Multiple Patient Safety Events Within a Single Hospitalization

Abstract

The objective was to examine co-occurrence of iatrogenic events in US hospitals. Using Agency for Healthcare Research and Quality patient safety indicators (PSIs), the authors defined multiple patient safety events (MPSEs) as the occurrence of multiple PSIs during a single hospitalization. The National Inpatient Sample was analyzed to estimate the national prevalence of MPSEs, risk factors for MPSEs, and the average length of stay and average hospital charges associated with MPSEs. MPSEs occurred in approximately 1 in every 1000 hospitalizations, affecting more than 30 000 patients in 2004. Significant risk factors for MPSEs include age, black race, Medicare coverage, and treatment at urban teaching hospitals. Compared with all admissions, the average length of stay for MPSE admissions was 4 times longer, and the average charge for MPSE admissions was 8 times greater. Despite the low prevalence, MPSEs affect large numbers of hospital patients in America. MPSEs have distinct characteristics and are far more resource intensive than hospital admissions generally.

Keywords

patient safety hospitalization risk factor adverse events

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References

Leape

LL.

Error in medicine. JAMA. 1994;272:1851-1857.

Institute of Medicine. To Err Is Human: Building A Safer Health System. Washington, DC: National Academies Press; 2000.

Miller

MR.

Patient safety events during pediatric hospitalizations. Pediatrics. 2003;111(6, pt 1):1358-1366.

Romano

Geppert

Davies

Miller

Elixhauser

McDonald

KM.

A national profile of patient safety in U.S. hospitals. Health Aff (Millwood). 2003;22:154-166.

Slonim

LaFleur

Ahmed

Joseph

JG.

Hospital- reported medical errors in children. Pediatrics. 2003;111: 617-621.

Zhan

Miller

MR.

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874.

Institute of Medicine. Patient Safety: Achieving a New Standard of Care. Washington, DC: National Academies Press; 2004.

Zhan

Miller

Wong

Meyer

GS.

The effects of HMO penetration on preventable hospitalization. Health Serv Res. 2004;39:345-361.

Weller

Gallagher

Cen

Hannan

EL.

Readmissions for venous thromboembolism: expanding the definition of patient safety indicators. Jt Comm J Qual Saf. 2004;30: 497-504.

10.

Coffey

Andrews

Moy

Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators. Med Care. 2005;43(3, suppl):I48-I57.

11.

Fiscella

Franks

Meldrum

Barnett

Racial disparity in surgical complications in New York State. Ann Surg. 2005;242:151-155.

12.

Poulose

Ray

Arbogast

. Resident work hour limits and patient safety. Ann Surg. 2005;241:847-856; discussion 856-860.

13.

Rosen

Rivard

Zhao

. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data? Med Care. 2005;43: 873-884.

14.

Sedman

Harris

II Schultz

. Relevance of the Agency for Health care Research and Quality patient safety indicators for children’s hospitals. Pediatrics. 2005;115:135-145.

15.

Shufelt

Hannan

Gallagher

BK.

The postoperative hemorrhage and hematoma patient safety indicator and its risk factors. Am J Med Qual. 2005;20:210-218.

16.

Stelfox

Palmisani

Scurlock

Orav

Bates

DW.

The “To Err is Human” report and the patient safety literature. Qual Saf Health Care. 2006;15:174-178.

17.

Agency for Healthcare Research and Quality. AHRQ Quality Indicators: Guide to Patient Safety Indicators, Version 3.1. Rockville, MD: Agency for Healthcare Research & Quality; 2007.

18.

Bahl

Thompson

Kau

Campbell

DJ.

Do the AHRQ patient safety indicators flag conditions that are present at the time of hospital admission?

Med Care. 2008;46:516-522.

19.

Miller

Elixhauser

Zhan

Meyer

GS.

Patient safety indicators: using administrative data to identify potential patient safety concerns. Health Serv Res. 2001;36(6, pt 2): 110-132.

20.

Agency for Healthcare Research and Quality. Introduction to the HCUP Nationwide Inpatient Sample (NIS), 2002. Rockville,MD: Agency for Healthcare Research & Quality; 2004.

21.

Agency for Healthcare Research and Quality. Introduction to the HCUP Nationwide Inpatient Sample (NIS), 2007. http://hcup-us.ahrq.gov/db/nation/nis/NIS_Introduction_2007.jsp#introduction. Accessed February 13, 2012.

22.

Agency for Healthcare Research and Quality. AHRQ Quality Indicators—Patient Safety Indicators: Software Documentation, Version 2.1—SAS. Rockville, MD: Agency for Health Care Research & Quality; 2003.

23.

Burstin

Lipsitz

Brennan

TA.

Socioeconomic status and risk for substandard medical care. JAMA. 1992;268:2383-2387.

24.

Iezzoni

Daley

Heeren

. Using administrative data to screen hospitals for high complication rates. Inquiry. 1994;31:40-55.

25.

Thomas

Brennan

TA.

Incidence and types of preventable adverse events in elderly patients: population based review of medical records. BMJ. 2000;320:741-744.

26.

Zhan

Smith

Stryer

Accidental iatrogenic pneumothorax in hospitalized patients. Med Care. 2006;44:182-186.

27.

Iezzoni

. Data sources and implications: administrative database. In: Iezzoni

, ed. Risk Adjustment for Measuring Health Outcomes. 2nd ed. Chicago, IL: Health Administration Press; 1997:169-242.

28.

Simborg

DRG creep: a new hospital-acquired disease. N Engl J Med. 1981;304:1602-1604.

29.

Hsia

Ahern

Ritchie

Moscoe

Krushat

Accuracy of diagnostic coding for Medicare patients under the Prospective Payment System. N Engl J Med. 1988;318:303-311.