Validating and applying AHRQ patient safety indicators in the veterans health administration
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Patient safety has become a national priority since the Institute of Medicine report "To Err is Human." The Agency for Healthcare Research and Quality developed the Patient Safety Indicators (PSIs) to screen for potentially preventable patient safety events in the inpatient setting using hospital administrative data. We undertook three studies that sought to validate and apply selected PSis in the Veterans Health Administration (VA) to assess quality/safety of care. The first study was to assess the criterion validity (i.e., how well this indicator identifies true events) of PSI #5 "Foreign Body Left During Procedure" using chart review as the gold standard. Among 93 cases flagged by this PSI, 42 were true positives, yielding a positive predictive value of 45% (95% CI, 35%-56%). False positives were due to foreign bodies that were present on admission (57%) or coding errors (43%). The second study was to examine the attributional validity (i.e., whether true PSI events reflect process of care problems) of PSis #14 "Postoperative Wound Dehiscence" (PWD) and #15 "Accidental Puncture or Laceration" (APL) based on chart-abstracted data. Among 95 case-control pairs for each PSI, we were unable to confirm the association between examined processes of care and the occurrence of PWD/APL events. Documentation of process details was frequently missing in medical charts. The third study applied individual PSIs to measure the safety of care that Veterans received in the VA and in the private sector under Medicare financing. One important finding is that among Veterans who were concurrently obtaining inpatient care in both healthcare systems, the rates for PSIs that reflect areas prioritized by the VA for quality improvement (i.e., "Pressure Ulcer," "Central Venous Catheter-Related Bloodstream Infections," and "Postoperative Sepsis") were significantly lower for VA hospitalizations compared to Medicare hospitalizations. These three studies together provide useful insights into ways in which the PSIs can be applied to assess quality of care. The first two studies demonstrate two aspects of PSI validity, and the third one uses the PSis as outcome measures to compare patient safety in and outside the VA.
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