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National Healthcare Quality Report, 2013

Chapter 4. Patient Safety

Importance

Mortality
Number of Americans who die in hospitals each year from medical errors (1999 est.) 44,000-98,000 (Kohn, et al., 2000)i
Prevalence
Rate of harms associated with hospital stays (2000-2007) 25.1 per 100 admissions (Landrigan, et al., 2010)
Number of preventable adverse events among adults (excluding obstetrics) per year in U.S. hospitals (2004 est.) 3,023,000 (Jha, et al., 2009)
All-payer 30-day readmission rate 14.4% of admissions (HHS, 2012)
Cost
Cost of preventable adverse events for adults (nonobstetric) in U.S. hospitals (2013 est.) $22 billion (Jha, et al., 2009 adjusted)ii
Total cost per error in U.S. hospitals (2013 est.) $15,000 (Shreve, et al., 2010 adjusted)

Measures 

The Institute of Medicine (IOM) defines patient safety as "freedom from accidental injury due to medical care or medical errors" (Kohn, et al., 2000). In 1999, the IOM published To Err Is Human: Building a Safer Health System, which called for a national effort to reduce medical errors and improve patient safety.

Measuring and tracking patient safety incidents is a necessary step to improving quality of care. Measuring patient safety is complicated by difficulties in ensuring the systematic reporting of patient safety incidents in ongoing, protected, consistent, and informative ways. For example, health care providers may fear that if they participate in the analysis of patient safety incidents, the findings may be used against them in court or harm their professional reputations.

Aggregating data that are defined differently across facilities or State lines is fraught with scientific difficulties, such as:

  • Counting the relevant subpopulation for calculating rates of error.
  • Having sufficient numbers to identify prevalent risks and hazards in the delivery of patient care.
  • Having the detail to identify underlying causes of these events and practices that are most effective in mitigating risks.

A combination of administrative data, medical record abstraction, voluntary adverse event reporting, and patient surveys is needed to understand what is and is not improving.

Despite these challenges, progress has been made in raising awareness, passing legislation, developing reporting systems, establishing national data collection standards, and conducting research:

  • The Joint Commission's sentinel event program, established in 1996, signaled to hospitals that accreditation depends on their timely review of unexpected death or serious injury and mitigation of such risks. It is believed that hospitals underreport sentinel events to the Joint Commission.
  • President George W. Bush signed the Patient Safety and Quality Improvement Act of 2005 to spur the development of voluntary, provider-driven initiatives to improve the quality, safety, and outcomes of patient care.
  • As of 2009, 27 States developed voluntary or mandatory reporting systems for, at a minimum, serious reportable events. These are adverse events that should never happen to a patient (NASHP, 2013).
  • The Agency for Healthcare Research and Quality (AHRQ) has certified 76 Patient Safety Organizations (PSOs) as of November 18, 2013. PSOs work to develop learning communities in patient safety and collect patient safety event reports that are legally protected from legal disclosure when reported to a PSO. This new program shifts from a culture of blame to a learning collaboration among providers and patient safety experts.
  • AHRQ has also developed a set of "common formats" for health care facilities and professionals to report patient safety events, near misses, and unsafe conditions to PSOs in a consistent way for aggregation and learning.
  • The National Quality Strategyiii is the result of collaborations among private and public organizations and aims to increase access to high-quality, affordable health care for all Americans, by spurring health care providers to reduce rates of care-related injury to zero when possible and redesign systems that reliably provide high-quality health care.
  • The Partnership for Patients, created by the U.S. Department of Health and Human Services, has set goals to make care safer.
  • More than 100 studies, using myriad data sources, have addressed patient safety progress made since the IOM report (Raetzman, et al., 2012).

Based on these efforts, this 2013 National Healthcare Quality Report (NHQR) presents a number of patient safety measures organized around the major health care settings that must measure, understand, and improve health care in order for Americans to be cared for in a safer health care environment:

Hospital setting:

  • Hospital-acquired conditions overall.
  • Postoperative sepsis.
  • Catheter-associated urinary tract infections (UTIs).
  • Central line-associated bloodstream infections (CLABSIs).
  • Surgical site infections (SSIs).
  • Mechanical adverse events associated with central venous catheters.
  • Obstetric trauma.

Nursing home setting:

  • Pressure ulcers, use of restraints, and UTIs.

Home health setting:

  • Improvement in surgical site wound healing.
  • Ability to take medications orally.

Ambulatory care setting:

  • Ambulatory visits due to adverse effects of medical care.
  • Receipt of potentially inappropriate prescription medications.
  • Hospital readmissions.

Infrastructure:

  • Diagnosis-related errors.
  • Patient safety event reporting in Pennsylvania. .
  • Patient safety culture.
  • Root cause analysis and risk mitigation—Veterans Health Administration.

Findings

Hospital Setting

Outcome: Overall Hospital-Acquired Condition Rate

Patient safety events that occur in the hospital setting are referred to as hospital-acquired conditions (HACs). Hospitals are a common setting for patient safety events in part because of the clinically compromised state of many patients admitted to the hospital and because of the high volume of care transactions and interventions that take place during a hospital stay.

A key goal of the Federal Government's Partnership for Patients program is to make hospital care safer by reducing the rate of preventable HACs. To track progress on this goal, a national estimate of HACs was developed based on 28 different measures from three national data sources: Medicare Patient Safety Monitoring Systemiv (MPSMS) implemented by AHRQ and the Centers for Medicare & Medicaid Services (CMS), Patient Safety Indicators (PSIs) implemented by AHRQ, and the National Healthcare Safety Network (NHSN) implemented by the Centers for Disease Control and Prevention (CDC). The rate developed is intended to reflect the entire population over age 17.

Although the 28 measures have been combined, the overall rate is not an all-inclusive HAC rate. Some important types of adverse events are not included in the rate due to a lack of data. For example, the rate does not include adverse drug events due to allergies or use of narcotics, venous thromboembolic events in nonsurgical patients, or most infections that are hospital acquired but do not produce symptoms until after hospital discharge. In addition, retained surgical items and wrong-site surgeries are not included.

Figure 4.1. Distribution of hospital-acquired conditions, based on national rates per 1,000 adult hospital discharges, 2011

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Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2011; Centers for Disease Control and Prevention, National Healthcare Security Network, 2010-2012; and Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.1, 2011.
Note: Data are for patients 18 years of age and over. Estimates are rounded to the nearest tenth.

  • In 2011, the national overall HAC rate was 142 per 1,000 hospital discharges. By comparison, the rate was 145 per 1,000 hospital discharges in 2010.
    • The overall HAC rate in 2011 includes nine specific HACs as well as an "other" category that covers an additional 14 specific HACsv (Figure 4.1):
    • Adverse drug events (48.7 per 1,000 hospital discharges [34.2% of total]).
    • Pressure ulcers (40.3 per 1,000 hospital discharges [28.4% of total]).
    • Catheter-associated UTIs (11.4 per 1,000 hospital discharges [8% of total]).
    • Falls (7.7 per 1,000 hospital discharges [5.4% of total]).
    • SSIs (2.6 per 1,000 hospital discharges [1.8% of total]).
    • Obstetric adverse events (2.6 per 1,000 hospital discharges [1.8% of total]).
    • Ventilator-associated pneumonia (1.1 per 1,000 hospital discharges [0.8% of total]).
    • CLABSIs (0.52 per 1,000 hospital discharges [0.4% of total]).
    • Venous thromboembolisms (0.5 per 1,000 hospital discharges [0.3% of total]).
    • All other HACs (26.8 per 1,000 hospital discharges [18.9% of total]). Note that this category covers 14 specific HACs but does not include every type of HAC beyond the nine specific HACs listed above.

Also, in the National Healthcare Disparities Report (NHDR):

  • In 2010, the overall HAC rate for Blacks was 148 per 1,000 hospital discharges compared with a rate for Whites of 143 per 1,000 hospital discharges.
  • For both Blacks and Whites, the HAC categories with the highest rates in 2010 were adverse drug events, pressure ulcers, and all other HACs.
  • Among Blacks, the 2010 rate of adverse drug events is roughly double that of pressure ulcers. Among Whites, the rates for adverse drug events and for pressure ulcers are more similar.

Healthcare-Associated Infections

Infections acquired during hospital care (nosocomial infections) are one of the most serious patient safety concerns. They are the most common complication of hospital care (Gastmeier, 2004). Approximately 1 out of every 20 hospitalized patients will contract an HAI (CDC, 2010). Annual costs for adult inpatients that are attributable to the five HAIs with the highest impact on the health care system (CLABSIs, surgical site infections, catheter-associated UTIs, ventilator-associated pneumonia, and Clostridium difficile infections) are estimated at $9.8 billion (Zimlichman, et al, 2013).

A specific medical error cannot be identified in most cases of HAIs. However, better application of evidence-based preventive measures can reduce HAI rates within an institution.

Outcome: Postoperative Sepsis

Sepsis is a potentially life-threatening bloodstream infection that can be acquired in various settings. One study of sepsis occurring in community settings as well as hospital settings found that both higher rates of infection and higher risk of acute organ dysfunction contributed to higher rates of sepsis seen among Blacks compared with Whites (Mayr, et al., 2010). Sepsis can occur after surgery, and another recent study showed that postoperative sepsis occurred in 5% of emergency surgery patients and 2% of elective surgery patients (Moore, et al., 2010). One way that sepsis rates can be reduced is by giving patients appropriate prophylactic antibiotics, starting 1 hour prior to surgical incision.

Figure 4.2. Postoperative sepsis per 1,000 adult discharges with an elective operating room procedure, by age and hospital bed size, 2008-2010

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Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2008-2010.
Denominator: All elective hospital surgical discharges, age 18 and over, with length of stay of 4 or more days, excluding patients admitted for infection, patients with cancer or immunocompromised states, patients with obstetric conditions, and admissions specifically for sepsis.
Note: For this measure, lower rates are better. Rates are adjusted by age, gender, age-gender interactions, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers into the hospital. When reporting by age, the adjustment is by gender, comorbidities, MDC, DRG, and transfers into the hospital.
2008 Achievable Benchmark: 8.7.

  • From 2008 to 2010, there were no statistically significant changes in the overall risk-adjusted rate of postoperative sepsis (Figure 4.2).
  • In 2009 and 2010, surgery patients ages 18-44 had lower risk-adjusted rates of postoperative sepsis than those ages 45-64 and those age 65 and over.
  • In 2008, surgery patients in hospitals with fewer than 100 beds had lower risk-adjusted rates of postoperative sepsis than those in hospitals with 500 or more beds. In 2009 and 2010, the rate was higher in the smallest hospitals (under 100 beds) than in the largest hospitals (500 or more beds).
  • The 2008 top 3 State achievable benchmark was 8.7 per 1,000 discharges.vi As of 2010, the benchmark had not been met for any age group or hospital bed size. Based on the available trend data, it is unclear when any groups would reach the benchmark.

Also, in the NHDR:

  • In all years, Whites had a lower risk-adjusted rate of postoperative sepsis than Blacks and Hispanics. The rate for Whites was also lower than for Asians and Pacific Islanders (APIs) in 2009 and 2010.
  • Surgery patients with Medicare or Medicaid had higher risk-adjusted rates of postoperative sepsis than surgery patients with private insurance in 2009 and 2010. In 2008, only Medicaid patients had a higher rate than private insurance patients.
  • No racial/ethnic group or insurance group has met the achievable benchmark.
Outcome: Catheter-Associated Urinary Tract Infections

The urinary tract is a common site of HAIs. Urinary catheter use and specific comorbid conditions can increase the risk of developing a UTI. Approximately 40% of all HAIs are attributed to catheter-associated UTIs (Niel-Weise & van den Broek, 2005).

Figure 4.3. Adult surgery patients with postoperative catheter-associated urinary tract infection, by age and renal disease status, 2009-2011

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Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2009-2011.
Denominator: Selected discharges of hospitalized patients age 18 and over having major surgery and meeting specific criteria for each measure.
Note: For this measure, lower rates are better.

  • From 2009 to 2011, there were no statistically significant changes in the overall rate of postoperative catheter-associated UTIs (Figure 4.3).
  • In all years, the percentage of adult surgery patients with catheter-associated UTIs was higher for those ages 65-74, 75-84, and 85 and over than for adult surgery patients under age 65.
  • In all years, the percentage of adult surgery patients with catheter-associated UTIs was higher for patients with renal disease than for patients without renal disease. The percentage was more than double for renal disease patients in each of these years.

Also, in the NHDR:

  • In 2010, the percentage of adult surgery patients with catheter-associated UTIs was higher for Hispanics than for Whites. There were no statistically significant differences among racial/ethnic groups in 2009 or 2011.
Outcome: Central Line-Associated Bloodstream Infections and Surgical Site Infections

SSIs and bloodstream infections often increase the patient's length of stay in the hospital, risk of mortality, and hospital costs. SSIs can occur at the site of surgical incisions and in deeper tissues affected by the procedure. In the inpatient setting, bloodstream infections and other complications are often associated with the placement and use of central venous lines that are passed into the great vessels leading to the heart to administer medications or fluids, draw blood for tests, or directly obtain cardiovascular measurements.

Standardized infection ratios (SIRs) calculated by CDC using data reported to the NHSN compare the number of infections, such as CLABSIs or SSIs, seen in adults in a hospital's intensive care unit with a national benchmark. SIRs are based on the infection rates in a referent time period (in this case, January 2006 through December 2008). A score of less than 1 means that the hospital had fewer infections than hospitals of similar type and size during the referent time period.

CLABSI SIRs are adjusted for key factors, including the type of patient care location, bed size of the care location, and hospital affiliation with a medical school. SIRs for SSIs are adjusted for procedure-related risk factors such as duration of surgery, surgical wound class, use of endoscopes, status as a reoperation, patient age, and anesthesiologist-assessed patient preoperative mortality risk.

Figure 4.4. Standardized infection ratios for central line-associated bloodstream infections and surgical site infections in adults, 2009-2011

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Source: 2009-2011 national and State healthcare-associated infections standardized infection ratio report using the National Healthcare Safety Network (NHSN) data.
Note: For this measure, lower numbers are better. This SIR compares the number of infections reported to NHSN in 2011 with the number of infections predicted based on 2006-2008 national historic data. Because the 2006-2008 data are used as a baseline, that period is reported as 1.000. There were 1,603 facilities that reported CLABSI rates to NHSN in 2009, 2,389 facilities in 2010, and 3,468 facilities in 2011. SCIP procedures refers to Surgical Care Improvement Project procedures performed on adults. These procedures include abdominal aortic aneurysm repair, peripheral vascular bypass surgery, coronary artery bypass graft with both chest and donor site incisions or with chest incision only, other cardiac surgery, colon surgery, rectal surgery, hip arthroplasty, abdominal hysterectomy, knee arthroplasty, and vaginal hysterectomy.

  • From the referent period (2006-2008) to 2011, CLABSIs reported to the NHSN decreased roughly 40% (Figure 4.4).
  • There was a significant decrease in CLABSIs among facilities that reported in both 2010 and 2011 and among facilities that reported in both 2009 and 2010. There was no statistically significant difference in SIRs from January-June 2009 to July-December 2009 among facilities that reported for both time periods.
  • From the referent period (2006-2008) to 2011, SSIs reported to the NHSN decreased 17%.
  • There was a significant decrease from 2010 to 2011 in SIRs among facilities that reported rates for both years. There was no statistically significant change in SIRs from 2009 to 2010 and from the first half of 2009 to the second half of 2009 reported among facilities continuously enrolled for these time periods.

Also, in the NHDR:

  • CLABSI rates per 1,000 central line days in medical intensive care units (ICUs) and combined medical/surgical ICUs located in major teaching hospitals were higher than rates in similar units in nonteaching hospitals.

The information above describes CLABSIs among reporting hospitals when aggregated nationally. The map below shows the change between 2010 and 2011 in the CLABSI SIRs at the State level.

Figure 4.5. Change in State-specific hospital SIRs for CLABSIs in adults, 2010-2011

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*Indicates existence of state mandate to report CLABSI to NHSN at beginning of 2011.
**Fewer than five facilities reporting in Utah, Wyoming, and South Dakota.

  • CLABSI SIRs in 2011 were significantly less than 1.0. Among the 50 States, District of Columbia, and Puerto Rico, hospitals in 49 jurisdictions had fewer CLABSIs than hospitals of similar type and size across the Nation during the January 2006 through December 2008 referent period.
  • All but three States and Puerto Rico had sufficient data to produce an overall CLABSI SIR in both 2010 and 2011. Of the remaining 48 jurisdictions, 30 had no change in the CLABSI SIR from 2010 to 2011 and 18 reported a decrease (Figure 4.5).
  • States that reported a CLABSI SIR decrease from 2010 to 2011 were more likely than States that did not experience a CLABSI rate decrease to have a State mandate at the beginning of 2011 to report CLABSI rates to the NHSN.
Outcome: Central Line-Associated Bloodstream Infections in Neonatal and Pediatric Intensive Care Units

Children who require central lines are often already in critical condition due to illness, trauma, or premature birth; any new infections generally reduce their chances of recovering. Proper insertion and management of central lines can lower infection rates significantly.

Figure 4.6. Bloodstream infections per 1,000 central-line days in neonates and older children, by birth weight of child in Level III neonatal ICU and by type of pediatric ICU, 2009-2011

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Key: ICU = intensive care unit.
Source: Centers for Disease Control and Prevention, National Healthcare Safety Network, 2009-2011.
Denominator: Number of central-line days.
Note: For this measure, lower rates are better.

  • In 2011, among patients in Level III neonatal ICUs, which treat the smallest and sickest neonates, the pooled mean CLABSI rates ranged from a low of 0.9 per 1,000 central-line days among neonates born at >1,500 grams to a high of 2.5 per 1,000 central-line days among neonates born at ≤750 grams (Figure 4.6).
  • In 2011, the pooled mean rates of CLABSIs were 1.8 per 1,000 central-line days for pediatric medical-surgical ICUs, 1.6 per 1,000 central-line days for pediatric cardiothoracic ICUs, and 1.4 per 1,000 central-line days for pediatric medical ICUs.

Other Adverse Events

Outcome: Mechanical Adverse Events Associated With Central Venous Catheters

Some patients need central venous catheters inserted into major veins in the neck, chest, or groin so that health care providers can administer medication or fluids, obtain blood for tests, or take cardiovascular measurements. Patients who require a central venous catheter tend to be severely ill. The placement and use of these catheters can result in mechanical adverse events, including bleeding; hematoma; perforation; pneumothorax; air embolism; and misplacement, occlusion, shearing, or knotting of the catheter.

Figure 4.7. Composite: Mechanical adverse events associated with central venous catheter placement in adults, by age, 2009-2011

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Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2009-2011.
Denominator: Selected discharges of hospitalized patients age 18 and over with central venous catheter placement.
Note: For this measure, lower rates are better. Mechanical adverse events include allergic reaction to the catheter, tamponade, perforation, pneumothorax, hematoma, shearing off of the catheter, air embolism, misplaced catheter, thrombosis or embolism, knotting of the pulmonary artery catheter, and certain other events.

  • From 2009 to 2011, there were no statistically significant changes in the overall percentage of mechanical adverse events associated with central venous catheter placement (Figure 4.7).
  • In all years, there were no statistically significant differences by age in the percentage of mechanical adverse events associated with central venous catheter placement.

Also, in the NHDR:

  • In all years, there were no statistically significant differences by sex in the percentage of mechanical adverse events associated with central venous catheter placement.
  • Only in 2009 did Blacks have a higher percentage of mechanical adverse events associated with central venous catheter placement than Whites.
Outcome: Obstetric Trauma

Childbirth and reproductive care are the most common reasons that women of childbearing age use health care services. With an average of 10,957 babies born each day in the United States (Martin, et al., 2012), childbirth is the most common reason for hospital admission among women.

Obstetric trauma involving a severe tear to the vagina or surrounding perineal tissues during delivery is a potentially serious complication of childbirth. Higher risks of severe (i.e., 3rd or 4th degree) perineal laceration may be related to the degree of fetal-maternal size disproportion. Adolescents, who often have smaller body sizes, may be more likely to experience obstetric trauma than older women. In addition, although any delivery can result in trauma, existing evidence shows that severe perineal trauma can be reduced by restricting the use of episiotomies and forceps (Kudish, et al., 2008).

Previous reports used AHRQ Quality Indicators version 3.1 to generate obstetric trauma rates. As of the 2011 NHQR, the reports use a modified version 4.1 of the software. While the effects of this version change are extremely small, these estimates should not be compared with estimates found in previous reports.

Figure 4.8. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by age and insurance, 2004-2010

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Key: Private indicates private health insurance as the payment sources; uninsured indicates self-pay, uninsured, or no charge as the payment source.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2004-2010.
Denominator: All patients hospitalized for vaginal delivery without indication of instrument assistance.
Note: For this measure, lower rates are better. Rates are adjusted by age. Rates by age are not age adjusted.
2008 Achievable Benchmark: 17.8.

  • From 2004 to 2010, the overall rate of obstetric trauma with 3rd or 4th degree laceration decreased from 30 to 22.8 per 1,000 vaginal deliveries without instrument assistance. The rates for all age groups and insurance types decreased (Figure 4.8).
  • In most years, mothers ages 18-24 had a lower rate of obstetric trauma than mothers ages 10-14, 15-17, and 25-34. Similarly, mothers with private insurance had higher rates of obstetric trauma than all other insurance types in almost every year.
  • The 2008 top 4 State achievable benchmark was 17.8 per 1,000 deliveries.vii At the current annual rate of decrease, this benchmark could be attained within about 1 year by several age groups and insurance types. However, it could take up to 10 years for mothers under age 18 and ages 25-34, as well as for those with private insurance. Mothers with Medicare or Medicaid already have achieved the benchmark.

Also, in the NHDR:

  • From 2004 to 2010, rates of obstetric trauma with 3rd or 4th degree laceration decreased for all racial/ethnic and area income groups.
  • In each year from 2004 to 2010, API mothers had higher rates of obstetric trauma than White mothers. In the same period, Black and Hispanic mothers had lower rates of obstetric trauma than White mothers.
  • In all years, residents in the upper three area income quartiles had higher rates than residents in the lowest area income quartile.
  • Hispanic and Black mothers and residents in the lowest area income quartile already have attained the achievable benchmark. At the current annual rate of decrease, it could take up to 5 years for White mothers and up to 16 years for API mothers. All income groups could reach the benchmark within about 7 years.

Nursing Home Setting

Outcome: Pressure Ulcers, Use of Restraints, and Urinary Tract Infections

People may seek nursing home care for short periods of time after hospitalization while they are recuperating to be able to return to their homes, or they may enter a nursing home permanently because they can no longer care for themselves at home. For both types of nursing home residents, optimal care seeks to maximize quality of life and minimize unintended complications.

Since 2002, CMS has collected data using the Minimum Data Set (MDS). The MDS provides data on nursing home residents at specified intervals during their stay that describe the resident's physical and clinical conditions. In 2010, nursing homes began reporting data using an updated instrument (MDS 3.0). We present the 2011 results for new quality measures developed for this version of the MDS that look at pressure ulcers, use of restraints, and UTIs.

A pressure ulcer, or pressure sore, is an area of soft tissue injury caused by sitting or lying in one position for an extended time and can be very painful and lead to infections. Nursing homes can do several things that may help to prevent or treat pressure sores, such as frequently changing the resident's position, providing proper nutrition, and using soft padding to reduce pressure on the skin.

Residents who are restrained daily can become weak, lose their ability to move around (e.g., to go to the bathroom by themselves), and may develop pressure sores or other medical conditions. Restraints should only be used when medically necessary, and even then only under careful supervision.

Most UTIs can be prevented by keeping the genital area clean, emptying the bladder regularly, and drinking enough fluid. Finding the cause and getting early treatment of a UTI can prevent the infection from spreading and becoming more serious or causing complications.

Figure 4.9. Nursing home residents experiencing various adverse events, by sex and age, 2011

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Source: Centers for Medicare & Medicaid Services, Minimum Data Set 3.0, 2011.
Denominator: For pressure ulcers, the denominator was short-stay residents, who are defined as residents whose cumulative stay was less than or equal to 100 days. For restraints and urinary tract infections, the denominator was long-stay residents, who are defined as residents whose cumulative stay was greater than 100 days.
Note: For these measures, lower rates are better. Measures were calculated as follows: Pressure ulcers: Percentage of short-stay residents for whom a look-back scan indicates one or more new or worsening stage II-IV pressure ulcers. Restraints: Percentage of long-stay residents who are physically restrained on a daily basis. UTI: Percentage of long-stay residents with a urinary tract infection within the 30 days prior to assessment.

  • In 2011, the percentage of short-stay residents with pressure ulcers was higher for males than for females (Figure 4.9).
  • There were no statistically significant differences by sex in the percentage of long-stay residents who were physically restrained.
  • The percentage of long-stay residents with UTIs was higher for females than for males.
  • The percentage of short-stay residents with pressure ulcers and the percentage of long-stay residents with UTIs increase with age. For both measures, the percentage of residents ages 65-74, 75-84, and 85 and over who met the criteria was greater than the percentage of residents ages 0-64.
  • Compared with long-stay residents under age 65, a lower percentage of long-stay residents ages 65-74 were physically restrained on a daily basis. There was no statistically significant difference in the percentage with restraint use between those under age 65 and those ages 75-84 or 85 and over.

Also, in the NHDR:

  • In 2011, a higher percentage of Black short-stay residents had pressure ulcers compared with White residents. The percentage was lower for Asian and Hispanic residents than for White residents.
  • The percentage of long-stay residents with restraint use was higher for Asian, Native Hawaiian or Other Pacific Islander, Hispanic, and multiple-race residents than for White residents. The percentage was lower for Blacks than for Whites.
  • The percentage of long-stay residents with a UTI was higher for Whites than for other racial and ethnic groups except residents described as multiple race.

Home Health Setting

Outcome: Improvement in Surgical Site Wound Healing

Normal wound healing after an operation is an important marker of good care. Patients whose wounds heal normally generally feel better and can get back to their daily activities sooner than those whose wounds do not heal normally. The home health team can assist with wound healing in several ways, including changing the wound dressing and teaching the patient or caregiver about wound healing (e.g., signs of wound healing, type of foods that promote wound healing, signs of infection, what to do about signs of infection or other concerns). One way to measure the quality of care that home health agencies give is to look at how well their patients' wounds heal after an operation.

Since 1999, CMS has required home health agencies to collect and report data using the Outcome and Assessment Information Set (OASIS). OASIS provides data on patients whose care is reimbursed by Medicare or Medicaid. Beginning in 2010, home health agencies used a revised version of the instrument called OASIS-C.

This outcome measure is derived from the OASIS-C dataset and describes the percentage of home health episodes where the status of the surgical incision site was better at the end of the home health care episode than at the start of the episode.

Figure 4.10. Home health patients with improvement in their surgical site wounds, by age, 2010-2011

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Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2010-2011.
Denominator: The number of home health episodes during the measurement period in which the patient had a surgical wound and the episode ended with the patient discharged from home health care.

  • The overall percentage of home health patients with improvement in their surgical site wound healing was 85.9% in 2010 and 87.9% in 2011 (data not shown).
  • In 2011, 84.7% of home health patients ages 0-64 had improvement in their surgical site wounds; for home health patients ages 65-74, 88.2% had improvement. The percentage of home health patients ages 75-84 with improvement was 89.4%, and the percentage of patients age 85 and over was 90.4% (Figure 4.10).

Also, in the NHDR:

  • In 2010 and 2011, there were no statistically significant racial or ethnic differences in the percentage of home health patients with improvement in surgical site wound healing.

Outcome: Ability To Take Medications Orally

The ability to perform daily activities, such as taking medications correctly, is important to the health status and quality of life of people living in the community. Taking too much or too little can keep the drugs from working properly and may cause unintended harm, including death.

The home health team can help teach patients ways to organize medications and to take them properly. If patients get better at taking medications correctly, this means the home health team is doing a good job teaching patients how to take their drugs, and about the harm that can occur if they do not follow these instructions. Specific items that should be discussed include all the prescriptions and other medications the patient takes, allergic or other adverse reactions to drugs experienced in the past, and actions to take if a medication is not working.

This measure shows how often the home health team helped patients get better at taking their prescription and other medications correctly (including prescription medications, over-the-counter medications, vitamins, and herbal supplements). Only medications the patient takes by mouth are considered.

Figure 4.11. Home health patients with improvement in their ability to take medications orally, by age, 2010-2011

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Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2010-2011.
Denominator: Number of home health episodes of care in which a patient was unable to take oral medications independently at the start of the episode that ended during the measurement period.

  • The overall percentage of home health patients with improvement in their ability to take medications orally was 46.2% in 2010 and 47.3% in 2011 (data not shown).
  • In 2010 and 2011, the percentage of home health patients with improvement in their ability to take medications orally was significantly lower for those age 85 and over compared with those ages 0-64 (Figure 4.11).

Also, in the NHDR:

  • The percentage of home health patients with improvement in their ability to take medications orally was significantly lower for Hispanics than for non-Hispanic Whites in 2010 and 2011.
  • In both years, there were no statistically significant racial differences in the percentage of home health patients with improvement in their ability to take medications orally.
  • In Nevada, Texas, North Carolina, and Florida, the percentage of patients with improvement in their ability to take medications orally was significantly lower for Hispanics than for non-Hispanic Whites.
  • In Washington and South Carolina, the percentage of patients with improvement in their ability to take medications orally was significantly higher for Hispanics than for non-Hispanic Whites.

Ambulatory Care Setting

Outcome: Ambulatory Care Visits Due to Adverse Effects of Medical Care

Although patient safety initiatives are predominantly focused on inpatient hospital events, many adverse effects of medical care will be treated during visits to outpatient settings. Outpatient providers who see patients experiencing adverse effects of medical care include physician offices, urgent care centers, ambulatory surgery centers, and hospital outpatient departments. Patient safety events that are identified and treated in the ambulatory setting may also originate from that setting.

While most ambulatory care is less technologically complex than inpatient care, it is often more complex logistically, potentially involving failures in communication and coordination among a number of providers and locations. Some adverse effects, such as known side effects of appropriately prescribed medications, may be unavoidable, while others may be considered avoidable medical errors.

Figure 4.12. Ambulatory care visits due to adverse effects of medical care, per 1,000 people, by age and sex, 2006-2009

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Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2006-2009.
Denominator: U.S. Census Bureau estimated civilian noninstitutionalized population as of July 1 of each data year.
Note: For this measure, lower rates are better. Ambulatory care includes visits to office-based physicians, hospital outpatient departments, and hospital emergency departments.

  • For the 2-year rolling averages shown, there were no statistically significant differences between 2006-2007 and 2008-2009 in the rate of ambulatory care visits due to adverse effects of medical care seen in different subgroups (Figure 4.12).
  • In all three time periods (2006-2007, 2007-2008, 2008-2009), the rates of ambulatory care visits due to adverse effects were higher for patients ages 18-44, 45-64, and 65 and over than for patients ages 0-17.
  • The rate of ambulatory care visits due to adverse effects of medical care was higher for females compared with males in all three time periods.

Also, in the NHDR:

  • Only in 2007-2008 was the rate of ambulatory care visits due to adverse effects of medical care different (higher) for residents of metropolitan areas compared with residents of nonmetropolitan areas.

Outcome: Receipt of Potentially Inappropriate Prescription Medications

Some medications are potentially harmful for older patients but still are prescribed to them (Zhan, et al., 2001).viii Using inappropriate medications can be life threatening and may result in hospitalization, as well as increased costs of pharmaceutical services (Lau, et al., 2005). Measures of inappropriate medication use include the Beers criteria, which have been generally accepted by the medical community and by expert opinion, although there is still some disagreement (Fick, et al, 2012). This disagreement relates to the many factors that must be considered when identifying what constitutes inappropriate use by certain populations (Zhan, et al., 2001).

Figure 4.13. Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year, by age and perceived health status, 2002-2010

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Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: For this measure, lower rates are better. Prescription medications received include all prescribed medications initially purchased or otherwise obtained, as well as any refills.

  • From 2002 to 2010, the overall percentage of adults age 65 and over who received potentially inappropriate medications decreased from 19.3% to 13.9% (data not shown). The percentages for all age groups (except those ages 65-69) and all health status groups also declined during this period (Figure 4.13).
  • Except in 2002, there were no statistically significant differences between adults ages 65-69 and older age groups in the percentage who received potentially inappropriate medications.
  • In all years, the percentage of adults age 65 and over who received potentially inappropriate medications was higher for those with fair/poor perceived health than for those with excellent/very good/good perceived health.

Also, in the NHDR:

  • The percentage of older adults who received potentially inappropriate medications decreased for all racial/ethnic and family income groups from 2002 to 2010.
  • In all years, there were no statistically significant racial/ethnic differences in the percentage of adults age 65 and over who received potentially inappropriate medications.
  • In most years, there were no statistically significant income differences in the percentage of adults age 65 and over who received potentially inappropriate medications.

Outcome: Hospital Readmissions

One aim of the National Quality Strategy (NQS) is to make care safer by reducing the harm caused in the delivery of care. One of the two measures that the NQS has endorsed to describe improved safety is an all-payer 30-day readmission rate. The baseline rate calculated for the all-payer 30-day readmission rate in 2010 was 14.4%, based on 32.9 million admissions. The goal is to reduce this rate by 20% by the end of 2014. In 2011, the rate was 14.4% based on 32.7 million admissions (HHS, 2013).

In addition, for certain diseases (acute myocardial infarctions [i.e., heart attacks], heart failure, and pneumonia), CMS's Hospital Quality Alliance (2008-2010)ix tracked and published 30-day risk-standardized readmission rates among Medicare fee-for-service hospital patients age 65 and over on their Hospital Compare Web site. Rates of readmission may reflect hospital efforts to prevent complications, teach patients at discharge, and ensure that patients make a smooth transition to their home or another setting such as a nursing home.

Figure 4.14. Median hospital 30-day risk-standardized readmission rate for certain conditions in adults, 2006-2010

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Key: AMI = acute myocardial infarction.
Source: Medicare Hospital Quality Chartbook, 2010, 2011, and 2012.
Denominator: Expected number of readmissions for each disease type given the hospital's case mix.
Note: For this measure, lower rates are better. Readmission rates presented for 2006 do not include Veterans Affairs hospitals. Rates after 2006 include these hospitals.

  • The median 30-day risk-standardized readmission rates for hospitals remained stable from 2006 to 2010 for all three diseases (Figure 4.14).
  • The median 30-day risk-standardized readmission rates for acute myocardial infarction ranged from 19.4% (2010) to 20% (2007).
  • The median 30-day risk-standardized readmission rates for heart failure ranged from 24.4% (2006) to 24.9% (2008).
  • The median 30-day risk-adjusted readmission rates for pneumonia ranged from 18.0% (2006) to 18.4% (2009 and 2010).

Also, in the NHDR:

  • There were no statistically significant differences between hospitals serving a high percentage of African Americans and hospitals serving a low percentage of African Americans in the median 30-day risk-standardized readmission rates for all three diseases.
  • There were no statistically significant differences between hospitals serving a high percentage of Medicaid recipients and hospitals serving a low percentage of Medicaid recipients in the median 30-day risk-standardized readmission rates for all three diseases.

Patient Safety Infrastructure

The patient safety infrastructure also plays a role in making care better. This infrastructure includes scientific research, lessons from data-driven investigations, cultural shifts, and other actions taken to make care safer. This section highlights four hallmark activities in this regard:

  • Investigation of a new frontier of frequently invisible diagnosis-related errors.
  • An innovative State reporting system that allows learning from near misses and unsafe conditions.
  • An assessment of the patient safety culture in U.S. hospitals.
  • The critical actions of root cause analysis and risk mitigation to learn from and prevent mistakes in the future.

Outcome: Diagnosis-Related Errors

Diagnosis-related errors are among the most difficult errors to detect. Autopsies and malpractice claims can reveal these errors in retrospect. Autopsies, however, substantially declined in use over the last several decades; most are now conducted for forensic investigations rather than medical education.

New research, drawing on the National Practitioner Data Bank of malpractice payouts in the United States over a 25-year period, provides more insights regarding the types of error leading to serious harm. Of 351,000 malpractice settlements or judgments from 1986 to 2010, diagnosis-related error was the most frequent type of error (29% of paid malpractice claims). By contrast, medication errors, the focus of much patient safety activity, accounted for only 5% of paid malpractice claims.

Figure 4.15. Malpractice claims by type of error and harm, 2004-2010 combined

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Source: 1986-2010 National Practitioner Data Bank analysis as reported in Saber Tehrani, et al., 2013.

  • The harm documented in malpractice suits from diagnostic error exceeded the harm from other types of errors on average, across the filing period 2004-2010, when harm information was collected by the National Practitioner Data Bank (Figure 4.15).
  • Nearly 40% of paid malpractice claims for diagnosis-related errors documented death of the patient, while the next highest death rate (24.3%) was for medical-treatment-related errors.
  • Nearly 35% of the paid malpractice claims for diagnosis-related errors documented disability (mostly permanent disability), while the next highest disability rate (21.5%) was for surgery-related errors.

While the estimates and trends shown in the prior sections derive mainly from studies of hospitals, the National Practitioner Data Bank shows that diagnosis-related errors are more likely to occur in outpatient than inpatient settings of care.

Figure 4.16. Diagnosis-related-error claims: frequency and harm by setting of care, 2004-2010 combined

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Source: 1986-2010 National Practitioner Data Bank analysis as reported in Saber Tehrani, et al., 2013.

  • Serious diagnostic errors that resulted in malpractice payouts originated more often in outpatient settings (68.8% of malpractice paid claims) than inpatient settings (31.2%) (data not shown).
  • Serious diagnostic errors resulting in malpractice payments were more likely to result in death if they originated in inpatient settings than outpatient settings (48.4% vs. 36.9%; Figure 4.16).

Patient Safety Event Reporting in Pennsylvania

In June 2004, Pennsylvania began implementing a statewide mandatory reporting system for patient safety events. All hospitals, ambulatory surgical facilities, birthing centers, and abortion facilities licensed by the State report through the Pennsylvania Patient Safety Reporting System. Pennsylvania was the first State to require the reporting of both patient safety events that cause harm and those events, such as "near-misses" or "unsafe conditions," that do not result in patient harm. Under the Pennsylvania reporting system, events with no patient harm that are still reported include the following:

  • Unsafe conditions or circumstances that could cause adverse events (e.g., medications that look alike).
  • Near misses or events that occurred but that the individual did not experience because of either chance alone or active recovery efforts by caregivers.
  • Events that reached the individual but did not cause harm.

Examples of patient events that did not result in harm could be a missed medication dose or prescribing of an incorrect dose where timely intervention prevented harm.

In 2012, more than 235,000 reports were made by hospitals and ambulatory surgical facilities; 96.5% of these reports did not involve patient harm. The Pennsylvania Patient Safety Authority's collection and analysis of information reported about no-harm events is an essential component of learning how to minimize patient safety events that cause harm.

Figure 4.17. Pennsylvania patient safety reports by event type and harm, 2012

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Source: Pennsylvania Patient Safety Reporting System, 2012.
Note: Only hospital and ambulatory surgical facility data are presented. Values for bar segments less than 5% are not shown.

  • In 2012, of the 8,039 reports by hospitals and ambulatory surgical facilities of events that caused harm, the largest categories were "complications resulting from a procedure, treatment, or test" (44% of the total), "other/miscellaneous" (16%), and "falls" (14%) (Figure 4.17).
  • A different mix of patient safety events is involved when harm does not occur. Of the 227,210 reports in 2012 of events that did not cause harm, the most common categories were "errors related to procedures, treatments, or tests" (22%); "medication errors" (19%); and "skin integrity" and "falls" (15% each).

Outcome: Patient Safety Culture

High-reliability organizations—those that perform high-risk work but achieve low rates of adverse events—establish "cultures of safety." A culture of safety is characterized by shared dedication to making work safe, nonpunitive reporting and communication about error, collaboration and teamwork across disciplines, and adequate resources to prevent adverse events. AHRQ developed the Hospital Survey on Patient Safety Culture to help hospitals assess the culture of safety in their facilities. The 2013 NHQR presents data from the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report.

This report is based on survey responses collected from 567,703 hospital staff in 1,128 hospitals that represent approximately 18% of the country's hospitals. The average hospital response rate was 53%, with an average of 503 completed surveys per participating hospital. Hospitals contributing data to the comparative database mirror the population of U.S. hospitals as a whole, but participation is entirely voluntary.

Most hospitals administered Web surveys (66%). Web surveys resulted in slightly lower response rates (51%) than response rates from paper surveys (61%) but were about the same as mixed-mode administered surveys (49%). Most hospitals administered the survey to all staff or to a sample of all staff from all hospital departments. Nurses accounted for more than one-third of respondents. More than three-quarters of respondents had direct interaction with patients.

The survey assesses 12 patient safety culture composites, as an average percent positive response. Percent positive refers to the percentage of responses that agree or strongly agree with a positively worded item (e.g., "People support one another in this unit") and the percentage that disagree or disagree strongly with a negatively worded item (e.g., "We have patient safety problems in this unit").

Figure 4.18. Average patient safety culture composite percent positive response, 2012

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Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: User Comparative Database Report, 2012.

  • One area with potential for hospitals to improve is Nonpunitive Response to Error (Figure 4.18). Nonpunitive Response to Error is the extent to which staff feel that event reports and their own mistakes are not held against them and that mistakes are not kept in their personnel file.

Figure 4.19. Average percent positive for nonpunitive response to error and respondents reporting no events in the past 12 months, by geographic region, 2012

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Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: User Comparative Database Report, 2012.

  • Nonpunitive Response to Error is highlighted due to the consistently low percentage of positive response given by hospital staff. This topic area, as well as Handoffs and Transitions, had the lowest percent positive responses across all geographic regions. The New England (39%), Pacific (42%), and East North Central (42%) regions were the regions with the lowest percentages of positive response for Nonpunitive Response to Error (Figure 4.19).
  • On average, more than half of respondents within hospitals (55%) reported no events in their hospital over the past 12 months (data not shown). This may represent underreporting of events or lack of communication about them in a facility and is, therefore, a potential area of improvement for most hospitals.
  • At the geographic level, the relationship between cultures with nonpunitive response to error and event reporting does not appear to be statistically significant.

Root Cause Analysis and Risk Mitigation: Veterans Health Administration

Root Cause Analysis

Root cause analyses (RCAs), used successfully in high-reliability fields such as aviation safety, have become a key learning tool for investigating adverse health care events. After an organization identifies causal factors through RCAs, followup steps must be taken to mitigate risk through changes in the health care system (to facilities, processes, or staffing). The Department of Veterans Affairs (VA) is a unique example of the use of RCAs and mitigating actions in a health system.

The VA's Veterans Health Administration (VHA) is a consolidated health system in terms of finance, governance, patient safety reporting, accountability, and prevention of adverse health care events. In 1999, VHA established the National Center for Patient Safety (NCPS) to encourage and coordinate patient safety activities within the VHA. A patient safety manager based at each VHA facility is responsible for investigating all adverse events at the facility, including instituting an RCA program and recommending action to mitigate safety events.

On average, VHA facilities conduct 1,258 RCAs per fiscal year. The annual number peaked in fiscal year 2008 at 1,472 (VHA, 2012). To encourage compliance, the VHA started a nonmonetary Cornerstone Award in 2008 to recognize facilities that conduct timely and high-quality RCAs and implement and evaluate corrective actions.

Figure 4.20. Root cause analyses completed within 45 days at VHA facilities, FY 2006-2011

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Source: Department of Veterans Affairs, 2012 VHA Facility Quality and Safety Report.

  • The speed of completing RCAs at VHA increased over time. The percentage of RCAs completed within 45 days increased from 44.5% in fiscal year 2006 to 97.7% in fiscal years 2010 and 2011 (Figure 4.20).

The VHA also has developed a system for categorizing actions resulting from an RCA to assess their potential impact on mitigating the risk of a future event. "Stronger" actions simplify the process and remove unnecessary steps (e.g., making architectural/physical plant changes, conducting usability testing of new devices before purchasing, forcing functions to reduce options to make mistakes, simplifying processes to remove unnecessary steps). "Intermediate" actions involve increasing staffing, decreasing workload, using checklist/cognitive aids, and building in redundancy. Finally, "weaker" actions involve using double checks, developing new procedures or policies, writing memoranda, or mandating training.

Risk Mitigation: Addressing Suicide as a Patient Safety Event

In a search of RCAs from 1999 to 2006, NCPS staff reviewed RCA reports of 143 inpatient suicide attempts and 42 completed suicides. They found that hanging was the most common method for completed suicides, with closets and room doors as the most common anchor points. A multidisciplinary committee of engineers, architects, patient safety experts, and mental health professionals was formed to develop actions to address architectural and other environmental hazards associated with inpatient suicide. The actions developed by the committee are considered "stronger" changes because they removed the physical supports that enabled suicidal patients to hang themselves.

The Mental Health Environment of Care Checklist (MHEOCC) was completed in November 2007 and released to clinical staff. It consists of 114 items, including 39 general items meant to be applied to various parts of a mental health unit and 75 items for other parts of the health facility. Use of the MHEOCC, a VHA requirement of mental health units treating suicidal patients, led to the abatement of 8,298 hazards in its first 2 years of use.

Figure 4.21. Inpatient suicides before and after MHEOCC implementation, 2000-2010

Line graph showing the rate of suicide in VHA hospitals versus non-VHA hospitals before and after MHEOCC implementation.

Source: Watts BV, Young-XU Y, Mills PD, et al. An examination of the effectiveness of a mental health environment of care checklist in reducing suicide on inpatient mental health units. Arch Gen Psychiatr 2012 June:69(6):588-92. Use with authors' permission.

  • An evaluation of all completed suicides between January 1999 and March 2011 found that the proportion of quarters with any suicide decreased from 69% during the pre-MHEOCC period to 21% during the post-MHEOCC period (Watts, et al., 2012).
  • Implementation of MHEOCC was associated with a roughly 87% decrease in odds of having a suicide occur in a quarter (OR: 0.13; 95% CI: 0.02 to 0.64; p-value=0.008).
  • The rate of suicide in the VHA hospitals (roughly 3 per 100,000 discharges) was already much lower than in general non-Federal hospitals (roughly 45 per 100,000 discharges, as estimated using the HCUP Nationwide Inpatient Sample) (Figure 4.21).

References

2013 annual progress report to Congress: National Strategy for Quality Improvement in Health Care. Washington, DC: U.S. Department of Health and Human Services; July 2013. Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.pdf (PDF File, 1.3 MB). Accessed July 24, 2013.

2012 annual progress report to Congress. National Strategy for Quality Improvement in Health Care. Washington, DC: U.S. Department of Health and Human Services; April 2012, corrected August 2012. Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf (PDF File, 408 KB). Accessed May 13, 2013.

Healthcare-associated infections (HAIs) data and statistics. Atlanta, GA: Centers for Disease Control and Prevention; December 13, 2010. Available at: http://www.cdc.gov/HAI/surveillance/index.html. Accessed April 15, 2014.

Fick D, Semla T, Beizer J, et al. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60(4):616-31.

Gastmeier P. Nosocomial infection surveillance and control policies. Curr Opin Infect Dis 2004 Aug;17(4):295-301.

Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Milwood) 2009 Sep-Oct;28(5):1475-84.

Kohn L, Corrigan J, Donaldson M, eds. To err is human: building a safer health system. Institute of Medicine, Committee on Quality of Health Care in America. Washington, DC: National Academy Press; 2000.

Kudish B, Sokol RJ, Kruger M. Trends in major modifiable risk factors for severe perineal trauma, 1996-2006. Int J Gynaecol Obstet 2008 Aug; 102(2):165-70.

Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010 Nov 25;363(22):2124-34. Erratum in: N Engl J Med 2010 Dec 23;363(26):2573.

Lau DT, Kasper JD, Potter DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med 2005 Jan 10;165(1):68-74.

Martin JA, Hamilton BE, Ventura SJ, et al. Births: final data for 2010. Natl Vital Stat Rep 2012 Aug 28;61(1).

Mayr FB, Yende S, Linde-Zwirble WT, et al. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. JAMA 2010 Jun 23;303(24):2495-2503.

Moore LJ, Moore FA, Todd SR, et al. Sepsis in general surgery: the 2005-2007 National Surgical Quality Improvement Program perspective. Arch Surg 2010 Jul;145(7):695-700.

National Academy for State Health Policy. Patient Safety Toolbox. Available at: http://www.nashp.org/pst-welcome. Accessed May 13, 2013.

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Raetzman SO, Fullerton C, Frankel S. Review to support AHRQ report on effective strategies for improving patient safety. (Prepared by Truven Health Analytics for AHRQ under the Network of Patient Safety Databases contract.) Rockville, MD: Agency for Healthcare Research and Quality; November 26, 2012.

Saber Tehrani AS, Lee HW, Mathews SC, et al. 25 years of U.S. malpractice claims for diagnostic errors 1986-2010: an analysis from the National Practitioners Data Bank. BMJ Qual Saf 2013;22(8):672-80.

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i Some argue that this estimate may be too high, while others argue the estimate is too low because diagnosis-related errors are not counted here. See diagnosis-related errors section.
ii The Jha, et al., estimate for 2004 at $16.622 billion was inflated by the Producer Price Index for medical and surgical hospitals through 2012, plus an assumed 2.2% increase for 2013.
iii Available at http://www.ahrq.gov/workingforquality/reports.htm.
iv MPSMS data were based solely on patients from four patient groups whose charts were requested by CMS for hospitals as part of the Inpatient Quality Reporting Program. These groups included all-payer patients >17 years old with a principal discharge diagnosis of: (1) pneumonia, (2) acute myocardial infarction, (3) heart failure, or (4) major surgery (as described in the Surgical Care Improvement Project [SCIP]).
v All Other HACs includes: inadvertent femoral artery puncture for catheter angiographic procedures, adverse event associated with hip joint replacement, adverse event associated with knee joint replacement, contrast nephropathy associated with catheter angiography, hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA), hospital-acquired vancomycin-resistant Enterococcus (VRE), hospital-acquired antibiotic-associated Clostridium difficile, mechanical complications associated with central venous catheters, postoperative cardiac events for cardiac and noncardiac surgeries, postoperative pneumonia, iatrogenic pneumothorax (HCUP Patient Safety Indicator [PSI] 6), postoperative hemorrhage or hematoma (PSI 9), postoperative respiratory failure (PSI 11), and accidental puncture or laceration (PSI 15).
vi The top 3 States that contributed to the achievable benchmark are Nebraska, New Hampshire, and Rhode Island.
vii The top 4 States that contributed to the achievable benchmark are South Dakota, Utah, West Virginia, and Wyoming
viii Medications that should always be avoided in older patients include barbiturates, flurazepam, meprobamate, chlorpropamide, meperidine, pentazocine, trimethobenzamide, belladonna alkaloids, dicyclomine, hyoscyamine, and propantheline. Medications that are rarely appropriate for older patients or sometimes indicated for older patients but often misused include carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, amitriptyline, chlordiazepoxide, diazepam, doxepin, indomethacin, dipyridamole, ticlopidine, methyldopa, reserpine, disopyramide, oxybutynin, chlorpheniramine, cyproheptadine, diphenhydramine, hydroxyzine, promethazine, and propoxyphene.
ix The Hospital Quality Alliance no longer exists but did collect and report data for 2008-2010 used on the Hospital Compare Web site. Future data on readmissions will come from the Hospital Inpatient Quality Reporting Program.


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Page last reviewed May 2014
Page originally created May 2014
Internet Citation: Chapter 4. Patient Safety. Content last reviewed May 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/nhqr13/chap4.html

 

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