2033. Patient Safety Indicators: Comparing Rates in VA and Non-VA Settings
Shibei Zhao, MPH, CHQOER, Bedford VAMC, R Elwy, CHQOER, Bedford VAMC, S Loveland, CHQOER, Bedford VAMC, D Tsilimingras, CHQOER, Bedford VAMC, A Elixhauser, Agency for Healthcare Research and Quality, P Romano, University of California, P Rivard, CHQOER, Bedford VAMC, A Rosen, CHQOER, Bedford VAMC

Objectives: Ensuring patient safety is a high priority for the VA. Little is known, however, about patient safety events occurring during hospitalizations in the VA or how the VA compares with non-VA settings. We compared VA and non-VA rates of selected patient safety indicators (PSIs) derived from inpatient administrative databases.

Methods: We constructed three PSIs--complications of anesthesia, decubitus ulcer, and postoperative pulmonary embolism/deep vein thrombosis (PE/DVT)--using the VA Patient Treatment Files and definitions from the Agency for Healthcare Research and Quality (AHRQ). Algorithms were developed using diagnoses, procedures and DRGs from FY2001 discharges, to create valid PSIs that allow comparisons between VA and AHRQ’s Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS). For example, acute bedsections were reconfigured into acute hospitalizations.

Results: Out of the 439,530 acute VA hospitalizations, complications of anesthesia, decubitus ulcers, and PE/DVT occurred in 0.06, 1.52, and 1.24 per 100 discharges, respectively. These rates are comparable to those found in the NIS (0.07, 2.15 and 0.93 per 100 discharges, respectively).

Conclusions: Because we report unadjusted PSI rates, risk-adjusted rates across the VA and between VA/non-VA settings need to be examined before conclusions can be drawn regarding the prevalence of patient safety events in each setting.

Impact: Administrative data may be an efficient and cost-effective screening tool for identifying inpatient safety events in the VA. This tool also may guide healthcare leaders in creating interventions to improve safety in the VA as well as outside the VA.