Complications of Anesthesia
Foreign Body left during Procedure
Postoperative Pulmonary Embolism or Deep Vein Thrombosis
Postoperative Sepsis
Postoperative Haemorrhage or Haematoma
Postoperative Physiologic Metabolic Derangements
Postoperative Respiratory Failure
PSI 15: Complications of Anesthesia
Origin: Review of a common OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Death due to anaesthesia has become rare, by contrast morbid events,
i.e. complications related to anaesthetic care such as anaesthetic
overdose, reaction, or endotrachial tube misplacement are much more
prevalent causing harm to the patient to a different extend. Thus
complications due to anesthesia are a relevant measure of patient
safety.
Aim of the PSI The PSI aims at surveillance of complications of anesthesia.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s)
A subset of this AHRQ indicator was originally proposed by Iezzoni et
al. as part of Complications Screening Program (CSP) (CSP 21,
“Complications relating to anesthetic agents and other CNS
depressants”). The CPS definition also included poisoning due to
centrally acting muscle relaxants and accidental poisoning by nitrogen
oxides, which are omitted from this AHRQ PSI. The CPS definition
excludes other codes included in this PSI, namely, poisoning by other
and unspecified general anesthetics and external cause of injury codes
for “endotracheal tube wrongly place during anesthetic procedure” and
adverse effects of anesthetics in therapeutic use.
Organisations responding to the same indicator theme are Australian
Incident Monitoring System and the National Patient Safety Agency in
the UK (3;33)
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process lead to a recommendation of 86 indicators of
which 21 covers aspects of patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time.
The literature review of the AHRQ project team focused on the
validity of complication indicators based on ICD-9-CM diagnosis or
SImPatIE WP4 – Catalogue of Patients Safety Indicators
41
procedure codes. Results of the literature review indicate no published
evidence for the sensitivity or predictive value of this indicator based
on detailed chart review or prospective data collection (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 0.56
for complications of anesthesia. This PSI was significantly associated
with the AHRQ PSI for “Technical Difficulty with Procedure”. No
significant differences were found for hospitalisations with PSI events
and those without PSI events for longer lengths of stay, higher
mortality, and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a consistent rate over time. After accounting for
patient and hospital characteristics, hospitals' baseline risk-adjusted PSI
rates were the most important predictors of the 2004 risk-adjusted rates
for eight PSIs (decubitus ulcer, failure to rescue, iatrogenic
pneumothorax, infection resulting from medical care, postoperative
hemorrhage or hematoma, postoperative respiratory failure,
postoperative pulmonary embolism or deep vein thrombosis and
accidental puncture/laceration). It was concluded, that the PSIs are
useful tools for tracking and monitoring patient safety events. Future
research should investigate whether trends reflect better or worse care
or increased attention to documenting patient safety events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Complications of anesthesia occur significantly
more often among black and Hispanic people than among white. It
was concluded that: ”The AHRQ PSIs are a broad screen for potential
safety events that point to needed improvement in the quality of care
for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7;8;33;34).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
42
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Cases of anesthetic overdose, reaction, or endotrachial tube
misplacement per 1000 surgery discharges with an operating room
procedure.
Numerator Description Discharges with ICD-9-CM diagnosis codes for anesthesia
complications in any secondary diagnosis field.
Denominator Description All surgical discharges, 18 years and older or MDC 14 (pregnancy,
childbirth, and puerperium), defined by specific DRGs and an ICD-9-
CM code for an operating room procedure.
Exclude cases with:
− ICD-9-CM diagnosis codes for anesthesia complications in the
principal diagnosis field
− codes for self-inflicted injury, poisoning due to anesthetics
(E8551, 9681-4, 9687) and any diagnosis code for active drug
dependence, or active non-dependent abuse of drugs.
Data Source Administrative data. Ideally, this PSI is used with a coding designation
that distinguishes conditions present on admission from those that
develop in-hospital.
Identifying the
institutional context
This PSI is relevant to quality improvement, accreditation and cost
containment, as complications due to anesthetic overdose, reaction, or
endotrachial tube misplacement can have considerable economic
impact.
Care Setting The PSI applies for high quality anaesthesia care.
Professionals Responsible
for Health Care
Anaesthesiologists.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Risk adjustment for age, sex, DRG, comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given. Hospital-wide surveillance.
Scoring AHRQ has PSI software for scoring.
PSI 16: Foreign Body left during Procedure
Origin: Review of a common OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Although surgeons and operating room teams rely on the practice of
counts of sponges, sharp and instrument as a means to eliminate
detained foreign bodies, practices are not standardised and every single
events may signal a serious system failure that should be addressed.
Thus foreign body left during procedure is a suitable measure of
patient safety.
Aim of the PSI This PSI is intended to flag cases of a foreign body accidentally left in
a patient during a procedure.
Level of Determination of
Patient Safety
Safety can be assessed at the individual and the aggregated patient
level. Though due to the rarity of foreign body left during procedure
and the severity of the event, safety is recommended assessed at the
individual patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program (CSP “sentinel events”). It was also
included as one component of a broader indicator (“adverse events and
iatrogenic complications”) in AHRQs original HCUP Quality
Indicators.
It was proposed by Miller et al. in the “Patient Safety
Indicator Algorithms and Groupings.”
The PSI is defined on both a provider level (by restricting cases to
those included both medical and surgical patients, but flagged by a
secondary diagnosis or procedure code) and an area level (by including
all cases).
Organisations responding to the same theme are Australian Incident
Monitoring System and National Patient Safety Agency in the UK
(3;33).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process lead to a recommendation of 86 indicators of
which 21 covers aspects of patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
SImPatIE WP4 – Catalogue of Patients Safety Indicators
44
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 0.17
for foreign body left during procedure. This PSI was significantly
associated with the AHRQ PSIs for selected infections due to medical
care and technical difficulty with procedure. Statistical significantly
differences were found for hospitalisations with PSI events and those
without PSI events for longer lengths of stay and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a consistent rate over time. Future research should
investigate whether trends reflect better or worse care or increased
attention to documenting patient safety events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. No differences in the occurrence of this PSI event
were found according to race. It was concluded that: ”The AHRQ
PSIs are a broad screen for potential safety events that point to needed
improvement in the quality of care for specific populations” (7).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7;8;33;34).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Discharges with foreign body accidentally left in during procedure per
1000 discharges.
Numerator Description Discharges with ICD-9-CM codes for foreign body left in during
procedure in any secondary diagnosis field.
Denominator Description All medical and surgical discharges, 18 years and older or MDC 14
(pregnancy, childbirth, and puerperium), defined by specific DRGs.
Exclude cases with ICD-9-CM codes for foreign body left in during
procedure in the principal diagnosis field.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
45
Data Source Administrative data.
Identifying the
institutional context
Complications due to foreign bodies left during procedure make this
PSI important for both financial and quality improvement policies.
Care Setting The PSI applies for high quality surgical care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Risk Adjustment for: Age, sex, DRG, comorbidity categories when
restricting cases to those included both medical and surgical patients,
but flagged by a secondary diagnosis or procedure code.
No risk adjustment when including all cases.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 17: Postoperative Pulmonary Embolism or Deep Veins Thrombosis
Origin: Review of OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The occurrence of postoperative pulmonary embolism (PE) or deep
vein thrombosis (DVT) can range from mild symptoms to devastating
clinical consequences including pain, respiratory distress, and death.
PE/DVT can be prevented through the appropriate use of
anticoagulants and other preventive measures. Thus PE or DVT is a
suitable measure of patient safety.
Aim of the PSI This PSI is intended to capture cases of PE or DVT.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program: CSP 22, “venous thrombosis and
pulmonary embolism” and it was one of AHRQs original HCUP
Quality Indicators for major surgery and invasive vascular procedure
patients.
(3;33).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process lead to a recommendation of 86 indicators of
which 21 covers aspects of patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 13.00
for postoperative PE or DVT. This PSI was significantly associated
with the AHRQ PSI for failure to rescue. Statistical significantly
differences were found for hospitalisations with PSI events and those
without PSI events for longer lengths of stay, mortality and higher
costs (4).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
47
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a consistent rate over time. After accounting for
patient and hospital characteristics, hospitals' baseline risk-adjusted PSI
rates were the most important predictors of the 2004 risk-adjusted rates
for eight PSIs among these also this one. It was concluded, that the
PSIs are useful tools for tracking and monitoring patient safety events.
Future research should investigate whether trends reflect better or
worse care or increased attention to documenting patient safety events
(5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Postoperative PE or DVT occurs significantly
more often among African American, Non-Hispanic than among
white. It was concluded that: ”The AHRQ PSIs are a broad screen for
potential safety events that point to needed improvement in the quality
of care for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7;8;33;34).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Cases of deep vein thrombosis or pulmonary embolism per 1000
surgical discharges with an operating room procedure.
Numerator Description Discharges with ICD-9-CM codes for deep vein thrombosis or
pulmonary embolism in any secondary diagnosis field.
Denominator Description All surgical discharges age 18 and older defined by specific DRGs and
an ICD-9-CM code for an operating room procedure.
Exclude cases:
− with ICD-9-CM codes for deep vein thrombosis or pulmonary
embolism in the principal diagnosis field
− where a procedure for interruption of vena cava is the only
operating room procedure
− where a procedure for interruption of vena cava occurs before or
on the same day as the first operating room procedure
SImPatIE WP4 – Catalogue of Patients Safety Indicators
48
Note: If day of procedure is not available in the input data file, the
rate may be slightly lower than if the information was available.
− With obstetrical patients in MDC 14 (Pregnancy, Childbirth and
the Puerperium
Data Source Administrative data.
Identifying the
institutional context
Because PE/DVT can cause unnecessary prolongation of hospital stays
as well as unnecessary pain, suffering and death, this PSI is important
in financial and quality policies.
Care Setting The PSI applies for high quality surgical care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Risk adjustment for age, sex, DRG, comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 18: Postoperative Sepsis
Origin: Review of a common OECD/AHRQ PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The occurrence of sepsis following surgery is a severe complication
with a mortality rate of up to 30%. Even less severe cases will require
prolonged ICU treatment for organ failure. As many cases of
postoperative sepsis can be prevented through the appropriate use of
prophylactic antibiotics, good surgical site preparation, careful and
sterile surgical techniques and good post-op care this postoperative
sepsis is a suitable measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of nosocomial postoperative sepsis.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program: CSP 7 “Septicamia” Needlemann
and Buerhaus identified sepsis as an “Outcome Potential Sensitive to
Nursing” using the same CSP definition (3;33).
Extent of Clinically
Testing
The OECD Health Care Quality Indicators (HCQI) Project was
initiated to implement quality measures for international
benchmarking of medical care at the health system level. Five priority
areas including patient safety were selected. International expert
panels were formed to identify clinically important, scientifically
sound, and feasible measures based on a structured consensus process.
The consensus process lead to a recommendation of 86 indicators of
which 21 covers aspects of patient safety (34).
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 6.13
for postoperative sepsis. This PSI was significantly associated with the
AHRQ PSI for postoperative respiratory failure. Statistical
significantly differences were found for hospitalisations with PSI
events and those without PSI events for longer lengths of stay,
mortality and higher costs (4).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
50
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated a consistent rate over time. After accounting for
patient and hospital characteristics, hospitals' baseline risk-adjusted PSI
rates were the most important predictors of the 2004 risk-adjusted rates
for eight PSIs. It was concluded, that the PSIs are useful tools for
tracking and monitoring patient safety events. Future research should
investigate whether trends reflect better or worse care or increased
attention to documenting patient safety events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Postoperative sepsis occurs significantly more
often among other races than among white. It was concluded that:
”The AHRQ PSIs are a broad screen for potential safety events that
point to needed improvement in the quality of care for specific
populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7;8;33;34).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Cases of sepsis per 1000 elective surgery patients with an operating
room procedure and a length of stay of four days or more.
Numerator Description Discharges with ICD-9-CM code for sepsis in any secondary diagnosis
field
Denominator Description All elective* surgical discharges age 18 and older defined by specific
DRGs and an ICD-9-CM code for an operating room procedure.
*Elective - Admission type # is recorded as elective (Admission Type
= 3)
Exclude cases:
− with ICD-9-CM codes for sepsis in the principal diagnosis field
− with a principal diagnosis of infection, or any code for
immunocompromised state, or cancer
− MDC 14 (pregnancy, childbirth, and puerperium)
− with a length of stay of less than 4 days
Data Source Administrative data.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
51
Identifying the
institutional context
This PSI is relevant to both quality improvement and cost containment.
Care Setting The PSI applies for high quality nursing care.
Professionals Responsible
for Health Care
Surgeons and nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical units or departments.
Allowance for Patient
Factors
Risk adjustment for age, sex, DRG, comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
PSI 19: Postoperative Haemorrhage or Haematoma
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Postoperative Haemorrhage or Haematoma is a harmful and potentially
life-threatening complication in surgical care. Thus it is a suitable
measure of patient safety.
Aim of the PSI This PSI aims at surveillance of cases of hemorrhage or hematoma
following a surgical procedure.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complications Screening Program (CSP 24, “post-procedural
hemorrhage or hematoma”), although their definition allowed either
procedure or diagnosis codes. The indicator was also included as one
component of a broader indicator in AHRQs original HCUP Quality
Indicators (3).
This AHRQ indicator is defined on both a provider level by including
cases of Postoperative Haemorrhage or Haematoma occurring as a
secondary diagnosis during hospitalisation and on an area level by
including all cases of Postoperative Haemorrhage or Haematoma in the
area.
Extent of Clinically
Testing
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time.
Also they team concluded, that the overall usefulness of this PSI is
favourable. AHRQ panellists noted in their review of the PSI that
some patients may be at higher risk for developing a postoperative
hemorrhage or hematoma than others, especially patients with
coagulopathies and those on anticoagulants. The panellist also noted
that patients admitted for trauma may be at a higher risk for
developing postoperative hemorrhage or may have a hemorrhage
diagnosed that occurred during the trauma. AHRQ panellists
suggested this PSI to be stratified for patients with underlying clotting
differences and for trauma and non-trauma patients – if possible (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 3.23
SImPatIE WP4 – Catalogue of Patients Safety Indicators
53
for Postoperative Haemorrhage or Haematoma. This PSI was
significantly associated with the AHRQ PSIs for failure to rescue,
iatrogenic pneumothorax, postoperative wound dehiscence, technical
difficulties with procedure and infections due to medical care.
Significant differences were found for hospitalisations with PSI and
those without PSI events for longer lengths of stay, higher mortality,
and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated no trend in the rate over time. After accounting
for patient and hospital characteristics, hospitals' baseline riskadjusted
PSI rates were the most important predictors of the 2004 riskadjusted
rates for Postoperative Hemorrhage or Hematoma among
seven other PSIs. It was concluded, that this PSI is a useful tools for
tracking and monitoring patient safety events. Future research should
investigate whether trends reflect better or worse care or increased
attention to documenting patient safety events (5).
The Agency for Healthcare Research and Quality PSI algorithms were
applied to administrative data across four years of 1.92 million
discharges from children's hospitals. The mean risk-adjusted rates of
PSI events ranged from 0.1 events per 1000 discharges for a foreign
body left in during a procedure to 140 events per 1000 discharges for
failure to rescue. The researchers concluded: “PSIs derived from
administrative data are indicators of patient safety concerns and can be
relevant as screening tools for children's hospitals; however, cases
identified by these indicators do not always represent preventable
events. Some, such as a foreign body left in during a procedure,
iatrogenic pneumothorax, infection attributable to medical care,
decubitus ulcer, and venous thrombosis, seem to be appropriate for
paediatric care and may be directly amenable to system changes”(6).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Postoperative Haemorrhage or Haematoma occur
significantly more often among Asian and Pacific Islander and
African American, Non Hispanics than among white. It was
concluded that: ”The AHRQ PSIs are a broad screen for potential
safety events that point to needed improvement in the quality of care
for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
54
The results suggest that this PSI may be useful as a measure of patient
safety (3-7).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Cases of hematoma or hemorrhage requirering a procedure per 1000
surgical discharges with an operating room procedure.
Numerator Description Discharges with ICD-9-CM code for postoperative hematoma or
hemorrhage require ring a procedure in any secondary diagnosis field
and code for postoperative control of hemorrhage or drainage of
hematoma (respectively) in any procedure field.
Denominator Description All medical and surgical discharges 18 years and older defined by
specific DRGs and an ICD-10-CM code for an operating room
procedure.
Exclude cases with:
− With an ICD-9-CM codes postoperative hematoma or hemorrhage
diagnosis in any principal diagnosis field
− Where the only operating room procedure is postoperative control
of hemorrhage or drainage of hematoma
− Where a procedure for postoperative control of hemorrhage or
drainage of hematoma occurs before the first operating procedure.
Note: If day of procedure is not available in the input data file, the
rate may be slightly lower than if the information was available.
− MDC 14 (pregnancy, childbirth, and puerperium)
Data Source Administrative data.
Identifying the
institutional context
The impact of postoperative haemorrhage or haematoma makes this
PSI important for both financial and quality improvement policies.
Care Setting The PSI applies for quality surgical care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age, sex and comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 20: Postoperative Physiologic Metabolic Derangements
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Postoperative Physiologic Metabolic Derangements is a potentially
life-threatening complication in surgical care. Thus it is a suitable
measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of postoperative metabolic or
physiologic complications.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complication Screening Programme (CSP 20, “postoperative
physiologic and metabolic derangements”). The University Health
System Consortium adopted the CSP indicator for major surgery
patients (3).
Extent of Clinically
Testing
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time.
AHRQ panellists had concern about the definition of acute renal
failure: what one doctor may call acute renal failure, another may not.
To ensure that the only renal failure cases that are accounted for are
those that are clinically severe, the panel suggested that acute renal
failure be included only when it is paired with a procedure code for
dialysis. Panellists also noted that coding of relatively transient
metabolic and physiologic complications may be lacking, e.g. cases of
diabetic ketoacidosis. Conversely, some physicians may capture nonclinically
significant events in this indicator. (3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 1.89
for Postoperative Physiologic Metabolic Derangements. Significant
differences were found for hospitalisations with PSI and those without
PSI events for longer lengths of stay, higher mortality, and higher
costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
SImPatIE WP4 – Catalogue of Patients Safety Indicators
56
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated no trend in the rate over time. It was concluded,
that this PSI is a useful tools for tracking and monitoring patient safety
events. Future research should investigate whether trends reflect better
or worse care or increased attention to documenting patient safety
events (5).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Postoperative Physiologic Metabolic
Derangements occur significantly more often among Asian and
Pacific Islander and African American, Non Hispanics than among
white. It was concluded that: ”The AHRQ PSIs are a broad screen for
potential safety events that point to needed improvement in the quality
of care for specific populations” (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-5;7)
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Cases of specified physiological or metabolic derangement per 1000
elective surgical discharges with an operating room procedure.
Numerator Description Discharges with ICD-9-CM codes for physiologic and metabolic
derangements in any secondary diagnosis field.
Discharges with acute renal failure (subgroup of physiologic and
metabolic derangements) must be accompanied by a procedure code
for dialysis (3995, 5498).
Denominator Description All elective* surgical discharges age 18 and older defined by specific
DRGs and an ICD-9-CM code for an operating room procedure.
*Defined by admit type.
Exclude cases:
− with ICD-9-CM codes for physiologic and metabolic
derangements in the principal diagnosis field
− with a principal ICD-9-CM code for chronic renal failure
− with acute renal failure where a procedure for dialysis occurs
before or on the same day as the first operating room procedure
Note: If day of procedure is not available in the input data file, the
rate may be slightly lower than if the information was available
SImPatIE WP4 – Catalogue of Patients Safety Indicators
57
− with both a diagnosis code of ketoacidosis, hyperosmolarity, or
other coma (subgroups of physiologic and metabolic derangements
coding) and a principal diagnosis of diabetes
− with both a secondary diagnosis code for acute renal failure
(subgroup of physiologic and metabolic derangements coding) and
a principal diagnosis of acute myocardial infarction, cardiac
arrhythmia, cardiac arrest, shock, hemorrhage, or gastrointestinal
hemorrhage
− MDC 14 (pregnancy, childbirth and the puerperium)
Data Source Administrative data.
Identifying the
institutional context
The impact of postoperative physiologic metabolic derangements
makes this PSI important for both financial and quality improvement
policies.
Care Setting The PSI applies for quality medical care.
Professionals Responsible
for Health Care
Surgeons, anaesthesiologists and nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age, sex and comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
PSI 21: Postoperative Respiratory Failure
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Postoperative Respiratory Failure is an important and potentially lifethreatening
complication in surgical care. Thus it is a suitable measure
of patient safety.
Aim of the PSI This PSI aims at surveillance of cases of postoperative respiratory
failure.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This indicator was originally proposed by Iezzoni et al. as part of the
Complication screening program; CSP 3, ˇ°postoperative pulmonary
compromiseˇ±. The CSP definition also includes pulmonary congestion,
other (or postoperative) pulmonary insufficiency, and acute pulmonary
edema.
The University Health System Consortium (#2927) and AHRQs
original HCUP Quality Indicators adopted the CSP indicator for major
surgery patients.
Needleman and Buerhaus identified postoperative pulmonary Failure
as an ˇ°Outcome Potentially Sensitive to Nursing,ˇ± using the original
CSP definition (3).
Extent of Clinically
Testing
The project team developing the AHRQ PSI conducted extensive
empirical analyses on this PSI. The team concluded that this PSI
generally performs well on several different dimensions, including
reliability, bias, relatedness of indicators, and persistence over time
(3).
The AHRQ PSI software was applied to Veteran Affairs (VA)
administrative data to identify potential instances of compromised
patient safety; determine occurrence rates of PSI events in the VA;
and examine the construct validity of the PSIs. The study population
was 97% male, with a mean age of 65 years, 54% were age 65 and
older. All together 11411 PSI events were identified, 46% of PSI
events occurred in surgical hospitalisation and 54% in medical
hospitalisation. The observed PSI rate per 1000 discharges was 3.43
for Postoperative Respiratory Failure. Significant differences were
found for hospitalisations with PSI and those without PSI events for
longer lengths of stay, higher mortality, and higher costs (4).
The performance of the AHRQ PSIs was analysed to: 1) provide a
descriptive analysis of the incidence of PSI events from 2001 to 2004
in the VA; 2) examine trends in national PSI rates at the hospital
discharge level over time; and 3) assess whether hospital
characteristics (teaching status, number of beds, and degree of quality
improvement implementation) and baseline safety-related hospital
SImPatIE WP4 ¨C Catalogue of Patients Safety Indicators
59
performance predict future hospital safety-related performance. Riskadjusted
rates of the PSI for iatrogenic pneumothorax and failure to
rescue demonstrated significant trends over time. After accounting for
patient and hospital characteristics, hospitals' baseline risk-adjusted
PSI rates were the most important predictors of the 2004 risk-adjusted
rates for Postoperative Respiratory Failure among seven other PSIs. It
was concluded, that this PSI is a useful tools for tracking and
monitoring patient safety events. Future research should investigate
whether trends reflect better or worse care or increased attention to
documenting patient safety events (5).
The Agency for Healthcare Research and Quality PSI algorithms were
applied to administrative data across four years of 1.92 million
discharges from children's hospitals. The mean risk-adjusted rates of
PSI events ranged from 0.1 events per 1000 discharges for a foreign
body left in during a procedure to 140 events per 1000 discharges for
failure to rescue. The researchers concluded: ˇ°PSIs derived from
administrative data are indicators of patient safety concerns and can be
relevant as screening tools for children's hospitals; however, cases
identified by these indicators do not always represent preventable
events. Some, such as a foreign body left in during a procedure,
iatrogenic pneumothorax, infection attributable to medical care,
decubitus ulcer, and venous thrombosis, seem to be appropriate for
paediatric care and may be directly amenable to system changesˇ±(6).
Administrative data from community hospitals in 16 US states with
reliable race/ethnicity measures using the AHRQ PSIs was analysed to
determine whether racial and ethnic differences in patient safety
events disappear when income (a proxy for socioeconomic status) is
taken into account. Postoperative Respiratory Failure occurs
significantly more often among Asian and Pacific Islander, African
American, Non Hispanics and Hispanic than among white. It was
concluded that: ˇ±The AHRQ PSIs are a broad screen for potential
safety events that point to needed improvement in the quality of care
for specific populationsˇ± (7).
AHRQ is determining the feasibility and practicality in a project
concerning validation of selected AHRQ Quality Indicators (8).
The results suggest that this PSI may be useful as a measure of patient
safety (3-7).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: ˇ°Surgical Complicationˇ±.
Data definitions Cases of acute respiratory failure per 1000 elective surgical discharges
with an operating room procedure.
Numerator Description Either 1) Discharges with ICD-9-CM codes for acute respiratory
Failure (518.81) in any secondary diagnosis field (After 1999, include
518.84) OR 2) ICD-9-CM procedure codes for postoperative
reintubation procedure based on number of days after the major
operating procedure code: 96.04 ˇÝ1 days, 96.70 or 96.71 ˇÝ2 days, or
SImPatIE WP4 ¨C Catalogue of Patients Safety Indicators
60
96.72 ˇÝ0 days.
Denominator Description All elective (Defined by admit type) surgical discharges age 18 and
over defined by specific DRGs and an ICD-9-CM code for an
operating room procedure.
Exclude cases:
− with ICD-9-CM codes for acute respiratory Failure in the principal
diagnosis field
− with an ICD-9-CM diagnosis code of neuromuscular disorder
− where a procedure for tracheostomy is the only operating room
procedure or tracheostomy occurs before the first operating room
procedure
− MDC 14 (pregnancy, childbirth, and puerperium)
− MDC 4 (diseases/disorders of respiratory system)
− MDC 5 (diseases/disorders of circulatory system)
Note: If day of procedure is not available in the input data file, the
rate may be slightly lower than if the information was available.
Data Source Administrative data.
Identifying the
institutional context
The impact of postoperative respiratory failure makes this PSI
important for both financial and quality improvement policies.
Care Setting The PSI applies for quality medical care.
Professionals Responsible
for Health Care
Surgeons, anaesthesiologists and nurses
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
Risk adjustment for age, sex and comorbidity categories.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring.
