Patient Safety and Quality

Patient Safety Indicators may be useful screening tools in Veterans Health Administration hospitals

The Patient Safety Indicators (PSIs), an administrative data-based tool developed by the Agency for Healthcare Research and Quality, are increasingly being used to measure potential in-hospital patient safety problems. PSIs may be useful as patient safety screening tools in Veterans Health Administration (VA) hospitals, concludes a new study. PSIs use hospital discharge data to flag potential safety problems.

In this study, researchers, including Anne Elixhauser, Ph.D., of the Center for Delivery, Organization, and Markets, Agency for Healthcare Research and Quality, applied AHRQ PSI software to VA administrative data to identify potential instances of compromised patient safety. Overall, they identified 11,411 potentially preventable PSI events in the VA nationwide in 2001. Slightly more than 2 percent of patients in VA hospitals experienced a PSI event. These low rates are consistent with the low incidence of PSI events reported in other studies. PSI rates per 1,000 discharges ranged from 0.007 for "transfusion reaction" to 155.5 for "failure to rescue" (failure to keep patients from dying of complications, such as pneumonia or blood infections).

The most frequent PSI events were failure to rescue, decubitus ulcer, and postoperative pulmonary embolism (blood clot lodged in the lungs) or deep vein thrombosis (blood clot in a deep leg vein). Patients hospitalized with PSI events had longer lengths of stay, higher mortality, and higher costs than those who did not experience PSI events.

See "Evaluating the patient safety indicators: How well do they perform on Veterans Health Administration data?" by Amy K. Rosen, Ph.D., Peter Rivard, M.H.S.A., Shibei Zhao, M.P.H., and others, in the September 2005 Medical Care 43(9), pp. 873-884. Reprints (AHRQ Publication No. 06-R012) are available from the AHRQ Publications Clearinghouse.

Return to Contents
Proceed to Next Article