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| The Vermont Health Care Quality Report 2008 |
Ch2: Measuring Quality of Care Ch3: Chronic Illness in Vermont
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Patient Safety Indicators (click for printable PDF) How can the patient safety indicators be used? healthcare should be safe. Patients should not be injured by the care that is intended to help them. Safety is the first improvement aim for healthcare recommended by the Institute of Medicine (IOM).[1] Freedom from accidental injury should be self-evident in Vermont’s healthcare system. As our healthcare system has grown more complex, the potential for medical errors has increased. Improving the safety of healthcare has recently come to the forefront of quality improvement efforts both nationally and locally. From two studies of adverse events occurring in hospitals, it is estimated that as many as 44,000 to 98,000 people die as the result of medical errors in the US each year. More people die from medical errors in the US than motor vehicle accidents (43,000), breast cancer, (42,000), or AIDS (17,000).1 Measuring the safety of our healthcare system is a new endeavor. “What is safety?” and “How can it be measured?” are both active and evolving discussions. One pervasive obstacle to improving the safety of the health system is that the current healthcare culture does not encourage reporting of errors and near-misses, rather, the typical reaction is to blame and shame the individuals involved when something goes wrong. This shame and blame atmosphere results in under reporting of errors and near misses, and opportunities to identify needed improvements and prevent repeated errors are lost. An untapped resource for improving safety is to make healthcare more transparent to consumers and patients and in so doing recruit those being cared for in efforts to make care safer. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are a tool that takes advantage of hospital administrative data to identify and measure the safety of hospital care through analysis of inpatient discharge data. Examining rates for a single year provides a snapshot view of the hospital performance. Trending these indicators over time, affords the ability to assess whether observed differences are likely the result of normal variation (i.e., rates differ from average in a single year) or if observed differences reflect a pattern (i.e., rates differ from average for longer periods of time). Subsequently this longitudinal perspective may identify hospitals as a model for excellence or areas that may benefit from quality improvement initiatives. What are the patient safety indicators? These provider-level indicators are measures of the potentially preventable complications for patients who received their initial care and the complication of care within the same hospitalization. Provider-level indicators include only those cases where a secondary diagnosis code identifies a potentially preventable complication or adverse event.
There are several other provider-level AHRQ Patient Safety Indicators that are not being presented in this year’s Quality Report due to the fact that the results of these measures are not severity adjusted: Death in Low-Mortality DRGs Foreign Body left during Procedure Obstetric Trauma – Cesarean Delivery Transfusion Reaction There are another seven area-level Patient Safety Indicators that are not being presented because they are not severity adjusted. These Indicators track similar events to the provider-level indicators, but use county population data as a denominator rather than hospital discharges as are used in the provider-level measures: Accidental Puncture or Laceration Foreign Body left during Procedure Iatrogenic Pneumothorax Postoperative Hemorrhage or Hematoma Postoperative Wound Dehiscence Selected Infections Due to Medical Care Transfusion Reaction
[1] Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press. 2001. |
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