Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

Garth H. Utter; Joanne Cuny; Pradeep Sama; Michael R. Silver; Patricia A. Zrelak; Ruth Baron; Saskia E. Drösler; Patrick S. Romano

Study

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

September 29, 2010

Utter GH, Cuny J, Sama P, et al. J Am Coll Surg. 2010;211(3):347-354.e1-29.

View more articles from the same authors.

The AHRQ Patient Safety Indicator for postoperative respiratory failure accurately identified cases of clinically diagnosed respiratory failure, with a false-positive rate of approximately 17%.

PubMed citation

Available at

Related Resources From the Same Author(s)

Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement.

November 23, 2011

How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism?

January 13, 2010

Designing an abstraction instrument: lessons from efforts to validate the AHRQ Patient Safety Indicators.

January 12, 2011

Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator.

January 20, 2010

Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90).

January 26, 2022

International comparability of patient safety indicators in 15 OECD member countries: a methodological approach of adjustment by secondary diagnoses.

January 30, 2005

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

November 15, 2017

Application of patient safety indicators internationally: a pilot study among seven countries.

August 5, 2009

Opportunities and challenges for quality and safety applications in ICD-11: an international survey of users of coded health data.

February 17, 2016

ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group.

January 29, 2014

Deriving ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data.

October 12, 2016

Can medical students identify a potentially serious acetaminophen dosing error in a simulated encounter? A case control study.

April 15, 2015

How often are potential patient safety events present on admission?

February 27, 2008

Residency training at a crossroads: duty-hour standards 2010.

November 3, 2010

Can teaching medical students to investigate medication errors change their attitudes towards patient safety?

February 16, 2011

Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study.

March 6, 2005

Team working in intensive care: current evidence and future endeavors.

September 15, 2010

Prolonged hospital stay and the resident duty hour rules of 2003.

January 13, 2010

Safety on the ground: using critical incident technique to explore the factors influencing medical registrars' provision of safe care.

March 20, 2024

Comparison of traditional trigger tool to data warehouse based screening for identifying hospital adverse events.

October 24, 2012

Failure-to-rescue: comparing definitions to measure quality of care.

October 10, 2007

Teaching hospital financial status and patient outcomes following ACGME duty hour reform.

September 26, 2012

Tracking rates of patient safety indicators over time: lessons from the Veterans Administration.

September 6, 2006

Burnout syndrome among healthcare professionals.

December 13, 2017

Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients.

July 1, 2009

Did duty hour reform lead to better outcomes among the highest risk patients?

November 4, 2009

A national profile of patient safety in U.S. hospitals.

March 6, 2005

Evaluation of medication-related clinical decision support alert overrides in the intensive care unit.

May 10, 2017

Using patient safety indicators to estimate the impact of potential adverse events on outcomes.

January 30, 2008

Repurposing clinical decision support system data to measure dosing errors and clinician-level quality of care.

November 11, 2020

Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform.

September 12, 2007

Telemedicine consultations and medication errors in rural emergency departments.

December 11, 2013

Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data.

August 13, 2008

A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.

October 14, 2020

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries.

April 27, 2011

Evaluating the Patient Safety Indicators: how well do they perform on Veterans Health Administration data?

September 7, 2005

Addressing patient safety in rapid response activations for nonhospitalized persons.

July 2, 2014

Teaching hospital five-year mortality trends in the wake of duty hour reforms.

August 7, 2013

Developing critical thinking skills for delivering optimal care

July 28, 2021

November 15, 2017

Improving prescription drug warnings to promote patient comprehension.

January 20, 2010

Prevalence and predictors of delayed clinical diagnosis of Type 2 diabetes: a longitudinal cohort study.

November 14, 2018

The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution?

November 16, 2005

A patient-centered prescription drug label to promote appropriate medication use and adherence.

January 18, 2017

Misunderstanding of prescription drug warning labels among patients with low literacy.

June 7, 2006

Literacy and misunderstanding prescription drug labels.

December 13, 2006

Factors associated with intern fatigue.

October 8, 2008

Validity of selected AHRQ Patient Safety Indicators based on VA National Surgical Quality Improvement program data.

October 15, 2008

Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey.

February 4, 2015

Increasing demands for quality measurement.

November 27, 2013

National hospital ratings systems share few common scores and may generate confusion instead of clarity.

March 11, 2015

The impact of anti-infective drug shortages on hospitals in the United States: trends and causes.

February 8, 2012

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.

April 13, 2016

Variability in pharmacy interpretations of physician prescriptions.

March 4, 2009

What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management?

June 25, 2008

Quality improvement, patient safety, and continuing education: a qualitative study of the current boundaries and opportunities for collaboration between these domains.

April 15, 2015

Patient safety culture, health information technology implementation, and medical office problems that could lead to diagnostic error.

October 3, 2018

The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors.

June 14, 2006

Communication techniques for patients with low health literacy: a survey of physicians, nurses, and pharmacists.

October 24, 2007

Helping patients simplify and safely use complex prescription regimens.

March 16, 2011

Improving patient understanding of prescription drug label instructions.

January 21, 2009

Taking aim at infusion confusion.

April 12, 2006

Creating a culture of safety in the emergency department: the value of teamwork training.

June 12, 2013

Primary medication non-adherence: analysis of 195,930 electronic prescriptions.

February 17, 2010

Medication safety in the operating room: literature and expert-based recommendations.

February 22, 2017

Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice.

February 18, 2015

Implementing an error disclosure coaching model: a multicenter case study.

February 22, 2017

Medication errors among acutely ill and injured children treated in rural emergency departments.

May 2, 2007

Disclosing harmful mammography errors to patients.

December 16, 2009

Partners in our care: patient safety from a patient perspective.

January 12, 2011

Resident and RN perceptions of the impact of a medical emergency team on education and patient safety in an academic medical center.

December 2, 2009

An objective study of the impact of the electronic medical record on outcomes in trauma patients.

November 21, 2012

Compliance to technical guidelines for radiotherapy treatment in relation to patient safety.

May 19, 2010

Trends and patterns in reporting of patient safety situations in transplantation.

February 10, 2016

Barriers and facilitators to nursing handoffs: recommendations for redesign.

June 9, 2010

Patient safety instruction in US health professions education.

December 21, 2011

Resident supervision and patient safety: do different levels of resident supervision affect the rate of morbidity and mortality cases?

August 26, 2015

Using "near misses" analysis to prevent wrong-site surgery.

October 30, 2013

Surgical safety and hospital volume across a wide range of interventions.

September 29, 2010

Preparing clinicians for transitioning patients across care settings and into the home through simulation.

July 25, 2018

Identification of in-hospital complications from claims data. Is it valid?

March 6, 2005

Clinical alarms: improving efficiency and effectiveness.

November 9, 2005

Beyond the prescription: medication monitoring and adverse drug events in older adults.

August 31, 2011

A comparative analysis of incident reporting lag times in academic medical centres in Japan and the USA.

April 28, 2010

Avoiding the unintended consequences of growth in medical care: how might more be worse?

March 6, 2005

Addressing dual patient and staff safety through a team-based standardized patient simulation for agitation management in the emergency department.

June 13, 2018

Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care.

June 17, 2009

To err is human: patient misinterpretations of prescription drug label instructions.

November 7, 2007

Analysing potential harm in Australian general practice: an incident-monitoring study.

March 27, 2005

Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents.

July 11, 2007

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

December 8, 2010

Setting priorities for patient safety: ethics, accountability, and public engagement.

September 2, 2009

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.

July 13, 2016

"Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs.

September 23, 2015

"Mr Smith's been our problem child today...": anticipatory management communication (AMC) in VA end-of-shift medicine and nursing handoffs.

September 16, 2015

Validation of a teamwork perceptions measure to increase patient safety.

August 27, 2014

Case study research: the view from complexity science.

May 4, 2005

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

February 17, 2010

A patient safety checklist for the cardiac catheterisation laboratory.

January 7, 2015

Related Resources

Association of hospital markup with preventable adverse events following pancreatic surgery in the United States.

February 7, 2024

International perspectives on modifications to the surgical safety checklist.

June 21, 2023

Patient Safety Innovations

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

March 15, 2023

In situ simulation as a tool to longitudinally identify and track latent safety threats in a structured quality improvement initiative for SARS-CoV-2 airway management: a single-center study.

February 22, 2023

Association between unmet nonmedication needs after hospital discharge and readmission or death among acute respiratory failure survivors: a multicenter prospective cohort study.

February 15, 2023

WebM&M Cases

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.

October 27, 2022

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States.

June 22, 2022

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

May 25, 2022

Hospital Performance Report.

October 28, 2021

Changes in hospital-acquired conditions and mortality associated with the hospital-acquired condition reduction program.

September 29, 2021

Effects of pharmacist-conducted medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary disease.

June 9, 2021

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

Racial bias in pulse oximetry measurement.

December 20, 2020

Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out.

September 25, 2019

Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy.

September 11, 2019

Ambulatory safety nets to reduce missed and delayed diagnoses of cancer.

August 14, 2019

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

May 8, 2019

A patient safety dilemma: obesity in the surgical patient.

February 15, 2017

Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care.

November 16, 2016

Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass.

October 22, 2014

The "weekend effect" in pediatric surgery—increased mortality for children undergoing urgent surgery during the weekend.

August 6, 2014

The surgical safety checklist and teamwork coaching tools: a study of inter-rater reliability.

July 30, 2014

A case for improving measurement of intraoperative iatrogenic injuries.

July 23, 2014

Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption.

July 23, 2014

Diffusion of surgical innovations, patient safety, and minimally invasive radical prostatectomy.

July 16, 2014

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

June 4, 2014

Failure events in transition of care for surgical patients.

March 5, 2014

Sustainable, effective implementation of a surgical preprocedural checklist: an "attestation" format for all operating team members.

January 15, 2014

Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items.

October 2, 2013

See More About The Topic

Operating Room

Health Care Providers

Quality and Safety Professionals

Pulmonology

Surgery

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site