Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms

Appendix

Exhibit A1 provides the interim 2013 data on HACs. The HACs that are the focus of the PfP initiative are shown, as well as the source of the data and the corresponding measures related to each HAC. The interim rate for 2013 is 121 HACs per 1,000 discharges, which is a 17 percent reduction from the 2010 baseline of 145 HACs per 1,000 discharges before the start of the PfP initiative.

Exhibit A1. 2013 Interim AHRQ National Scorecard Data on HACs (Calculated October 23, 2014)

PfP Hospital-Acquired Conditions Interim 2013 PfP HACs: Interim Final 2013 Data for MPSMS, Preliminary 2013 CDC NHSN Data on SSIs, and 2012 Data for Obstetric Adverse Events and Other PSIs
Partnership for Patients Hospital-Acquired Condition Source (& Data Year) Measure PfP HACs (Normalized to 32,750,000 Discharges—Based on 2010 Baseline) PfP Measured HACs per 1,000 Discharges
ADEs MPSMS (2013) ADE Associated With Digoxin 8,800 0.27
MPSMS (2013) ADE Associated With Hypoglycemic Agents 760,000 23.3
MPSMS (2013) ADE Associated With IV Heparin 170,000 5.1
MPSMS (2013) ADE Associated With Low Molecular Weight Heparin and Factor Xa Inhibitor 240,000 7.3
MPSMS (2013) ADE Associated With Warfarin 140,000 4.3
MPSMS (2013) Total ADE (rounded sum of above 5 measures) 1,320,000 40.3
CAUTIs MPSMS (2013) Catheter-Associated Urinary Tract Infections 290,000 8.8
CLABSIs MPSMS (2013) Blood Stream Infections Associated With Central Venous Catheters 9,200 0.28
Falls MPSMS (2013) In-Hospital Patient Falls 240,000 7.2
Obstetric Adverse Events PSI (2012) OB Trauma in Vaginal Delivery With (PSI 18) and Without Instrument (PSI 19) 77,000 2.4
Pressure Ulcers MPSMS (2013) Hospital-Acquired Pressure Ulcers 1,060,000 32.5
Surgical Site Infections NHSN (preliminary 2013) SSIs for 17 selected procedures 78,000 2.4
VAPs MPSMS (2013) Ventilator-Associated Pneumonia 37,000 1.1
VTEs MPSMS (2013) Postoperative Venous Thromboembolic Events 23,000 0.71
All Other Hospital-Acquired Conditions MPSMS (2013) Femoral Artery Puncture for Catheter Angiographic Procedures 59,000 1.8
MPSMS (2013) Adverse Events Associated With Hip Joint Replacements 21,000 0.63
MPSMS (2013) Adverse Events Associated With Knee Joint Replacements 14,000 0.42
MPSMS (2013) Contrast Nephropathy Associated With Catheter Angiography 250,000 7.6
MPSMS (2013) Hospital-Acquired MRSA 11,000 0.35
MPSMS (2013) Hospital-Acquired VRE 10,000 0.31
MPSMS (2013) Hospital-Acquired Antibiotic-Associated C. difficile 100,000 3.1
MPSMS (2013) Mechanical Complications Associated With Central Venous Catheters 110,000 3.3
MPSMS (2013) Postoperative Cardiac Events for Cardiac and Non-cardiac Surgeries 35,000 1.1
MPSMS (2013) Postoperative Pneumonia 65,000 2.0
PSI (2012) Iatrogenic Pneumothorax (PSI 6) 12,000 0.37
PSI (2012) Post-Op Hemorrhage or Hematoma (PSI 9) 20,000 0.60
PSI (2012) Post-Op Respiratory Failure (PSI 11) 50,000 1.5
PSI (2012) Accidental Puncture or Laceration (PSI 15) 66,000 2.0
MPSMS (2013) & PSI (2012) Total All Other HACs (sum of above 14 measures) 823,000 25.1
Interim Total of 2013 PfP HACs and HACs per 1,000 discharges (rounded) 3,957,200 121

Source: AHRQ National Scorecard Estimates from Medicare Patient Safety Monitoring System, National Healthcare Safety Network, and Healthcare Cost and Utilization Project.

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Page last reviewed December 2014
Page originally created December 2014
Internet Citation: Appendix. Content last reviewed December 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/hai/pfp/interimhac2013-ap1.html
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