Patient Safety Indicators by

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

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.”

Key words
Patient safety indicators
Quality indicators
Health status indicators
Provider-level indicators
Area-level indicators

What are Patient Safety Indicators (PSIs)?
•Subset of quality indicators;
•Ways of measuring the quality of health care services during
or after hospitalization;
•Concerned only about preventable situations.

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

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 - 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

Types of Data
• Administrative data from the National System of Health
▫ Data from
 hospitalizations
 Diagnoses
 Procedures
 Age
 Gender
 Admission source
 Hospital classification

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.

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”

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

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?

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

Data withdrawn from the AHRQ website

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)

PSI 5 - Gender per year
0
0,02
0,04
0,06
0,08
0,1
0,12
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Male Female
PSI 5 - Economic Groups per year
0
0,05
0,1
0,15
0,2
0,25
0,3
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Group I Group II Group III Group IV
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

PSI 5 - Administrative Groups per year
0
0,02
0,04
0,06
0,08
0,1
0,12
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Central Hospital County Hospital County Hospital Level 1
Central Hospital = 0,0773
County Hospital = 0,0522
County Hospital Level 1 = 0,0474

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

0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
0,4
0,45
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Male Female
0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
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

PSI 6 - Administrative Group per year
0
0,1
0,2
0,3
0,4
0,5
0,6
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases

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
• 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

0
0,2
0,4
0,6
0,8
1
1,2
1,4
1,6
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
0
0,2
0,4
0,6
0,8
1
1,2
1,4
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Male Female
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

0
0,2
0,4
0,6
0,8
1
1,2
1,4
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases

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

0
2
4
6
8
10
12
14
16
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Male Female
0
2
4
6
8
10
12
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
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

PSI 14 - Administrative Group per year
0
2
4
6
8
10
12
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases

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
• 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

0
0,5
1
1,5
2
2,5
3
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Male Female
0
1
2
3
4
5
6
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
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

0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases

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

0
0,001
0,002
0,003
0,004
0,005
0,006
0,007
0,008
0,009
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
Male Female
0
0,005
0,01
0,015
0,02
0,025
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases
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

0
0,005
0,01
0,015
0,02
0,025
2000 2001 2002 2003 2004 2005
Year
Rateper1000cases

General Comparisons
Gender General Comparison
0,0
0,5
1,0
1,5
2,0
2,5
PSI 5 PSI 6 PSI 7 PSI 15
PSIRate
Male
Female
PSI 14 per Year
0
1
2
3
4
5
6
7
8
9
10
PSI14
PSIRate
Male
Female

Year General Comparison
-0,1
0,1
0,3
0,5
0,7
0,9
1,1
1,3
1,5
1,7
1,9
2,1
2,3
2,5
PSIRates
2000
2001
2002
2003
2004
2005
PSI 14 per Year
0
1
2
3
4
5
6
7
8
9
10
PSI 14
PSIRate
2000
2001
2002
2003
2004
2005

Economical Groups General Comparison
0,0
0,5
1,0
1,5
2,0
2,5
3,0
3,5
4,0
4,5
PSIRate
I
II
III
IV
PSI 14 per Economical Group
0
1
2
3
4
5
6
7
8
9
PSI 14
PSIRate
I
II
III
IV

Administrative Groups General Comparison
0,0
0,5
1,0
1,5
2,0
2,5
3,0
PSIRate
Central Hospital
County Hospital
County Hospital Level 1
PSI 14 per Administrative Group
0
1
2
3
4
5
6
7
8
PSI 14
PSIRate
Central Hospital
County Hospital
County Hospital Level 1

Obtained Rates
(per 1000
cases)
AHRQ rates
(per 1000
cases)
PSI 5 0,063 0,085
PSI 6 0,323 0,570
PSI 7 0,671 2,087
PSI 14 7,16 2,101
PSI 15 2,048 3,563
PSI 16 0,004 0,004

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.

References
Patient Safety Indicators: A way to Improval
• AHRQ Quality Indicators. Guide to Patient Safety Indicators 2007. http://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.

• 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.
• 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

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      Ana Filipe Rocha
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