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Better admissions data challenges the validity of some patient safety indicators

Some hospital measures of patient safety events-patient safety indicators (PSIs)-alert the hospital to problems that actually had arisen before admission, according to a new study. Without information on whether these patient safety events are present when the patient is admitted, the PSIs cannot help the hospital identify problems and solutions to those problems, explains Anne Elixhauser, Ph.D., of the Agency for Healthcare Research and Quality.

Dr. Elixhauser and colleagues analyzed data from California and New York, two States that require hospitals to collect reliable information on potential patient safety problems present at admission (POA). The researchers looked at 13 of the 20 PSIs, designed to reflect in-hospital quality of care, that could be made unreliable by lack of POA information.

They found that for three PSIs-decubitus ulcer (pressure sores), postoperative hip fracture, and postoperative pulmonary embolism/deep vein thrombosis-the majority of cases do not represent problems that developed during the patient's hospital stay. Thus, prevention of these conditions must be addressed elsewhere in the health care system. However, the other 10 PSIs are potentially useful measures even in the absence of POA codes. For these 10 measures-complications of anesthesia, foreign body left during procedure, iatrogenic pneumothorax, infection due to medical care, postoperative hemorrhage, postop physiologic derangement, postop respiratory failure, postop sepsis, accidental puncture and laceration, and transfusion reaction-the majority of events were not present on admission.

Dr. Elixhauser and her colleagues used 2003 data on hospitalized patients from the California and New York State Healthcare Cost and Utilization Program State Inpatient Databases, which included POA codes. After excluding records with suspect POA coding, the researchers found that most cases of decubitus ulcer (86-89 percent), postoperative hip fracture (74-79 percent), and postoperative pulmonary embolism/deep vein thrombosis (54-58 percent) were present at admission, and could not be considered in-hospital patient safety events. In contrast, no complications of anesthesia were eliminated when POA diagnoses were taken into account. The study was funded by the Agency for Healthcare Research and Quality (Contract No. 290-00-0004).

More details are in "How often are potential patient safety events present on admission?" by Robert L. Houchens, Ph.D., Dr. Elixhauser, and Patrick S. Romano, M.D., M.P.H., in the March 2008 The Joint Commission Journal on Quality and Patient Safety 34(3), pp. 154-163. Reprints (AHRQ Publication No. 08-R069) are available from the AHRQ Publications Clearinghouse.

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