Theme Related PSI's: 'Medication Error'

Transfusion Reaction

Wrong Blood Type

Medication Error

Electronic Trigger Tool - Surveillance of Adverse Drug Events

PSI 26: Transfusion Reaction
Origin: Review of OECD/AHRQ/CIHI PSI (3;33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The chance of a patient suffering a fatal transfusion reaction due to
ABO-incompatibility is roughly equivalent to the risk of acquiring HIV
infection from a blood transfusion. Thus transfusion reaction is an
important measure of patient safety.
Aim of the PSI This indicator is intended to flag cases of major reactions due to
transfusions.
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 “sentinel events”). It was also
included as one component of a broader PSI for “adverse events and
iatrogenic complications” in AHRQs original HCUP Quality
Indicators.
It was proposed by Miller et al. in the original “AHRQ PSI
Algorithms and Groupings (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 was successfully completed in all five priority
areas leading to a recommendation of 86 indicators of which 21
covered patient safety (33).
The AHRQ project team developing the PSI conducted empirical
analyses on this PSI. Given the low rates or occurrences for
Transfusion Reaction, the team did not measure reliability or minimum
bias. The indicator could not be risk-adjusted due to the small number
of numerator cases. The Literature review conducted by the ARHQ
team did not reveal evidence on validity from prior studies, it was
explained due to the rarity of this complication (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. Mean length of stay was 7.1.days. All together 11411 PSI
events were identified, 46% of PSI events occurred in surgical
hospitalisation and 54% in medical hospitalisation. The observed PSI
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rate per 1000 discharges was 0.007 the lowest of all studied for
transfusion reaction. No statistically significant differences were
found for hospitalisations with this 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. 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).
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;33).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: ”Medication Error”.
Data definitions Cases of transfusion reaction per 1000 discharges.
Numerator Description Discharges with ICD-9-CM codes for transfusion reaction in any
secondary diagnosis field per 100 discharges.
Denominator Description All medical and surgical discharges.
The OECD expert panel recommended changing the original AHRQdenominator
to: “all transfusions”.
Data Source Administrative data.
Identifying the
institutional context
The impact of transfusion reactions makes this PSI important for both
financial and quality improvement policies.
Care Setting The PSI applies for high quality transfusion care.
Professionals Responsible
for Health Care
Doctors.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
No stratification.
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Standard of Comparison No specific standards given.
Scoring AHRQ has PSI software for scoring. Users of the PSI software should
note the output will only contain observed rates of transfusion reaction
(3).

PSI 27: Wrong blood type
Origin: Review of an OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
The chance of a patient suffering a fatal transfusion reaction due to
ABO-incompatibility is roughly equivalent to the risk of acquiring HIV
infection from a blood transfusion. Half of the reported deaths due to
major complications of transfusion in United Kingdom were shown a
consequence of transfusing the wrong blood to a patient. Reports from
a period of two years from October 1996 of death or major
complications of transfusions revealed that he most common (52%)
adverse event was giving the wrong blood type to the patient. Thus
wrong blood type is a suitable measure of patient safety.
Aim of the PSI This PSI is intended to flag cases of patients given the wrong blood
type.
Level of Determination of
Patient Safety
Safety can be assessed at the individual and the aggregated patient
level. Though du to the rarity of the wrong blood type and the severity
of the event, safety is recommended assessed at the individual patient
level.
Source(s) This indicator was originally proposed by the Australian Council for
Safety and Quality.
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: “Medication Error”
Data definitions Not specified.
Numerator Description Number of haemolytic blood transfusion reaction resulting from ABO
incompatibility.
Denominator Description All transfusions.
Data Source Not specified.
Identifying the
institutional context
The impact of this PSI theme is important for both financial and quality
improvement policies.
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Care Setting The PSI applies for quality transfusion care.
Professionals Responsible
for Health Care
Doctors.
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 28: Medication Error
Origin: Review of an OECD PSI (33)
Dimension Description
Description of Specific
Aspects of Patient Safety
Medication errors are known to be fairly common but preventable
events. Medication errors refer to errors in processes of ordering,
transcribing, dispensing, administering, or monitoring medications.
Many medication errors are thought to have no or few consequences
for the patient’s health by health care workers also many medication
errors are thought undetected. Though medication errors may result in
serious patient morbidity or mortality. Patient compliance has an
impact on preventing medication errors. Medication errors are a
suitable theme for measuring patient safety.
Aim of the PSI This PSI is intended to flag cases of in-hospital medication errors.
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).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Theme Related PSI: “Medication Errors”.
Data definitions Not specified by OECD.
Numerator Description Number of patient deaths, paralysis, coma, or other major permanent
loss of function associated with a medical error.
Denominator Description According to the SimPatIE Stepwise Assessment Indicator Framework
Approach, this PSI is not described further as the denominator is not
defined by OECD or by JACHO
PSI 29: Electronic Trigger Tool - Surveillance of Adverse Drug Events
Origin: PSI by SimPatIE
Dimension Description
Description of Specific
Aspects of Patient Safety
Adverse drug events (ADEs) are continually placing patients at
risk of harm. ADEs are the single most frequent adverse event
type. Tracking the occurrences of ADEs over time is a useful way
to tell about the development of safety related to medication.
Thus use of specified "triggers" or clues – signalising that an ADE
might have occurred – is a suitable patient safety measure.
Aim of the PSI This PSI is intended to flag rates of ADEs.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Manual chart review has been considered the "gold-standard" for
identifying adverse events in many patient safety studies. The
methodology is expensive and has shown imperfect (46).
Automated surveillance for adverse drug events has been
demonstrated firstly by Classen et al. in the early 1990s (47).
Since then more groups have developed electronic methods
suitable for detecting adverse events based on the use of
"triggers", coded data, free-text clinical narratives, or a
combination of techniques (47-53). Advances in such electronic
systems will facilitate our ability to monitor adverse events (46).
Thus this PSI is based upon a computerised screening tool that
searches free-text discharge summaries for trigger words
representing possible adverse drug events.
Extent of Clinically Testing To assess the accuracy and define the epidemiology of computer
based medication error reports a retrospective cohort study of 581
error reports containing 1010 medication errors was conducted.
Of medication errors reviewed, 298 (30%) were prescribing
errors, 245 (24%) were dispensing errors, 410 (41%) were
administration errors, and 57 (6%) involved medication
administration records (MAR). Following expert review the
overall distribution of error type categories did not change
significantly, although only MAR errors were underreported by
the reporters. The researchers concluded “despite clear
imperfections in the data captured, medication error reporting
tools are effective as a means of collecting reliable information on
errors rapidly and in real time. Our data suggest that
administration errors are at least as common as prescribing errors
in children” (49).
A recent study by Murff et al. of the development of an electronic
trigger tool was based on a cohort study including 424 randomly
selected admissions. All discharge summaries with a trigger word
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present underwent chart review by two independent physician
reviewers. The presence of adverse events was assessed using
structured implicit judgment. A random sample of discharge
summaries without trigger words was reviewed too. It was found
that 59% of the discharge summaries contained trigger words.
Based on discharge summary review, 44.8% (327 of 730) of the
alerted trigger words indicated a possible adverse event. After
medical record review, the tool detected 131 adverse events. The
sensitivity and specificity of the screening tool were 69% and
48%, respectively. The positive predictive value of the tool was
52%. The study showed that the computerised screening method
offers researchers and quality managers a means to routinely
detect adverse events (50).
The use of Trigger Tools appears to increase the rate of ADE
detection approximately 50-fold over traditional reporting
methodologies. This result is based upon a retrospective review of
patient records (52). This result is supported by another study
using the Trigger Tool in a neonate ICU. The researchers found
that the rate of adverse event was substantially higher than
previously described. Many adverse events resulted in permanent
harm and the majority of events were classified as preventable.
Only 8% of the ADEs were identified using traditional voluntary
reporting methods (54).
It has been found, that the use of the trigger tool decreased patient
harm significantly (55)
Evidence of Clinically use of
Standards
The following standard has been used by IHI: “Decrease the
number of ADEs per 1000 doses by 75 percent within 1 year”
Indicator category Theme Related PSI: “Medication Errors”.
Data definitions The total number of ADEs per 1000 doses.
Numerator Description The total number of ADEs identified in a (defined) sample of
patient records.
Denominator Description Total number of medication doses administered to the patient
records reviewed.
Data Source Applying Trigger Tool for measuring the frequency of adverse
drugs events to patient’s records.
Identifying the institutional
context
The assessment of and development of safety related to
medication is important in general clinical and organisational
improvement policies.
Care Setting The indicator applies for medication safety.
Professionals Responsible for
heath care
Doctors and cares.
Lowest Level of Health Care
Delivery Addressed
Individual clinical units or departments.
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Allowance for Patient
Factors
Not applicable.
Stratification by Vulnerable
Populations
Not applicable.
Standard of Comparison Comparison over time can be made. No set time frame for
comparison has been identified.
Scoring Scoring is made according to the Electronic Trigger Tool chosen
e.g. (50)