Table 25 'Medical Equipment-Related Adverse Events'

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
SImPatIE WP4 – Catalogue of Patients Safety Indicators
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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.