Accidental Puncture or Laceration
Wrong-Site Surgery
Medical Equipment Related Adverse Events
Patients' experience of Adverse Events - Surgical Interventions
PSI 22: Accidental Puncture Or Laceration
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Accidental puncture or laceration 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 accidental puncture or
laceration - arising due to technical difficulties in medical care.
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. This PSI was present – in a slightly
different form in AHRQs original HCUP Quality Indicators.
The University Health System Consortium adopted the CSP as an
indicator for medical (#2806) and major surgery (#2956) patients (3).
This AHRQ indicator is defined on both a provider level by including
cases of Accidental Puncture or Laceration occurring as a secondary
diagnosis during hospitalisation and on an area level by including all
cases of Accidental Puncture or Laceration.
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 were unsure about how the culture of quality
improvement in a hospital would affect coding of this complication.
Out of fear of punishment , some physicians may be reluctant to record
the occurrence of accidental puncture or laceration (3).
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 significant trends over time. For this PSI a non
significant increase in the rate was found 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 Accidental Puncture or Laceration 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).
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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. Accidental Puncture or Laceration occurs
significantly more often among 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).
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 technical difficulty (e.g., accidental cut or laceration during
procedure) per 1000 discharges.
Numerator Description Discharges with ICD-9-CM code denoting technical difficulty (e.g.,
accidental cut, puncture, perforation, or laceration) in any secondary
diagnosis field.
Denominator Description All medical and surgical discharges age 18 years and older defined by
specific DRGs.
Exclude cases:
− with ICD-9-CM code denoting technical difficulty (e.g., accidental
cut, puncture, perforation, or laceration) in the principal diagnosis
field
− MDC 14 (pregnancy, childbirth, and puerperium)
Data Source Administrative data.
Identifying the
institutional context
The impact of accidental puncture or laceration makes this PSI
important for both financial and quality improvement policies.
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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 23: Wrong Site-surgery
Origin: Review of an OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The consequences of wrong-site surgery can be severe. It is estimated
that one in four orthopaedic surgeons may make such an error once in
25 years of practice. Thus wrong-site surgery has potential as a patient
safety measure.
Aim of the PSI This PSI is intended to flag cases of wrong-site surgery.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a JCAHO sentinel events indicator.
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 was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21 cover
patient safety. The results suggest that this PSI may be useful as a
measure of patient safety (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Not specified by OECD.
Numerator Description Number of procedures on the wrong patient, wrong side of the body, or
wrong organ.
Denominator Description All surgical procedures.
Data Source Not specified by OECD.
Identifying the
institutional context
In addition to being a good measure of safety, the impact of wrong-site
surgery makes this indicator important for both financial and quality
improvement policies.
Care Setting The PSI applies for high quality surgery care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
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Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring No scoring advice given.
PSI 24: Medical Equipment-Related Adverse< Events
Origin: Review of an OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Equipment related adverse events may occur due to a variety of causes,
such as equipment defect, improper set-up or maintenance,
environmental factors or improper use. Events related to medical
equipment can trigger an accident, harm the patient in various ways, or
it may complicate the recognition and treatment of other problems.
Thus it is a suitable measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital medical equipmentrelated
adverse events.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a JCAHO sentinel event indicator.
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 was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21 cover
patient safety (33).
The OECD HCQI project group found: “No studies to date have
developed a widely used standardised protocol for equipment
maintenance for clinical engineering departments, largely because the
lack of standardisation of endpoints renders assessing the relative value
of any particular maintenance protocol impossible. Nonetheless,
equipment failure does result in a small fraction of clinical events and
thus is an important safety intervention” (33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Not specified.
Numerator Description Number of patient deaths or major permanent losses of function
associated with a problem with medical equipment.
Denominator Description All hospital admissions.
Data Source Not specified.
Identifying the In addition to being a good measure of safety, the economic impact of
medical related equipment related adverse events makes this PSI
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institutional context important for both financial and quality improvement policies.
Care Setting The PSI applies for high quality surgery care.
Professionals Responsible
for Health Care
Surgeons.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific standards given.
Scoring No scoring advice given.
PSI 25: Patients Experience of Adverse Events – Surgical Interventions
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
The frequency of harmful surgical adverse events is cause for serious
concern. Patients are an important source of observations and
information about adverse events. The ultimate goal is to achieve the
best care and outcomes for patients each time they are in touch with the
health care system. Thus patient’s experiences of harm due to an
operation are an important measure of patient safety.
Aim of the PSI This PSI aims at surveillance of patient harm due to an operation
experienced by the patients.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This PSI is derived from the section on patient safety of the Danish
national patient survey: Patient’s experiences in hospital, question 18b
(9;11).
Extent of Clinically
Testing
Attitudes and responses to adverse events have been investigated from
Danish patient’s and the staff’s point of view, using a questionnaire
survey. Patients were asked about their experiences with errors and
staffs handling of errors. Comparison of responses to the same
questions was made between the two groups. Twenty percent of patient
had experiences minor errors and eight percent large errors during
hospitalisation (11).
Another Danish study using mailed questionnaires estimated the
incidence of medical errors; also the extent of agreement between
patients and staff of the type of error was investigated. Errors were
described in free text by informants and rated in categories by a risk
manager. 44% of staff had experienced an error within the last three
months in ambulatory or in-patient care, whereas 13% of the patients
had experienced an error. By the description the risk manager found
that 44% of the patient reported errors could be classified as
dissatisfaction. One percent of staff had experienced an erroneous
surgical procedure. Three percent of in-patients and 0.3% of staff has
experienced an error related to anaesthesia. The researchers concluded
that patients typically find it difficult to distinguish between an error
and their dissatisfaction, highlighting a need for firm criteria if patients
are to report errors as a basis for improvements. Comparison of error
rates between patients and staff – and indeed between hospitals - will
be misleading until these criteria are reliable and validated (10).
This PSI has not been clinically applied.
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
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PSI category Theme Related PSI: “Surgical Complication”.
Data definitions Number of patients experiencing a harmful adverse event due to an
operation per 1000 operation procedures.
Numerator Description Number of patients experiencing a harmful adverse event due to an
operation.
Denominator Description Number of operation procedures.
Data Source Administrative data and/or Patient’s Experiences (Satisfaction) Survey.
Identifying the
institutional context
The qualitative and quantitative impact harmful surgical procedures
make this PSI important in quality and economic improvement
policies.
Care Setting The PSI applies for quality surgical care.
Professionals Responsible
for Health Care
Surgeons, anaesthesiologists and nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
Standard of Comparison No specific time standards given, but comparison every second year
has shown to be good.
Scoring Scoring according to the manual of the Patient’s Experiences
(Satisfaction) Survey.
