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Journal Article > Study
Do the AHRQ Patient Safety Indicators flag conditions that are present at the time of hospital admission?
Bahl V, Thompson MA, Kau T-Y, Hu HM, Campbell DA Jr. Med Care. 2008;46:516-522.
The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) were designed to reflect the quality of inpatient care by triggering cases for review using administrative data and examining potentially preventable complications. With an increasing focus on withholding payment for complications of care not present on admission (POA), efforts to make this important distinction continue. This study applied the use of PSIs with and without a POA variable and discovered that event rates were significantly lower for five PSIs using the added variable (decubitus ulcer, foreign body left in, selected infections due to medical care, and postoperative derangements and thromboembolic events). These findings suggest that use of standard PSIs will overstate the number of hospital complications in failing to take into account those clearly POA. The authors conclude that unadjusted PSIs should not be used to profile hospital performance or determine reimbursement.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Golden, CO: HealthGrades, Inc.; April 2009.
This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.