1. Patient Safety Indicators A way to improve health care Serviço de Bioestatística e Informática Médica – Introdução à Medicina II

2. Patient Safety Indicators: A way to Improve Healthcare According to the Institute of Medicine, Patient Safety is: “freedom from accidental injury due to medical care, or medical errors.”

3. Patient Safety Indicators: A way to Improve Healthcare Key words Patient safety indicators Quality indicators Health status indicators Provider-level indicators Area-level indicators

4. What are Patient Safety Indicators (PSIs)? Patient Safety Indicators: A way to Improve Healthcare Subset of quality indicators; Ways of measuring the quality of health care services during or after hospitalization; Concerned only about preventable situations.

5. PSI’s Provider-level indicators The problem occurs within the same hospitalization. Area-level indicators The problem occurs within a given area.

6. PSI’s Patient Safety Indicators - Provider PSI Number ▫Complications of Anesthesia 1 ▫Death in Low-Mortality DRGs 2 ▫Decubitus Ulcer 3 ▫Failure to Rescue 4 ▫Foreign Body Left During Procedure 5 ▫Iatrogenic Pneumothorax 6 ▫Selected Infections Due to Medical Care 7 ▫Postoperative Hip Fracture 8 ▫Postoperative Hemorrhage or Hematoma 9 ▫Postoperative Physiologic and Metabolic Derangements 10 ▫Postoperative Respiratory Failure 11 ▫Postoperative Pulmonary Embolism or Deep Vein Thrombosis 12 ▫Postoperative Sepsis 13 ▫Postoperative Wound Dehiscence 14 ▫Accidental Puncture or Laceration 15 ▫Transfusion Reaction 16 ▫Birth Trauma – Injury to Neonate 17 ▫Obstetric Trauma – Vaginal with Instrument 18 ▫Obstetric Trauma – Vaginal without Instrument 19 ▫Obstetric Trauma – Cesarean Delivery 20 Patient Safety Indicators: A way to Improve Healthcare

7. Patient Safety Indicators - Area PSI Number ▫Foreign Body Left During Procedure 21 ▫Iatrogenic Pneumothorax 22 ▫Selected Infections Due to Medical Care 23 ▫Postoperative Wound Dehiscence 24 ▫Accidental Puncture or Laceration 25 ▫Transfusion Reaction 26 ▫Postoperative Hemorrhage or Hematoma 27 Patient Safety Indicators: A way to Improve Healthcare

8. Types of Data Administrative data from the National System of Health ▫Data from  hospitalizations  Diagnoses  Procedures  Age  Gender  Admission source  Hospital classification Patient Safety Indicators: A way to Improve Healthcare

9. Concerning all these items and the data we will have access to, our work is divided in… Analysis of hospitals, organized in groups Comparative analysis between groups of hospitals Analysis of data per year, from 2000 to 2005 Comparison between Provider-level indicators and Area-level indicators, in the cases of the ones which appear in both groups. Patient Safety Indicators: A way to Improve Healthcare

10. Type C – administrative groups 1 Central hospital 2 County* Hospital 3 County* Hospital level 1 Type A – economical groups [ in group I are included the most complex, specialized and technologically advanced hospitals ] Group I Group II Group III Group IV Hospital divisions we used *meaning the portuguese administrative division “distrito” Patient Safety Indicators: A way to Improve Healthcare

11. Objectives To conclude about the most prevalent PSI’s To identify the safety characteristics of each group of hospitals To evaluate the evolution of the PSI’s in the various groups of hospitals Patient Safety Indicators: A way to Improve Healthcare

12. Key questions What are the main differences between the various groups of hospitals? Which are the most safety hospitals? Which group of hospitals suffered the biggest evolution? Which are the most prevalent PSI’s? Patient Safety Indicators: A way to Improve Healthcare

13. Participants and methods Target population: inpatient episodes from public Portuguese hospitals, with discharges between years 2000 and 2005 Sample: no sample (we will use all the data) Inclusion criteria: having attended the National Service of Health Unity of analysis: each group of hospitals Patient Safety Indicators: A way to Improve Healthcare

14. Data withdrawn from the AHRQ website Patient Safety Indicators: A way to Improve Healthcare

15. PSI 5 – Foreign Body Left During Procedure, Secondary Diagnosis Field Numerator ICD-9-CM codes for foreign body left in during procedure in any secondary diagnosis Denominator All surgical and medical discharges 18 years and older or MDC 14 defined by Surgical and Medical Discharge DRGs. Exclude patients with ICD-9-CM codes for foreign body left in during procedure in the principal diagnosis field or secondary diagnosis present on admission. General result: PSI 5 = 0,0625 (Rate per 1000 cases) Patient Safety Indicators: A way to Improve Healthcare

16. Male = 0,077 Female = 0,052 AHRQ Rates: Male = 0,084 Female = 0,086 I = 0,1435 II = 0,0602 III = 0,0474 IV = 0,0508

17. Central Hospital = 0,0773 County Hospital = 0,0522 County Hospital Level 1 = 0,0474

18. PSI 6 – Iatrogenic Pneumothorax, Secondary Diagnosis Numerator Discharges with ICD-9-CM code of 512.1 in any secondary diagnosis field Denominator Include all surgical and medical discharges 18 years and older or MDC 14 defined by Surgical and Medical Discharge DRGs. Exclude cases with: ICD-9-CM code of 512.1 in the principal diagnosis field or secondary diagnosis, MDC 14 diagnosis code of chest trauma or pleural effusion ICD-9-CM procedure code of diaphragmatic surgery repair any code indicating thoracic surgery, lung or pleural biopsy, or assigned to cardiac surgery DRGs General results PSI 6 = 0,297 (Rate per 1000 cases) Patient Safety Indicators: A way to Improve Healthcare

19. I = 0,5195 II = 0,4110 III = 0,0344 IV = 0,2093 Male = 0,3573 Female = 0,2413 AHRQ Rates: Male = 0,506 Female = 0,622

20. Central Hospital = 0,435 County Hospital = 0,2127 County Hospital Level 1 = 0,034 Patient Safety Indicators: A way to Improve Healthcare

21. PSI 7 – Selected Infections due to Medical Care, Secondary Diagnosis Field Numerator Discharges with ICD-9-CM code of 999.3 or 996.62 in any secondary diagnosis field Denominator All surgical and medical discharges 18 years and older or MDC 14 defined by Surgical and Medical Discharge DRGs. Exclude cases with: ▫with ICD-9-CM code of 999.3 or 996.62 in the principal diagnosis field or secondary diagnosis present on admission, if known ▫length of stay less than 2 days ▫any code for immunocompromised state or cancer ▫cancer DRG General results PSI 7 = 0,671 (Rate per 1000 cases) Patient Safety Indicators: A way to Improve Healthcare

22. Male = 0,9877 Female = 0,4686 I = 1,1944 II = 1,1194 III = 0,2002 IV = 0,4375 AHRQ Rates: Male = 2,716 Female = 1,744

23. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 1,0333 County Hospital = 0,4830 County Hospital Level 1 = 0,2002

24. PSI 14 – Postoperative Wound Dehiscence Numerator Discharges with ICD-9-CM code for reclosure of postoperative disruption of abdominal wall Denominator Include all abdominopelvic surgical discharges age 18 and older. Exclude case: ▫where length of stay is less than 2 days ▫with immunocompromised state ▫MDC 14 General results PSI 14 = 7,16 (Rate per 1000 cases) Patient Safety Indicators: A way to Improve Healthcare

25. I = 6,0885 II = 8,0627 III = 1,9741 IV = 7,4808 Male = 9,3522 Female = 5,3288 AHRQ Rates: Male = 4,311 Female = 0,995

26. Central Hospital = 7,2904 County Hospital = 7,6758 County Hospital Level 1 = 1,9741 Patient Safety Indicators: A way to Improve Healthcare

27. PSI 15 – Accidental Puncture or Laceration, Secondary Diagnosis Field Numerator Discharges with ICD-9-CM code denoting accidental cut, puncture, perforation or laceration during a procedure. Denominator All surgical and medical discharges 18 years and older or MDC 14 defined by Surgical and Medical Discharge DRGs. Exclude cases with ▫ICD-9-CM code denoting technical difficulty in the principal diagnosis field or secondary diagnosis present on admission ▫MDC 14. General results PSI 15 = 2,048 (Rate per 1000 cases) Patient Safety Indicators: A way to Improve Healthcare

28. Male = 1,9776 Female = 2,1138 I = 4,1782 II = 2,6590 III = 0,6860 IV = 1,3434 AHRQ Rates: Male = 2,942 Female = 4,080

29. Central Hospital = 3,0253 County Hospital = 1,3657 County Hospital Level 1 = 0,6860 Patient Safety Indicators: A way to Improve Healthcare

30. PSI 16 – Transfusion Reaction, Secondary Diagnosis Numerator Discharges with ICD-9-CM codes for transfusion reaction. Denominator Include all surgical and medical discharges 18 years and older or MDC 14 defined by Surgical and Medical Discharge DRGs. Exclude cases with preexisting transfusion resction. General results PSI 16 = 0,004 (Rate per 1000 cases) Patient Safety Indicators: A way to Improve Healthcare

31. Male = 0,0073 Female = 0,0024 Group I = 0,0062 Group II = 0,0038 Group III = 0,01 Group IV = 0,0038 AHRQ Rates: Male = 0,003 Female = 0,005

32. Patient Safety Indicators: A way to Improve Healthcare Central Hospital = 0,0038 County Hospital = 0,0043 County Hospital Level 1 = 0,01

33. General Comparisons

37. Obtained Rates (per 1000 cases) AHRQ rates (per 1000 cases) PSI 50,0630,085 PSI 60,3230,570 PSI 70,6712,087 PSI 147,162,101 PSI 152,0483,563 PSI 160,004 Patient Safety Indicators: A way to Improve Healthcare

38. Some conclusions Generally, the men were more affected by these medical errors than women. Although we predicted the other way, the rate of complications has shown higher in Type I Hospitals than in less developed, economically and technically, hospitals. Overall, Central Hospitals show a higher rate of medical error than smaller hospitals. Concerning the time period we are analyzing, there seems to be an increase of the PSI rates along the years. Comparing with the reference values, our rates appear to be very similar or even better than the American rates, published by the AHRQ. Of the six PSI presented here, PSI 14 - Postoperative Wound Dehiscence - is the most prevalent. Patient Safety Indicators: A way to Improve Healthcare

39. References Patient Safety Indicators: A way to Improval AHRQ Quality Indicators. Guide to Patient Safety Indicators 2007. http://www.qualityindicators.ahrq.govhttp://www.qualityindicators.ahrq.gov MATTKE S, EPSTEIN A M, LEATHERMAN S. The OECD Health Care Quality Indicators Project: history and background. International Journal for Quality in Health Care. September 2006; 18 Suppl 1:1-4. MCLOUGHLIN V, MILLAR J, MATTKE S, FRANCA M, JONSSON P M, SOMEKH D, BATES D. Selecting indicators for patient safety at the health system level in OECD countries. International Journal for Quality in Health Care. 2006; 18 Suppl 1:14-20. MILLER M R, ZHAN C. Pediatric Patient Safety in Hospitals: A National Picture in 2000. Pediatrics. 2004; 113: 1741-1746. MILLER M R, ELIXHAUSER A, ZHAN C. Patient Safety Events During Pediatrics Hospitalizations. Pediatrics. 2003; 111: 1358-1366 SEDMAN A, HARRIS J M, SCHULZ K, SCHWALENSTOCKER E, REMUS D, SCANLON M, BAHL V. Relevance of the Agency for Healthcare Research and Quality Patient Safety Indicators for Children’s Hospitals. Pediatrics. 2005; 115: 135-145.

40. SCULLY K W, LYMAN J A, STUKENBORG G J. Improving Quality Measurement Using Multiple Data Sources. AMIA. 2003: 1001. LONGO D R, HEWETT J E, GE B, SCHUBERTS S. The Long Road to Patient Safety. Jama. 2005; 294: 2858-65. MILLER M R, ELIXHAUSER A, ZHAN C, MEYER G S. Patient Safety Indicators: Using Administrative Data to Identify Potential Patient Safety Concerns. HSR: Health Services Research. 2001; 36: 5-6. WOLLERSHEIM H, HERMENS R, HULSCHER M, BRASPENNING J, OUWENS M, SCHOUTEN J, MARRES H, DIJKSTRA R, GROL R. Clinical indicators: development and applications. The Netherlands Journal of Medicine. 2007; 65:15-22. RUNCIMAN W B. Shared meanings: preferred terms and definitions for safety and quality concepts. MJA. 2006; 184 Suppl 10: S41-3. SCOBIE S, THOMSON R, MCNEIL J J, PHILLIPS P A. Measurement of the safety and quality of health care. MJA. 2006; 184 Suppl 10: S51-5. AHRQ Quality Indicators. Patient Safety Indicators: Technical Specifications 2007. http://www.qualityindicators.ahrq.gov. http://www.qualityindicators.ahrq.gov HealthGrades. 2004. Patient Safety in American Hospitals. p.1-22 Bagian,J.P., A. K. Rosen, A.N. West, and W.B. Weeks.2008. Comparing measures of patient safety for inpatient care provided to veterans within and outside the VA system in New York. Qual. Safe. Health Care. 17:58-64

41. Turma 22 Ana Filipe Rocha Ana Rita Santos Carolina Cardoso Eva Brysch Joana Rodrigues Marina Pinto Pedro Vaz Sara Pinto Vasco Marques Patient Safety Indicators: A way to Improval