Table 23 'Accidental Puncture or Laceration'

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).
SImPatIE WP4 – Catalogue of Patients Safety Indicators
62
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.
SImPatIE WP4 – Catalogue of Patients Safety Indicators
63
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.