Patient Safety Indicators

1. Patient Safety Indicators A way to improve health care Serviço de Bioestatística e Informática Médica – Introdução à Medicina II

2. 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.”

3. Patient Safety Indicators: A way to Improve Healthcare Patient safety indicators Provider-level indicators Key words Quality indicators Area-level indicators Health status indicators

4. Patient Safety Indicators: A way to Improve Healthcare 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.

5. Patient Safety Indicators: A way to Improve Healthcare PSI’s Provider-level indicators The problem occurs within the same hospitalization. Area-level indicators The problem occurs within a given area.

6. Patient Safety Indicators: A way to Improve Healthcare 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

7. Patient Safety Indicators: A way to Improve Healthcare • 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

8. Patient Safety Indicators: A way to Improve Healthcare Types of Data • Administrative data from the National System of Health • Data from • hospitalizations • Diagnoses • Procedures • Age • Gender • Admission source • Hospital classification

9. Patient Safety Indicators: A way to Improve Healthcare Concerning all these items and the data we will have access to, our work is divided in… • Analysis of hospitals, organized in groups • Analysis of data per year, from 2000 to 2005 • Comparative analysis between groups of hospitals • Comparison between Provider-level indicators and Area-level indicators, in the cases of the ones which appear in both groups.

10. Patient Safety Indicators: A way to Improve Healthcare Hospital divisions we used 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 Type C – administrative groups 1 Central hospital 2 County* Hospital 3 County* Hospital level 1 *meaning the portuguese administrative division “distrito”

11. Patient Safety Indicators: A way to Improve Healthcare 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

12. Patient Safety Indicators: A way to Improve Healthcare 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?

13. Patient Safety Indicators: A way to Improve Healthcare 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

14. Patient Safety Indicators: A way to Improve Healthcare Data withdrawn from the AHRQ website

15. Patient Safety Indicators: A way to Improve Healthcare PSI 5 – Foreign Body Left During Procedure, Secondary Diagnosis Field Numerator • 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)

16. Patient Safety Indicators: A way to Improve Healthcare 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

17. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 0,0773 County Hospital = 0,0522 County Hospital Level 1 = 0,0474

18. Patient Safety Indicators: A way to Improve Healthcare PSI 6 – Iatrogenic Pneumothorax, Secondary Diagnosis Numerator • 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 results PSI 6 = 0,297 (Rate per 1000 cases)

19. Patient Safety Indicators: A way to Improve Healthcare Male = 0,3573 Female = 0,2413 AHRQ Rates: Male = 0,506 Female = 0,622 I = 0,5195 II = 0,4110 III = 0,0344 IV = 0,2093

20. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 0,435 County Hospital = 0,2127 County Hospital Level 1 = 0,034

21. Patient Safety Indicators: A way to Improve Healthcare 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 results PSI 7 = 0,671 (Rate per 1000 cases)

22. Patient Safety Indicators: A way to Improve Healthcare Male = 0,9877 Female = 0,4686 AHRQ Rates: Male = 2,716 Female = 1,744 I = 1,1944 II = 1,1194 III = 0,2002 IV = 0,4375

23. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 1,0333 County Hospital = 0,4830 County Hospital Level 1 = 0,2002

24. Patient Safety Indicators: A way to Improve Healthcare PSI 14 – Postoperative Wound Dehiscence Numerator • 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 PSI 14 = 7,16 (Rate per 1000 cases)

25. Patient Safety Indicators: A way to Improve Healthcare Male = 9,3522 Female = 5,3288 AHRQ Rates: Male = 4,311 Female = 0,995 I = 6,0885 II = 8,0627 III = 1,9741 IV = 7,4808

26. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 7,2904 County Hospital = 7,6758 County Hospital Level 1 = 1,9741

27. Patient Safety Indicators: A way to Improve Healthcare 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 PSI 15 = 2,048 (Rate per 1000 cases)

28. Patient Safety Indicators: A way to Improve Healthcare Male = 1,9776 Female = 2,1138 AHRQ Rates: Male = 2,942 Female = 4,080 I = 4,1782 II = 2,6590 III = 0,6860 IV = 1,3434

29. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 3,0253 County Hospital = 1,3657 County Hospital Level 1 = 0,6860

30. Patient Safety Indicators: A way to Improve Healthcare 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 PSI 16 = 0,004 (Rate per 1000 cases)

31. Patient Safety Indicators: A way to Improve Healthcare Male = 0,0073 Female = 0,0024 AHRQ Rates: Male = 0,003 Female = 0,005 Group I = 0,0062 Group II = 0,0038 Group III = 0,01 Group IV = 0,0038

32. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 0,0038 County Hospital = 0,0043 County Hospital Level 1 = 0,01

33. Patient Safety Indicators: A way to Improve Healthcare General Comparisons

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38. Patient Safety Indicators: A way to Improve Healthcare 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.

39. Patient Safety Indicators: A way to Improval References • AHRQ Quality Indicators. Guide to Patient Safety Indicators 2007. http://www.qualityindicators.ahrq.gov • MATTKE S, EPSTEIN A M, LEATHERMAN S. The OECD Health Care Quality Indicators Project: history and background. International Journal for Quality in Health Care. September 2006; 18 Suppl 1:1-4. • MCLOUGHLIN V, MILLAR J, MATTKE S, FRANCA M, JONSSON P M, SOMEKH D, BATES D. Selecting indicators for patient safety at the health system level in OECD countries. International Journal for Quality in Health Care. 2006; 18 Suppl 1:14-20. • MILLER M R, ZHAN C. Pediatric Patient Safety in Hospitals: A National Picture in 2000. Pediatrics. 2004; 113: 1741-1746. • MILLER M R, ELIXHAUSER A, ZHAN C. Patient Safety Events During Pediatrics Hospitalizations. Pediatrics. 2003; 111: 1358-1366 • SEDMAN A, HARRIS J M, SCHULZ K, SCHWALENSTOCKER E, REMUS D, SCANLON M, BAHL V. Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for Children’s Hospitals. Pediatrics. 2005; 115: 135-145.

40. SCULLY K W, LYMAN J A, STUKENBORG G J. Improving Quality Measurement Using Multiple Data Sources. AMIA. 2003: 1001. • LONGO D R, HEWETT J E, GE B, SCHUBERTS S. The Long Road to Patient Safety. Jama. 2005; 294: 2858-65. • MILLER M R, ELIXHAUSER A, ZHAN C, MEYER G S. Patient Safety Indicators: Using Administrative Data to Identify Potential Patient Safety Concerns. HSR: Health Services Research. 2001; 36: 5-6. • WOLLERSHEIM H, HERMENS R, HULSCHER M, BRASPENNING J, OUWENS M, SCHOUTEN J, MARRES H, 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. • SCOBIE S, THOMSON R, MCNEIL J J, PHILLIPS P A. Measurement of the safety and quality of health care. MJA. 2006; 184 Suppl 10: S51-5. • AHRQ Quality Indicators. Patient Safety Indicators: Technical Specifications 2007. http://www.qualityindicators.ahrq.gov. • HealthGrades. 2004. Patient Safety in American Hospitals. p.1-22 • 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

41. Patient Safety Indicators: A way to Improval Turma 22 Ana Filipe Rocha Ana Rita Santos Carolina Cardoso Eva Brysch Joana Rodrigues Marina Pinto Pedro Vaz Sara Pinto Vasco Marques

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