Examining the impact of the AHRQ Patient Safety Indicators (PSIs) on the Veterans Health Administration: the case of readmissions.
Approach to Improving Safety
Setting of Care
Patients who experience a preventable adverse event while hospitalized may experience prolonged hospitalizations and excess morbidity and mortality. However, as this study demonstrates, the deleterious effects of experiencing a medical error may extend after hospitalization. Examining data from the Veterans Affairs system, researchers found that the risk of readmission within 30 days after discharge increased by 22% if an adverse event (measured by the AHRQ Patient Safety Indicators) occurred during the index hospitalization. This finding corroborates a prior study in surgical patients. Although it is difficult to predict readmission risk in an individual patient, this study indicates that preventable adverse events may be considered a risk factor for readmission.