Failure to Rescue
Please find a pdf-file of Table 39 here
Iatrogenic Pneumothorax
Assesment of Suicidal Risk in Schizophrenic Patients
Monitoring Side Effects of Anti-Psychotic Treatment
PSI 39: Failure to Rescue
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Complications might occur in any care process – though good hospitals
identify such complications quickly and treat them aggressively to
avoid further complications and deaths.
Aim of the PSI The PSI aims at surveillance of patients who die following the
development of a complication.
Level of Determination of
Patient Safety
Safety can be assessed at the individual and the aggregated patient
level.
Source(s) This indicator was originally proposed by Silber et al. as a more
powerful tool than the risk-adjusted mortality rate. The Indicator is
intended to detect true differences in patient outcomes across hospitals.
The underlying premise was that better hospitals are distinguished not
by having fewer adverse occurrences but by more successfully
treatment of patients who experience complications.
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 noted that 1) this PSI is fundamentally different than
other AHRQ PSIs, as it reflects effectiveness in rescuing a patient
from a complication versus preventing a complication and 2) several
adverse incentives may be introduced by implementing this indicator.
In particular, since some type of adjustment may be desirable, this
indicator may encourage the up coding of complications and comorbidities
to inflate the denominator or manipulate risk adjustment.
Others noted that this indicator could encourage irresponsible resource
use and allocation, although this is likely to be a controversial idea.
Finally, panellists emphasised that this indicator should be used
internally by hospitals, as it is not validated for public reporting. (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 155.55
for failure to rescue, the highest rate observed among all AHRQ PSIs.
This PSI was significantly associated with the AHRQ PSIs for Death
SImPatIE WP4 – Catalogue of Patients Safety Indicators
98
in low-mortality DRGs, postoperative pulmonary embolism or deep
vein thrombosis, technical difficulties with procedure and decubitus
ulcer. Significant differences were found for hospitalisations with PSI
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 significant trend for a decreasing 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 failure to rescue 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. In
their present form, two of the indicators, namely, failure to rescue and
death in low-mortality DRGs, are inaccurate for the paediatric
population, do not represent preventable errors in the majority of
paediatric cases, and should not be used to estimate quality of care or
preventable deaths in children's hospitals”(6).
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 – Though special thoughts should be given to application of this
PSI to the paediatric population. (3-6).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Diagnose Specific as well as other Specific PSIs.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
99
Data definitions Number of deaths per 1000 patients having developed specified
complications of care during hospitalisation.
Numerator Description Number of in-hospital deaths. (Discharges with a disposition of
“deceased”).
Denominator Description Number of in-hospital deaths (Discharges with a disposition of
“deceased”) plus discharges 18 years and older with potential
complications of care listed in failure to rescue definition (i.e.,
pneumonia, DVT/PE, sepsis, acute renal failure, shock/cardiac arrest,
or GI hemorrhage/acute ulcer).
Exclude cases:
− age 75 years and older
− neonatal patients in MDC 15
− transferred to an acute care facility (Discharge Disposition = 2)
− transferred from an acute care facility (Admission Source = 2)
− admitted from a long-term care facility (Admission Source=3)
Additional exclusion criteria specific to each diagnosis.
Data Source Administrative data.
Identifying the
institutional context
This PSI is relevant to quality improvement.
Care Setting The PSI applies for high quality health care.
Professionals Responsible
for Health Care
Health care workers.
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 40: Iatrogenic Pneumothorax
Origin: Review of an AHRQ PSI (3)
Dimension Description
Description of Specific
Aspects of Patient Safety
Pneumothorax is a frequent and preventable complication in medical
care. Thus it is a suitable measure of patient safety.
Aim of the PSI This PSI aims at surveillance of cases of pneumothorax caused by
medical care.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) This diagnosis code was proposed by Miller et al. as one component of
a broader indicator for “iatrogenic conditions” in the “Patient Safety
Indicator Algorithms and Groupings.” It was also included as one
component of a broader indicator; “adverse events and iatrogenic
events complications” in AHRQ Version 1.3 HCUP (3).
This AHRQ indicator is defined on both a provider level by including
cases of iatrogenic pneumothorax occurring as a secondary diagnosis
during hospitalisation and on an area level by including all cases of
iatrogenic pneumothorax (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.
Also they team concluded, that the overall usefulness of this PSI is
favourable. In their literature review the AHRQ project team found no
published evidence for this PSI that supports that hospitals; a)
providing better processes of care experience fewer adverse events; b)
providing better overall care experience fewer adverse events; and c)
offering more nursing hours per patient day, better nursing skill mix,
better physician skill mix, or more experienced physicians experience
fewer adverse events (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 1.17
for iatrogenic pneumothorax. This PSI was significantly associated
with the AHRQ PSIs for decubitus ulcer, infections due to medical
care, postoperative haemorrhage or haematoma, postoperative wound
dehiscence and technical difficulties with procedure. Significant
differences were found for hospitalisations with PSI and those without
SImPatIE WP4 – Catalogue of Patients Safety Indicators
101
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 significant increasing 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 iatrogenic pneumothorax 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. Iatrogenic Pneumothorax occur significantly less
often among Hispanic people 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 (3-6).
Evidence of Clinically use
of Standards
No evidence of clinically use of standards was found.
PSI category Diagnose Specific as well as other Specific PSIs.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
102
Data definitions Cases of iatrogenic pneumothorax per 1000 discharges.
Numerator Description Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis
field.
Denominator Description All medical and surgical discharges age 18 years and older defined by
specific DRGs.
Exclude cases:
− ICD-9-CM code of 512.1 in the principal diagnosis field
− MDC 14 (pregnancy, childbirth, and puerperium)
− with an ICD-9-CM diagnosis code of chest trauma or pleural
effusion
− with an ICD-9-CM procedure code of diaphragmatic surgery
repair
− with any code indicating thoracic surgery or lung or pleural biopsy
or assigned to cardiac surgery DRGs
Data Source Administrative data.
Identifying the
institutional context
The impact of iatrogenic pneumothorax 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
Doctors 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 41: Assessment of Suicidal Risk in Schizophrenic Patients
Review of a PSI from the Danish National Indicator Project (NIP) (56-58)
Dimension Description
Description of Specific
Aspects of Patient Safety
Schizophrenic patients have a known higher risk of suicidal behaviour
especially in the time right after discharge from hospital. Thus
assessment of suicidal risk at discharge is an adequate measure of
patient safety.
Aim of the PSI This indicator is intended to survey assessment of suicidal risk in
schizophrenic patients discharged from the hospital.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a PSI of NIP in Denmark. This PSI is part of an indicator set
of nine indicators for surveillance of the quality of care provide for all
Danish inpatients with schizophrenia (58).
Extent of Clinically
Testing
Over mortality in schizophrenic has been found, this over mortality is
mainly due to suicide (59;60).
Mortality and causes of death was investigated in a total Danish
national sample of 9156 schizophrenic patients admitted for the first
time. Suicide accounted for 50% of deaths in men and 35% of deaths in
women. Suicide risk during the first year of follow-up increased by
56%, with a 50% reduction on psychiatric in-patient facilities (60).
This process PSI of NIP is bases on extensive literature studies and
described in detail (61) in agreement with the National Danish
Guidelines for Schizophrenia (62).
The Danish National Indicator Project aims at documenting and
improving the quality of care, the project was established in 2000 as a
nationwide mandatory multidisciplinary quality improvement project.
From 2000 to 2002, disease-specific clinical indicators and standards
were developed for six diseases: stroke, hip fracture, schizophrenia,
acute gastrointestinal surgery, heart failure, and lung cancer).
Indicators and standards have been implemented in all clinical units
and departments in Denmark treating patients with the six diseases.
Results feedback is monthly, and yearly regional and national audit
processes are organised to explain the results and to prepare
implementation of improvements. All results are published in order to
inform the public, and to give patients and relatives the opportunity to
make informed choices (57).
The NIP expert panel concluded that this PSI generally performs well.
Evidence of Clinically use
of Standards
For at least 90% of all patients discharged from hospital assessment of
suicidal risk is documented in the patients record.
PSI category Diagnose Specific as well as other Specific PSIs.
SImPatIE WP4 ¨C Catalogue of Patients Safety Indicators
104
Data definitions Patients with a primary or secondary diagnosis of schizophrenia (Any
ICD-10 F.20 diagnosis) discharged form hospital.
Numerator Description Assessed and documented suicidal risk within the last week prior to
discharge. Assessment should include an evaluation of depressive
symptoms and the risk of suicide.
Denominator Description Patients discharges from hospital with an ICD-10 diagnosis of any F.20
diagnose (F20.0-F20.99)
Data Source Patient records.
Identifying the
institutional context
The impact of suicides in schizophrenic patients makes this PSI
important in quality improvement policies.
Care Setting The PSI applies for quality health care.
Professionals Responsible
for Health Care
Doctors/Nurses.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
Stratification according to :
− Age: 1) Patients ˇÝ 18 years and 2) patients < 18 years
− Psychopathological status: 1) the patient has been diagnosed
within the last 12 month (incident) or 2) the patient was diagnosed
more than 12 month ago (prevalent)
Standard of Comparison No specific time standards given, but yearly comparison has shown to
be good.
Scoring NIP has software for scoring the PSI. Cumulated scores are subjected
to auditing.
On the basis of the first experience with NIP, a number of requirements
has been specified for a forthcoming second generation of clinical
database system has been described. The requirements regard:
coordination, rational management and experience-based development
of IT systems for the clinical databases and integration with present
and forthcoming systems including electronic patient record systems
(63).
PSI 42: Monitoring Side effects of Anti-psychotic treatment
Review of a PSI from the Danish National Indicator Project (NIP) (56-58)
Dimension Description
Description of Specific
Aspects of Patient Safety
Antipsychotic treatment often has side effects with a substantial
qualitative and quantitative harmful impact. Thus assessment of weight
gaining, sexuality, sedation and neurological symptoms must be
assessed in order to give adequate treatment and obtain compliance.
Thus is an adequate measure of patient safety.
Aim of the PSI This PSI is intended to survey the practice screening for side effects in
schizophrenic patients receiving anti-psychotic treatment.
Level of Determination of
Patient Safety
Safety is assessed at the aggregated patient level.
Source(s) Originally a PSI of NIP in Denmark. This PSI is part of an indicator set
of nine indicators for surveillance of the quality of care provide for all
Danish inpatients with schizophrenia (58).
Extent of Clinically
Testing
The Danish National Indicator Project aims at documenting and
improving the quality of care, the project was established in 2000 as a
nationwide mandatory multidisciplinary quality improvement project.
From 2000 to 2002, disease-specific clinical indicators and standards
were developed for six diseases: stroke, hip fracture, schizophrenia,
acute gastrointestinal surgery, heart failure, and lung cancer).
Indicators and standards have been implemented in all clinical units
and departments in Denmark treating patients with the six diseases.
Results feedback is monthly, and yearly regional and national audit
processes are organised to explain the results and to prepare
implementation of improvements. All results are published in order to
inform the public, and to give patients and relatives the opportunity to
make informed choices (57).
This process PSI of NIP is bases on extensive literature studies and
described in detail (61) in agreement with the National Danish
Guidelines for Schizophrenia (62).
The NIP expert panel concluded that this PSI generally performs well.
Evidence of Clinically use
of Standards
Side effects are monitored for 100% of all patients receiving
antipsychotic treatment.
PSI category Diagnose Specific as well as other Specific PSIs.
Data definitions All patients with a primary or secondary diagnosis of schizophrenia;
any ICD-10 F.20 diagnosis receiving antipsychotic treatment.
Numerator Description Assessed side effects of antipsychotic treatment.
Denominator Description Patients discharges from hospital with an ICD-10 diagnosis of any F20
– diagnose (F20.0-F20.99)
SImPatIE WP4 – Catalogue of Patients Safety Indicators
106
Data Source Patient records.
Identifying the
institutional context
The consequences of side effects of antipsychotic treatment in
schizophrenic patients make this PSI important in quality improvement
policies.
Care Setting The PSI applies for quality health care.
Professionals Responsible
for Health Care
Authorised health care workers.
Lowest Level of Health
Care Delivery Addressed
Individual clinical department.
Allowance for Patient
Factors
No risk adjustment described.
Stratification by
Vulnerable Populations
Stratification according to :
− Age: 1) Patients ≥ 18 years and 2) patients < 18 years
− Psychopathological status: 1) the patient has been diagnosed
within the last 12 month (incident) or 2) the patient was diagnosed
more than 12 month ago (prevalent)
− Treatment status: 1) the patient has been in treatment (ambulatory
care or inpatient) for the previous year or 2) the patient is
discharged from in-patient/out-patient treatment
− Type of side effects:
• Neurological side effects
• Sedation
• Gaining weight
• Sexual side effects
• Fasting blood sugar
Standard of Comparison No specific time standards given, but yearly comparison has shown to
be good.
Scoring NIP has software for scoring the PSI. Cumulated scores are subjected
to auditing.
On the basis of the first experience with NIP, a number of requirements
has been specified for a forthcoming second generation of clinical
database system has been described. The requirements regard:
coordination, rational management and experience-based development
of IT systems for the clinical databases and integration with present
and forthcoming systems including electronic patient record systems
(63).
