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Patient Safety and Quality

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Patient safety indicators are useful tools for tracking and monitoring patient safety events

Based on a recently published study conducted using Veterans Administration (VA) hospital data, the Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ) may be useful screening tools for tracking and monitoring patient safety events. PSIs range from bed sores (decubitus ulcers) to complications of anesthesia and accidental puncture/laceration. AHRQ researcher Anne Elixhauser, Ph.D., and colleagues used the VA database of records on all patients discharged from VA facilities over a 4-year period (FY 2001 through FY 2004) to examine trends in national PSI rates over time.

Most PSIs demonstrated consistent rates over time. After accounting for patient and hospital characteristics, hospitals' baseline risk-adjusted PSI rates were the most important predictors of their 2004 risk-adjusted rates for 8 of the 15 PSIs studied. Two PSIs demonstrated significant trends in rates over time, after adjustment for patient risk factors. Rates of iatrogenic (hospital-caused) pneumothorax increased over time, whereas rates of failure to rescue (deaths after major complications such as cardiac arrest and pneumonia) decreased.

The most frequent PSI events in all 4 years were failure to rescue, decubitus ulcer, accidental puncture/laceration, and pulmonary embolism or deep vein thrombosis. In contrast, complications of anesthesia, foreign body left in during a procedure, and postoperative hip fracture were rare occurrences in all 4 years. The researchers suggest that future research investigate whether trends in patient safety events reflect better or worse care or increased attention to documenting patient safety events.

See "Tracking rates of patient safety indicators over time: Lessons from the Veterans Administration," by Amy K. Rosen, Ph.D., Shibei Zhao, M.P.H., Peter Rivard, M.H.S.A., and others, in the September 2006 Medical Care 44(9), pp. 850-861. Reprints (AHRQ Publication No. 06-R078) are available from the AHRQ Publications Clearinghouse.

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