Patient Safety Indicators
A 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.”
Patient Safety Indicators: A way to Improve Healthcare
Patient safety indicators
Provider-level indicators
Key words
Quality indicators
Area-level indicators
Health status indicators
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.
Patient Safety Indicators: A way to Improve Healthcare
PSI’s
Provider-level indicators
Area-level indicators
The problem occurs within
The problem occurs
the same hospitalization.
within a given area.
Patient Safety Indicators: A way to Improve Healthcare
PSI’s
• Patient Safety Indicators - Provider
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
▫
PSI Number
Complications of Anesthesia
Death in Low-Mortality DRGs
Decubitus Ulcer
Failure to Rescue
Foreign Body Left During Procedure
Iatrogenic Pneumothorax
Selected Infections Due to Medical Care
Postoperative Hip Fracture
Postoperative Hemorrhage or Hematoma
Postoperative Physiologic and Metabolic Derangements
Postoperative Respiratory Failure
Postoperative Pulmonary Embolism or Deep Vein Thrombosis
Postoperative Sepsis
Postoperative Wound Dehiscence
Accidental Puncture or Laceration
Transfusion Reaction
Birth Trauma – Injury to Neonate
Obstetric Trauma – Vaginal with Instrument
Obstetric Trauma – Vaginal without Instrument
Obstetric Trauma – Cesarean Delivery
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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
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
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.
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
Type C – administrative groups
advanced hospitals]
Group I
1 Central hospital
Group II
2 County* Hospital
Group III
3 County* Hospital level 1
Group IV
*meaning the portuguese administrative division “distrito”
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
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?
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
Patient Safety Indicators: A way to Improve Healthcare
Data withdrawn from the AHRQ website
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)
Patient Safety Indicators: A way to Improve Healthcare
PSI 5 - Gender per year
Male = 0,077
Rate per 1000 cases
0,12
Female = 0,052
0,1
0,08
0,06
AHRQ Rates:
0,04
0,02
Male = 0,084
0
2000
2001
2002
2003
2004
2005
Year
Male
Female
PSI 5 - Economic Groups per year
I = 0,1435
0,3
Rate per 1000 cases
Female = 0,086
II = 0,0602
0,25
0,2
III = 0,0474
0,15
0,1
IV = 0,0508
0,05
0
2000
2001
2002
2003
2004
2005
Year
Group I
Group II
Group III
Group IV
Patient Safety Indicators: A way to Improve Healthcare
PSI 5 - Administrative Groups per year
Rate per 1000 cases
0,12
0,1
0,08
0,06
0,04
0,02
0
2000
2001
2002
2003
2004
2005
Year
Central Hospital
County Hospital
County Hospital Level 1
Central Hospital = 0,0773
County Hospital = 0,0522
County Hospital Level 1 = 0,0474
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)
Patient Safety Indicators: A way to Improve Healthcare
PSI 6 - Gender per year
Male = 0,3573
Rate per 1000 cases
0,45
0,4
0,35
Female = 0,2413
0,3
0,25
0,2
0,15
0,1
AHRQ Rates:
0,05
0
2000
2001
2002
2003
2004
2005
Year
Male
Male = 0,506
Female = 0,622
Female
PSI 6 - Economic Groups per year
0,9
I = 0,5195
Rate per 1000 cases
0,8
0,7
0,6
II = 0,4110
0,5
0,4
III = 0,0344
0,3
0,2
0,1
IV = 0,2093
0
2000
2001
2002
2003
2004
2005
Year
Group I
Group II
Group III
Group IV
Patient Safety Indicators: A way to Improve Healthcare
PSI 6 - Administrative Group per year
Rate per 1000 cases
0,6
0,5
0,4
0,3
0,2
0,1
0
2000
2001
2002
2003
2004
2005
Year
Central Hospital
County Hospital
County Hospital Level 1
Central Hospital = 0,435
County Hospital = 0,2127
County Hospital Level 1 = 0,034
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)
Patient Safety Indicators: A way to Improve Healthcare
PSI 7 - Gender per year
Rate per 1000 cases
1,4
Male = 0,9877
1,2
1
Female = 0,4686
0,8
0,6
AHRQ Rates:
0,4
0,2
0
2000
2001
2002
2003
2004
2005
Year
Male
Male = 2,716
Female = 1,744
Female
PSI 7 - Economic Groups per year
I = 1,1944
1,6
Rate per 1000 cases
1,4
II = 1,1194
1,2
1
III = 0,2002
0,8
0,6
IV = 0,4375
0,4
0,2
0
2000
2001
2002
2003
2004
Year
Group I
Group II
Group III
Group IV
2005
Patient Safety Indicators: A way to Improve Healthcare
PSI 7 - Administrative Groups per year
1,4
Rate per 1000 cases
1,2
1
0,8
0,6
0,4
0,2
0
2000
2001
2002
2003
2004
2005
Year
Central Hospital
County Hospital
County Hospital Level 1
Central Hospital = 1,0333
County Hospital = 0,4830
County Hospital Level 1 = 0,2002
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)
Patient Safety Indicators: A way to Improve Healthcare
PSI 14 - Gender per year
Rate per 1000 cases
16
14
Male = 9,3522
12
10
Female = 5,3288
8
6
4
AHRQ Rates:
2
0
2000
2001
2002
2003
2004
2005
Year
Male
Male = 4,311
Female = 0,995
Female
PSI 14 - Economic Groups per year
I = 6,0885
Rate per 1000 cases
12
10
II = 8,0627
8
6
III = 1,9741
4
2
IV = 7,4808
0
2000
2001
2002
2003
2004
2005
Year
Group I
Group II
Group III
Group IV
Patient Safety Indicators: A way to Improve Healthcare
PSI 14 - Administrative Group per year
Rate per 1000 cases
12
10
8
6
4
2
0
2000
2001
2002
2003
2004
2005
Year
Central Hospital
County Hospital
County Hospital Level 1
Central Hospital = 7,2904
County Hospital = 7,6758
County Hospital Level 1 = 1,9741
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)
Patient Safety Indicators: A way to Improve Healthcare
PSI 15 - Gender per year
Rate per 1000 cases
3
Male = 1,9776
2,5
Female = 2,1138
2
1,5
1
AHRQ Rates:
0,5
0
2000
2001
2002
2003
2004
2005
Male = 2,942
Year
Male
Female = 4,080
Female
PSI 15 - Economic Groups per year
Rate per 1000 cases
6
I = 4,1782
5
II = 2,6590
4
3
III = 0,6860
2
IV = 1,3434
1
0
2000
2001
2002
2003
2004
Year
Group I
Group II
Group III
Group IV
2005
Patient Safety Indicators: A way to Improve Healthcare
PSI 15 - Administrative Groups per year
4,5
Rate per 1000 cases
4
3,5
3
2,5
2
1,5
1
0,5
0
2000
2001
2002
2003
2004
2005
Year
Central Hospital
County Hospital
County Hospital Level 1
Central Hospital = 3,0253
County Hospital = 1,3657
County Hospital Level 1 = 0,6860
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)
Patient Safety Indicators: A way to Improve Healthcare
Rate per 1000 cases
PSI 16 - Gender per year
0,009
0,008
0,007
0,006
0,005
0,004
0,003
0,002
0,001
0
Male = 0,0073
Female = 0,0024
AHRQ Rates:
Male = 0,003
2000
2001
2002
2003
2004
2005
Female = 0,005
Year
Male
Female
PSI 16 - Economic Groups per year
Rate per 1000 cases
0,025
Group I = 0,0062
0,02
Group II = 0,0038
0,015
0,01
Group III = 0,01
0,005
Group IV = 0,0038
0
2000
2001
2002
2003
2004
2005
Year
Group I
Group II
Group III
Group IV
Patient Safety Indicators: A way to Improve Healthcare
PSI 16 - Administrative Groups per year
Rate per 1000 cases
0,025
0,02
0,015
0,01
0,005
0
2000
2001
2002
2003
2004
2005
Year
Central Hospital
County Hospital
County Hospital Level 1
Central Hospital = 0,0038
County Hospital = 0,0043
County Hospital Level 1 = 0,01
Patient Safety Indicators: A way to Improve Healthcare
General Comparisons
Gender General Comparison
2,5
1,5
Male
Female
1,0
0,5
0,0
PSI 5
PSI 6
PSI 7
PSI 15
PSI 14 per Year
PSI Rate
PSI Rate
2,0
10
9
8
7
6
5
4
3
2
1
0
Male
Female
PSI14
Patient Safety Indicators: A way to Improve Healthcare
2,5
2,3
2,1
1,9
1,7
1,5
1,3
1,1
0,9
0,7
0,5
0,3
0,1
-0,1
2000
2001
2002
2003
2004
2005
PSI 5
PSI 6
PSI 7
PSI 15
PSI 14 per Year
PSI Rate
PSI Rates
Year General Comparison
10
9
8
7
6
5
4
3
2
1
0
2000
2001
2002
2003
2004
2005
PSI 14
Patient Safety Indicators: A way to Improve Healthcare
Economical Groups General Comparison
3,5
3,0
2,5
I
II
2,0
1,5
1,0
III
IV
0,5
0,0
PSI 5
PSI 6
PSI 7
PSI 15
PSI 14 per Economical Group
9
8
PSI Rate
PSI Rate
4,5
4,0
7
6
5
I
II
4
3
2
III
IV
1
0
PSI 14
Patient Safety Indicators: A way to Improve Healthcare
Administrative Groups General Comparison
3,0
2,0
Central Hospital
1,5
County Hospital
County Hospital Level 1
1,0
0,5
0,0
PSI 5
PSI 6
PSI 7
PSI 15
PSI 14 per Administrative Group
8
7
6
PSI Rate
PSI Rate
2,5
5
Central Hospital
4
County Hospital
3
County Hospital Level 1
2
1
0
PSI 14
Patient Safety Indicators: A way to Improve Healthcare
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
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.
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.
•
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
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
Patient Safety Indicators: A way to Improval