-CM code denoting technical difficulty in the principal diagnosis field or secondary diagnosis present on admission

▫ MDC 14 .

General results




0

0,5

1

1,5

2

2,5

3

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s

Male Female


0

1

2

3

4

5

6

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s


Male = 1,9776

Female = 2,1138

I = 4,1782

II = 2,6590

III = 0,6860

IV = 1,3434


AHRQ Rates:

Male = 2,942

Female = 4,080


0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s






PSI 16 – Transfusion Reaction, Secondary Diagnosis

Numerator

• Discharges with ICD-9-CM codes for transfusion reaction.

Denominator• Include all surgical and medical discharges 18 years and older or MDC 14

defined by Surgical and Medical Discharge DRGs.• Exclude cases with preexisting transfusion resction.

General results





00,0010,0020,0030,0040,0050,0060,0070,0080,009

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s

Male Female


0

0,005

0,01

0,015

0,02

0,025

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s


Male = 0,0073

Female = 0,0024

Group I = 0,0062

Group II = 0,0038

Group III = 0,01

Group IV = 0,0038

AHRQ Rates:

Male = 0,003

Female = 0,005


0

0,005

0,01

0,015

0,02

0,025

2000 2001 2002 2003 2004 2005

Year

Rat

e p

er 1

000

case

s







General ComparisonsGender General Comparison

0,0

0,5

1,0

1,5

2,0

2,5

PSI 5 PSI 6 PSI 7 PSI 15

PS

I R

ate

Male

Female

PSI 14 per Year

0123456789

10

PSI14

PS

I R

ate

Male

Female


Year General Comparison

-0,10,10,30,50,70,91,11,31,51,71,92,12,32,5


PS

I R

ates

2000

2001

2002

2003

2004

2005

PSI 14 per Year

0123456789

10

PSI 14

PS

I Rat

e

2000

2001

2002

2003

2004

2005


Economical Groups General Comparison

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

4,5


PS

I R

ate

I

II

III

IV

PSI 14 per Economical Group

0

1

2

3

4

5

6

7

8

9

PSI 14

PS

I R

ate

I

II

III

IV


Administrative Groups General Comparison

0,0

0,5

1,0

1,5

2,0

2,5

3,0


PS

I R

ate Central Hospital

County Hospital

County Hospital Level 1

PSI 14 per Administrative Group

0

1

2

3

4

5

6

7

8

PSI 14

PS

I R

ate Central Hospital

County Hospital

County Hospital Level 1

Obtained Rates (per 1000 cases)

AHRQ rates (per 1000 cases)

PSI 5 0,063 0,085

PSI 6 0,323 0,570

PSI 7 0,671 2,087

PSI 14 7,16 2,101

PSI 15 2,048 3,563

PSI 16 0,004 0,004


Some conclusions

• Generally, the men were more affected by these medical errors than women.

• Although we predicted the other way, the rate of complications has shown higher in Type I Hospitals than in less developed, economically and technically, hospitals.

• Overall, Central Hospitals show a higher rate of medical error than smaller hospitals.

• Concerning the time period we are analyzing, there seems to be an increase of the PSI rates along the years.

• Comparing with the reference values, our rates appear to be very similar or even better than the American rates, published by the AHRQ.

• Of the six PSI presented here, PSI 14 - Postoperative Wound Dehiscence - is the most prevalent.


References

Patient Safety Indicators: A way to Improval

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http://www.qualityindicators.ahrq.gov

• MATTKE S, EPSTEIN A M, LEATHERMAN S. The OECD Health Care Quality Indicators

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2006; 18 Suppl 1:1-4.

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Selecting indicators for patient safety at the health system level in OECD countries.

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Pediatrics. 2004; 113: 1741-1746.

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DIJKSTRA R, GROL R. Clinical indicators: development and applications. The Netherlands Journal of Medicine.

2007; 65:15-22.

• RUNCIMAN W B. Shared meanings: preferred terms and definitions for safety and quality concepts. MJA. 2006;

184 Suppl 10: S41-3.

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• AHRQ Quality Indicators. Patient Safety Indicators: Technical Specifications 2007.

http://www.qualityindicators.ahrq.gov.

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• Bagian,J.P., A. K. Rosen, A.N. West, and W.B. Weeks.2008. Comparing measures of patient safety for inpatient

care provided to veterans within and outside the VA system in New York. Qual. Safe. Health Care. 17:58-64

Turma 22

Ana Filipe Rocha

Ana Rita Santos

Carolina Cardoso

Eva Brysch

Joana

Rodrigues

Marina Pinto

Pedro Vaz

Sara Pinto

Vasco Marques


Patient Safety Indicators

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