Refinement and Validation of the AHRQ Patient Safety Indicators

Developed by UC-Stanford Evidence Based Practice CenterDeveloped by UC-Stanford Evidence Based Practice Center

Funded by the Agency for Healthcare Research and QualityFunded by the Agency for Healthcare Research and Quality

EPC Team (PSI Development)

PI: Kathryn McDonald, M.M., StanfordPI: Kathryn McDonald, M.M., StanfordPatrick Romano, M.D., M.P.H, UC DavisPatrick Romano, M.D., M.P.H, UC DavisJeffrey Geppert, J.D., Ed.M., StanfordJeffrey Geppert, J.D., Ed.M., StanfordSheryl Davies, M.A., Stanford Sheryl Davies, M.A., Stanford Bradford Duncan, M.D., M.A., Stanford Bradford Duncan, M.D., M.A., Stanford Kaveh G. Shojania, M.D., UCSFKaveh G. Shojania, M.D., UCSF

Support of Quality Indicators

PI: Kathryn McDonald, M.M., StanfordPI: Kathryn McDonald, M.M., StanfordPatrick Romano, M.D., M.P.H, UC DavisPatrick Romano, M.D., M.P.H, UC DavisJeffrey Geppert, J.D. Ed.M., StanfordJeffrey Geppert, J.D. Ed.M., StanfordSheryl Davies, M.A., StanfordSheryl Davies, M.A., StanfordMark Gritz, PhD, Battelle Mark Gritz, PhD, Battelle Greg Hubert, BattelleGreg Hubert, BattelleDenise Remus, Ph.D., RN, AHRQDenise Remus, Ph.D., RN, AHRQ

AcknowledgmentsAcknowledgments

Funded by AHRQFunded by AHRQ Contract No. 290-97-0013 Contract No. 290-97-0013 Support of Quality Indicators Contract No. 290-02-0007 Support of Quality Indicators Contract No. 290-02-0007

Data used for analyses:Data used for analyses:Nationwide Inpatient Sample (NIS), 1995-2000. Healthcare Cost Nationwide Inpatient Sample (NIS), 1995-2000. Healthcare Cost

and Utilization Project (HCUP), Agency for Healthcare and Utilization Project (HCUP), Agency for Healthcare Research and QualityResearch and Quality

State Inpatient Databases (SID), 1997 (19 states). Healthcare State Inpatient Databases (SID), 1997 (19 states). Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and QualityResearch and Quality

For more information:For more information:http://www.qualityindicators.ahrq.http://www.qualityindicators.ahrq.govgov

AcknowledgmentsAcknowledgments We gratefully acknowledge the data organizations in participating We gratefully acknowledge the data organizations in participating

states that contributed data to HCUP and that we used in this study: states that contributed data to HCUP and that we used in this study: the Arizona Department of Health Services; California Office of the Arizona Department of Health Services; California Office of Statewide Health and Development; Colorado Health and Hospital Statewide Health and Development; Colorado Health and Hospital Association; CHIME, Inc. (Connecticut); Florida Agency for Health Association; CHIME, Inc. (Connecticut); Florida Agency for Health Care Administration; Georgia Hospital Association; Hawaii Health Care Administration; Georgia Hospital Association; Hawaii Health Information Corporation; Illinois Health Care Cost Containment Information Corporation; Illinois Health Care Cost Containment Council; Iowa Hospital Association; Kansas Hospital Association; Council; Iowa Hospital Association; Kansas Hospital Association; Maryland Health Services Cost Review Commission; Massachusetts Maryland Health Services Cost Review Commission; Massachusetts Division of Health Care Finance and Policy; Missouri Hospital Division of Health Care Finance and Policy; Missouri Hospital Industry Data Institute; New Jersey Department of Health and Senior Industry Data Institute; New Jersey Department of Health and Senior Services; New York State Department of Health; Oregon Association Services; New York State Department of Health; Oregon Association of Hospitals and Health Systems; Pennsylvania Health Care Cost of Hospitals and Health Systems; Pennsylvania Health Care Cost Containment Council; South Carolina State Budget and Control Containment Council; South Carolina State Budget and Control Board; Tennessee Hospital Association; Utah Department of Health; Board; Tennessee Hospital Association; Utah Department of Health; Washington State Department of Health; and Wisconsin Department Washington State Department of Health; and Wisconsin Department of Health and Family Service.of Health and Family Service.

Rationale for the PSIsRationale for the PSIs

Background: Perceived need for an inexpensive Background: Perceived need for an inexpensive patient safety surveillance system based on patient safety surveillance system based on readily available datareadily available data

UC-Stanford EPC charge: To review and improve UC-Stanford EPC charge: To review and improve the evidence base related to potential patient the evidence base related to potential patient safety indicators (PSIs) that can be ascertained safety indicators (PSIs) that can be ascertained from data elements in a standardized, multi-from data elements in a standardized, multi-state health data system, the Healthcare Cost state health data system, the Healthcare Cost and Utilization Project (HCUP).and Utilization Project (HCUP).

Literature review to find Literature review to find candidate indicatorscandidate indicators MEDLINE/EMBASE search guided by medical MEDLINE/EMBASE search guided by medical

librarians at Stanford and NCPCRD (UK)librarians at Stanford and NCPCRD (UK) Few examples described in peer reviewed journalsFew examples described in peer reviewed journals

Iezzoni et al.’s Complications Screening Program Iezzoni et al.’s Complications Screening Program (CSP)(CSP)

Miller et al.’s Patient Safety IndicatorsMiller et al.’s Patient Safety Indicators Review of ICD-9-CM code bookReview of ICD-9-CM code book Codes from above sources were grouped into Codes from above sources were grouped into

clinically coherent indicators with appropriate clinically coherent indicators with appropriate denominatorsdenominators

Structure of indicatorsStructure of indicators All definitions were created using ICD-9-CM diagnosis All definitions were created using ICD-9-CM diagnosis

and procedure codes (along with DRG, MDC, sex, age and procedure codes (along with DRG, MDC, sex, age and procedure dates) and procedure dates)

Numerator of each indicator is the number of cases Numerator of each indicator is the number of cases with the complication of interest (e.g., Postop DVT/PE)with the complication of interest (e.g., Postop DVT/PE)

Denominator of each indicator is the number of Denominator of each indicator is the number of hospitalizations (or patients) considered to be at risk hospitalizations (or patients) considered to be at risk (e.g. elective surgical patients)(e.g. elective surgical patients)

Exclusions were defined to restrict the denominator to Exclusions were defined to restrict the denominator to patients for whom the complication was less likely to patients for whom the complication was less likely to have been present at admission, and more likely to have been present at admission, and more likely to have been preventablehave been preventable

The indicator “rate” is the numerator/denominatorThe indicator “rate” is the numerator/denominator

PSI assessment methods PSI assessment methods Literature review to gather data on coding Literature review to gather data on coding

and construct validityand construct validity ICD-9-CM coding consultant review (face ICD-9-CM coding consultant review (face

validity)validity) Clinical panel review (face validity)Clinical panel review (face validity) Empirical analyses of nationwide rates, Empirical analyses of nationwide rates,

hospital variation, impact of risk hospital variation, impact of risk adjustment, and relationships among adjustment, and relationships among indicatorsindicators

Clinical panel reviewClinical panel review Intended to establish consensual validityIntended to establish consensual validity Modified RAND/UCLA Appropriateness MethodModified RAND/UCLA Appropriateness Method Physicians of various specialties/subspecialties, nurses, Physicians of various specialties/subspecialties, nurses,

other specialized professionals (e.g., midwife, pharmacist)other specialized professionals (e.g., midwife, pharmacist) Potential indicators were rated by 8 multispecialty panels; Potential indicators were rated by 8 multispecialty panels;

surgical indicators were also rated by 3 surgical panelssurgical indicators were also rated by 3 surgical panels All panelists rated all assigned indicators (1-9) on: All panelists rated all assigned indicators (1-9) on:

Overall usefulnessOverall usefulness Likelihood of identifying the occurrence of an adverse event Likelihood of identifying the occurrence of an adverse event

or complication (i.e., not present at admission)or complication (i.e., not present at admission) Likelihood of being preventable (i.e., not an expected result Likelihood of being preventable (i.e., not an expected result

of underlying conditions) of underlying conditions) Likelihood of being due to medical error or negligence (i.e., Likelihood of being due to medical error or negligence (i.e.,

not just lack of ideal or perfect care)not just lack of ideal or perfect care) Likelihood of being clearly charted in the medical recordLikelihood of being clearly charted in the medical record Extent to which indicator is subject to bias due to case mixExtent to which indicator is subject to bias due to case mix

Medical error and complications continuum

Evaluation frameworkEvaluation framework

Pre-conference ratings and comments/suggestionsPre-conference ratings and comments/suggestions Individual ratings returned to panelists with Individual ratings returned to panelists with

distribution of ratings and other panelists’ distribution of ratings and other panelists’ comments/suggestionscomments/suggestions

Telephone conference call moderated by PI and Telephone conference call moderated by PI and attended by note-taker, focusing on high-variability attended by note-taker, focusing on high-variability items and panelists’ suggestions (90-120 mins)items and panelists’ suggestions (90-120 mins)

Suggestions adopted only by consensusSuggestions adopted only by consensus Post-conference ratings and comments/ Post-conference ratings and comments/

suggestionssuggestions

Medical error NonpreventableComplications

Final selection of indicatorsFinal selection of indicators

Retained indicators for which “overall Retained indicators for which “overall usefulness” rating was “Acceptable” or usefulness” rating was “Acceptable” or “Acceptable-” “Acceptable-” : : Median score 7-9Median score 7-9 Definite or indeterminate agreementDefinite or indeterminate agreement

Excluded indicators rated “Unclear,” Excluded indicators rated “Unclear,” “Unclear-,” or “Unacceptable”“Unclear-,” or “Unacceptable”: : Median score <7, ORMedian score <7, OR At least 2 panelists rated the indicator in each of the At least 2 panelists rated the indicator in each of the

extreme 3-point rangesextreme 3-point ranges

PSIs reviewedPSIs reviewed

48 indicators reviewed in total48 indicators reviewed in total 37 reviewed by multispecialty panel37 reviewed by multispecialty panel 15 of those reviewed by surgical panel15 of those reviewed by surgical panel

20 “accepted” based on face validity20 “accepted” based on face validity 2 dropped due to operational concerns2 dropped due to operational concerns

17 “experimental” or promising indicators17 “experimental” or promising indicators 11 rejected11 rejected

““Accepted” PSIsAccepted” PSIsSelected postoperative Selected postoperative

complicationscomplications Postoperative thromboembolism Postoperative respiratory failure Postoperative sepsis Postoperative physiologic and

metabolic derangements Postoperative abdominopelvic

wound dehiscence Postoperative hip fracture Postoperative hemorrhage or

hematomaSelected technical adverse eventsSelected technical adverse events Decubitus ulcer Selected infections due to medical

careTechnical difficulty with proceduresTechnical difficulty with procedures Iatrogenic pneumothorax Accidental puncture or laceration Foreign body left in during procedure

Other Other Complications of anesthesia Death in low mortality DRGs Failure to rescue Transfusion reaction

Obstetric trauma and birth Obstetric trauma and birth traumatrauma

Birth trauma – injury to neonate Obstetric trauma – vaginal

delivery with instrument Obstetric trauma – vaginal

delivery without instrument Obstetric trauma – cesarean

section delivery

Romano et al., Health Affairs 2003; 22(2):154-166Romano et al., Health Affairs 2003; 22(2):154-166

National trends in PSI ratesNational trends in PSI rates

Nationwide Inpatient Sample (NIS), 1995-2000Nationwide Inpatient Sample (NIS), 1995-2000 7.5 million discharges/1,000 hospitals/28 States7.5 million discharges/1,000 hospitals/28 States Approximates 20% sample of nonfederal acute Approximates 20% sample of nonfederal acute

care hospitalscare hospitals Discharge level weights applied to generate Discharge level weights applied to generate

national estimates for each yearnational estimates for each year Adjusted for age, gender, age-gender inter-Adjusted for age, gender, age-gender inter-

actions, comorbidities, and DRG clustersactions, comorbidities, and DRG clusters 1,121,000 potential safety-related events 1,121,000 potential safety-related events

affecting 1,070,000 hospitalizationsaffecting 1,070,000 hospitalizations

Estimated cases in 2000Estimated cases in 2000

IndicatorIndicator

Frequency ± 95% CI

Rate per 100

Postoperative septicemia 14,055 ± 1060 1.091

Postoperative thromboembolism 75,811 ± 4,156 0.919

Postoperative respiratory failure 12,842 ± 938 0.359

Postoperative physiologic or metabolic derangement

4,003 ± 419 0.089

Decubitus ulcer 201,459 ± 10,104 2.130

Infection due to medical care 54,490 ± 2,658 0.193

Postoperative hip fracture 5,207 ± 327 0.080

Accidental puncture or laceration 89,348 ± 5,669 0.324

Iatrogenic pneumothorax 19,397 ± 1,025 0.067

Postoperative hemorrhage/hematoma 17,014 ± 968 0.206

Impact of patient safety events in 2000 Impact of patient safety events in 2000 (Zhan and Miller, JAMA 2003)(Zhan and Miller, JAMA 2003)

IndicatorIndicator

Excess LOSExcess LOS(days)(days)

Excess Excess charge ($)charge ($)

Postoperative septicemiaPostoperative septicemia 10.910.9 $57,700$57,700

Postoperative thromboembolismPostoperative thromboembolism 5.45.4 21,70021,700

Postoperative respiratory failurePostoperative respiratory failure 9.19.1 53,50053,500

Postoperative physiologic or metabolic Postoperative physiologic or metabolic derangementderangement

8.98.9 54,80054,800

Decubitus ulcerDecubitus ulcer 4.04.0 10,80010,800

Selected infections due to medical careSelected infections due to medical care 9.69.6 38,70038,700

Postoperative hip fracturePostoperative hip fracture 5.25.2 13,40013,400

Accidental puncture or lacerationAccidental puncture or laceration 1.31.3 8,3008,300

Iatrogenic pneumothoraxIatrogenic pneumothorax 4.44.4 17,30017,300

Postoperative hemorrhage/hematomaPostoperative hemorrhage/hematoma 3.93.9 21,40021,400

Estimated cases in 2000Estimated cases in 2000

IndicatorIndicator

Frequency ± 95% CI

Rate per 100

Birth trauma 27,035 ± 5,674 0.667

Obstetric trauma –cesarean 5,523 ± 597 0.593

Obstetric trauma - vaginal without instrumentation

249,243 ± 12,570 8.659

Obstetric trauma - vaginal w instrumentation 60,622 ± 3,104 24.408

Failure to rescue 267,541 ± 5,056 17.424

Postoperative abdominopelvic wound dehiscence

3,858 ± 289 0.193

Transfusion reaction 138 ± 49 0.0004

Complications of anesthesia 5,305 ± 455 0.056

Death in low mortality DRGs 5,912 ± 433 0.043

Foreign body left during procedure 2,710 ± 204 0.008

Impact of patient safety events in 2000 Impact of patient safety events in 2000 (Zhan and Miller, JAMA 2003)(Zhan and Miller, JAMA 2003)

IndicatorIndicator

Excess LOSExcess LOS(days)(days)

Excess Excess charge ($)charge ($)

Birth traumaBirth trauma -0.1 (NS)-0.1 (NS) 300 (NS)300 (NS)

Obstetric trauma –cesareanObstetric trauma –cesarean 0.40.4 2,7002,700

Obstetric trauma - vaginal without Obstetric trauma - vaginal without instrumentationinstrumentation

0.050.05 -100 (NS)-100 (NS)

Obstetric trauma - vaginal w instrumentationObstetric trauma - vaginal w instrumentation 0.070.07 220220

Postoperative abdominopelvic wound Postoperative abdominopelvic wound dehiscencedehiscence

9.49.4 40,30040,300

Transfusion reactionTransfusion reaction 3.4 (NS)3.4 (NS) 18,900 (NS)18,900 (NS)

Complications of anesthesiaComplications of anesthesia 0.2 (NS)0.2 (NS) 1,6001,600

Foreign body left during procedureForeign body left during procedure 2.12.1 13,30013,300

National trends 1995-2000National trends 1995-2000Low-Incidence Medical and Nursing-Related Adverse Events

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

0.40%

1995 1996 1997 1998 1999 2000

Postop physiologic/metabolic derangements

Postop respiratory failure

Infection due to medical care

Postop hip fracture

Romano, PS, Geppert, JJ, Davies, SM, Miller, M et al. A National Profile of Patient Safety in US

Hospitals Based on Administrative Data, Health Affairs 2003;22(2):154-166.

National trends 1995-2000National trends 1995-2000High-Incidence Medical and Nursing-Related Adverse Events

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

2.2%

1995 1996 1997 1998 1999 2000

Decubitus ulcer

Postop septicemia

Postop thromboembolism

Romano, PS, Geppert, JJ, Davies, SM, Miller, M et al. A National Profile of Patient Safety in US

Hospitals Based on Administrative Data, Health Affairs 2003;22(2):154-166.

National trends 1995-2000National trends 1995-2000Technical Difficulties with Selected Procedures

0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

1995 1996 1997 1998 1999 2000

Accidental puncture or laceration

Iatrogenic pneumothorax

Postoperative hemorrhage or hematoma

Postoperative abdominopelvic wound dehiscence

Romano, PS, Geppert, JJ, Davies, SM, Miller, M et al. A National Profile of Patient Safety in US

Hospitals Based on Administrative Data, Health Affairs 2003;22(2):154-166.

National trends 1995-2000National trends 1995-2000Obstetric and Birth Trauma

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

22%

24%

1995 1996 1997 1998 1999 2000

Obstetric trauma: cesarean delivery

Obstetric trauma: vaginal delivery without instrumentation

Obstetric trauma: vaginal delivery with instrumentation

Birth trauma

Romano, PS, Geppert, JJ, Davies, SM, Miller, M et al. A National Profile of Patient Safety in US

Hospitals Based on Administrative Data, Health Affairs 2003;22(2):154-166.

National trends 1995-2000National trends 1995-2000Rare Adverse (Sentinel) Events, 1995-2000

0.00%

0.01%

0.02%

0.03%

0.04%

0.05%

0.06%

0.07%

1995 1996 1997 1998 1999 2000

Foreign body left during procedure

Anesthesia reactions and complications

Death in low-mortality DRGs

Romano, PS, Geppert, JJ, Davies, SM, Miller, M et al. A National Profile of Patient Safety in US

Hospitals Based on Administrative Data, Health Affairs 2003;22(2):154-166.

Research/Policy QuestionResearch/Policy Question

Why are some PSIs increasing in incidence Why are some PSIs increasing in incidence over time while others are decreasing?over time while others are decreasing?

Selective changes in coding practiceSelective changes in coding practice Changes in severity of illness or underlying Changes in severity of illness or underlying

risk of potential safety-related eventsrisk of potential safety-related events True changes in quality due to technical True changes in quality due to technical

improvements in surgical or nursing improvements in surgical or nursing technique, counterbalanced by inadequate technique, counterbalanced by inadequate staffing to prevent some complicationsstaffing to prevent some complications

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htmPSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm

Standard deviation of hospital effects: Standard deviation of hospital effects: 1997 SID1997 SID

0

0.01

0.02

0.03

0.04

0.05

0.06

0.07

0.08

0.09

0.1 Postop hemorr/hemat

Postop physio/metab

Selected infection

Iatrogenic PTX

Anesth complications

Postop AP wound dehis

Postop hip fracture

Accid puncture/lac

Postop resp failure

Postop DVT/PE

Death low mort DRGs

Ob trauma –cesarean

Postop sepsis

Decubitus ulcer

Birth trauma

Ob trauma - vag w/out

Failure to rescue

Ob trauma - vag forc/vac

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htmPSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm

Ratio of hospital-level signal to total Ratio of hospital-level signal to total hospital variation: 1997 SIDhospital variation: 1997 SID

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1Postop hemorr/hemat

Postop physio/metab

Selected infection

Iatrogenic PTX

Anesth complications

Postop AP wound dehis

Postop hip fracture

Accid puncture/lac

Postop resp failure

Postop DVT/PE

Death low mort DRGs

Ob trauma –cesarean

Postop sepsis

Decubitus ulcer

Birth trauma

Ob trauma - vag w/out

Failure to rescue

Ob trauma - vag forc/vac

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htmPSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm

Year-to-year correlation of hospital Year-to-year correlation of hospital effects: 1996-97 Florida SIDeffects: 1996-97 Florida SID

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8 Postop hemorr/hemat

Postop physio/metab

Selected infection

Iatrogenic PTX

Postop hip fracture

Anesth complications

Postop AP wound dehis

Postop resp failure

Accid puncture/lac

Death low mort DRGs

Ob trauma –cesarean

Postop DVT/PE

Postop sepsis

Decubitus ulcer

Birth trauma

Ob trauma - vag w/out

Failure to rescue

Ob trauma - vag forc/vac

Risk adjustmentRisk adjustment methodsmethods

Must use only administrative dataMust use only administrative data APR-DRGs and other canned packages APR-DRGs and other canned packages

may adjust for complicationsmay adjust for complications Final model Final model

DRGs (complication DRGs aggregated) DRGs (complication DRGs aggregated) Modified Comorbidity Index based on list Modified Comorbidity Index based on list

developed by Elixhauser et al.developed by Elixhauser et al. Age, Sex, Age-Sex interactions Age, Sex, Age-Sex interactions

Hospital level variation:Hospital level variation:Impact of bias, 1997 SID (summary)Impact of bias, 1997 SID (summary)

High Bias Medium Bias Low Bias

Failure to rescue (44% change 2 deciles)

Postop respiratory failure(11%)

Postop abdominopelvicwound dehiscence (4%)

Accidental puncture orlaceration (24%)

Postop hip fracture (8%) Obstetric trauma –cesarean birth (2%)

Decubitus ulcer (26%) Iatrogenic pneumothorax(14%)

Postop hemorrhage orhematoma (4%)

Postop thromboembolism(14%)

Postop physio/metabolicderangement (5%)

Complications ofanesthesia (<1%)

Death in low mortalityDRGs (13%)

Obstetric trauma – vaginalbirth with instrumentation(5%)

Obstetric trauma – vaginalbirth without Instrumentation (<1%)

Postop sepsis (11%) Selected infections due tomedical care (10%)

Birth trauma (0%)

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htmPSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm

PSIs loading on “catheter-related and PSIs loading on “catheter-related and technical complications” (factor 1)technical complications” (factor 1)

-0.5

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Factor 1

Factor 2

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htmPSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm

PSIs loading on “post/intraoperative PSIs loading on “post/intraoperative complications” (factor 2)complications” (factor 2)

-0.5

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

Postop respfail

Postop sepsis Decubitusulcer

Postopphysio/metab

Accidpuncture/lac

Factor 1

Factor 2

PSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htmPSI Technical Review at http://www.qualityindicators.ahrq.gov/data/hcup/psi.htm

PSIs loading on neither factor PSIs loading on neither factor (<1% variance explained)(<1% variance explained)

-0.5

-0.4

-0.3

-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

Foreign body left Postop wound dehisFactor 1

Factor 2

ConclusionsConclusions Administrative data are appealing, but the Administrative data are appealing, but the

development of indicators is time-consumingdevelopment of indicators is time-consuming Variations across hospitals and over time merit Variations across hospitals and over time merit

further explorationfurther exploration Potentially useful screening tool for providers, Potentially useful screening tool for providers,

provider associations, and health data agencies to provider associations, and health data agencies to identify possible safety problemsidentify possible safety problems

Ongoing support and validation work expected to Ongoing support and validation work expected to offer many more insights into opportunities and offer many more insights into opportunities and obstacles in using administrative data for patient obstacles in using administrative data for patient safety surveillancesafety surveillance