Chartbook on Patient Safety: Slide Presentation

National Healthcare Quality and Disparities Report

Slide 1

Text Description is below the image.

National Healthcare Quality and Disparities Report

Chartbook on Patient Safety
July 2017

Slide 2

Text Description is below the image.

National Healthcare Quality and Disparities Report

  • Annual report to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129).
  • Provides a comprehensive overview of:
    • Quality of health care received by the general U.S. population.
    • Disparities in care experienced by different racial, ethnic, and socioeconomic groups.
  • Assesses the performance of our health system and identifies areas of strength and weakness along three main axes:
    • Access to health care.
    • Quality of health care.
    • Priorities of the National Quality Strategy.

Slide 3

Text Description is below the image.

National Healthcare Quality and Disparities Report

  • Based on more than 250 measures of quality and disparities covering a broad array of health care services and settings.
  • Includes data from 2015 QDR, which generally cover 2001-2014.
  • Produced with the help of an Interagency Work Group led by the Agency for Healthcare Research and Quality and submitted on behalf of the Secretary of the Department of Health and Human Services.

Slide 4

Text Description is below the image.

Chartbooks Organized Around Priorities of the National Quality Strategy

  1. Making care safer by reducing harm caused in the delivery of care.
  2. Ensuring that each person and family are engaged as partners in their care.
  3. Promoting effective communication and coordination of care.
  4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
  5. Working with communities to promote wide use of best practices to enable healthy living.
  6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Note:

Patient Safety is one of the six national priorities identified by the National Quality Strategy (http://www.ahrq.gov/workingforquality/index.html).

Slide 5

Text Description is below the image.

Priority 1: Making care safer by reducing harm caused in the delivery of care

Long-Term Goals:

  • Reduce preventable hospital admissions and readmissions.
  • Reduce the incidence of adverse health care-associated conditions.
  • Reduce harm from inappropriate or unnecessary care.

Notes:

  • The National Quality Strategy has identified three long-term goals related to patient safety: reduce preventable hospital admissions and readmissions, reduce the incidence of adverse health care-associated conditions, and reduce harm from inappropriate or unnecessary care.
  • This chartbook focuses on adverse health care-associated conditions and harm from care.
  • Preventable admissions and readmissions can result from problems with patient safety or problems with care coordination. We have chosen to include measures of preventable admissions and readmissions in the Care Coordination chartbook.

Slide 6

Text Description is below the image.

Chartbook Contents

  • This chartbook includes:
    • Summary of trends across measures of patient safety from the QDR.
    • Figures illustrating select measures of patient safety.
    • Supplemental descriptions and data on patient safety measures from several outside sources.
  • Introduction and Methods contains information about methods used in the chartbook.
  • A Data Query tool (http://nhqrnet.ahrq.gov/inhqrdr/data/query) provides access to all data tables.

Slide 7

Text Description is below the image.

Number and percentage of all QDR quality measures that are improving, not changing, or worsening through 2014 or 2015, overall and by NQS priority area

Image: Chart shows number and percentage of all quality measures that are improving, not changing, or worsening through 2014 or 2015:

National Quality Strategy Priorities Improving No Change Worsening
Total (n=172) 99 56 17
Person-Centered Care (n=12) 10 2  
Patient Safety (n=32) 21 9 2
Healthy Living (n=54) 33 17 4
Effective Treatment (n=36) 19 15 2
Care Coordination (n=31) 15 8 8
Affordable Care (n=7) 1 5 1

Key: n = number of measures.

Notes: For most measures, trend data are available from 2000-2002 through 2014 or 2015. For each measure with at least four estimates over time, unweighted log-linear regression is used to calculate average annual percentage change and to assess statistical significance. Measures are aligned so that positive change indicates improved access to care.

  • Improving = Rates of change are positive at 1% per year or greater and are statistically significant.
  • No Change = Rate of change is less than 1% per year or is not statistically significant.
  • Worsening = Rates of change are negative at -1% per year or greater and are statistically significant.
  • Through 2014 or 2015, across a broad spectrum of measures of health care quality, 58% showed improvement (green).
    • About 83% of measures of Person-Centered Care improved.
    • About two-thirds (66%) of measures of Patient Safety improved.
      • The two measures with worsening results were "Postoperative physiologic and metabolic derangements per 1,000 elective-surgery admissions, age 18 and over" and "Adult surgery patients with postoperative venous thromboembolic events, age 18 and over."
    • About 61% of measures of Healthy Living improved.
    • More than half (53%) of measures of Effective Treatment improved.
    • Nearly half (48%) of measures of Care Coordination improved.
    • Only about 14% of measures of Affordable Care improved.
    • Access measures are not represented on this slide.

Slide 8

Text Description is below the image.

Number and percentage of patient safety measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group, 2013 or 2014

Image: Chart shows number and percentage of patient safety measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group:

  Poor vs. High Income
(n=18)
Black vs. White
(n=29)
Asian vs. White
(n=23)
AI/AN vs. White
(n=5)
Hispanic vs. White
(n=27)
Better 3 6 4   7
Same 10 16 11 4 14
Worse 5 7 8 1 6

Key: AI/AN = American Indian and Alaska Native; n = number of measures.

Note: Numbers of measures differ across groups in part because of data limitations. The measures shown here are from 2013 or later. The relative difference between a selected group and its reference group is used to assess disparities. Poor indicates family income less than the Federal poverty level. High Income indicates family income four times the Federal poverty level or greater.

  • Better = Selected group received better quality of care than reference group. Differences are statistically significant, are equal to or larger than 10%, and favor the selected group.
  • Same = Selected group and reference group received about the same quality of care. Differences are not statistically significant or are smaller than 10%.
  • Worse = Selected group received worse quality of care than reference group. Differences are statistically significant, are equal to or larger than 10%, and favor the reference group.
  • People in poor households received worse care than people in high-income households for about 28% of patient safety measures.
  • Blacks and Hispanics received worse care than Whites for more than 20% (24% and 22%, respectively) of patient safety measures.
  • Asians received worse care than Whites for about one-third (35%) of patient safety measures.

Slide 9

Text Description is below the image.

Examples of Patient Safety Measures With Disparities That Were Getting Smaller Over Time

  • Age Gap: 65 years and older vs. 18-44 years of age:
    • Admissions with central venous catheter-related bloodstream infection per 1,000 medical and surgical discharges of length 2 or more days.
  • Income Gap: Low vs. High:
    • Adults with postoperative hip fracture per 1,000 surgical admissions who were not susceptible to falling.
  • Income Gap: Poor vs. High:
    • Adults with postoperative hip fracture per 1,000 surgical admissions who were not susceptible to falling.
  • Location Gap: Medium Metro vs. Large Fringe Metro:
    • Adults with postoperative physiologic and metabolic derangements per 1,000 elective surgical hospital discharges.

Note: Disparities are shown for the comparison group relative to the reference group. Low income and poor are based on the Federal poverty level (100%- <200% and <100% of FPL, respectively).

Slide 10

Text Description is below the image.

Examples of Patient Safety Measures With Disparities That Have Worsened or Showed No Change Over Time

  • Worsening:
    • Asian vs. White Gap: Obstetric trauma per 1,000 instrument-assisted vaginal deliveries.
  • No Change:
    • Hispanic vs. Non-Hispanic White Gap: Accidental puncture or laceration during procedure per 1,000 medical and surgical admissions, adults.
    • Black vs. White Gap: Deaths per 1,000 hospital admissions with low expected mortality.
    • Age Gap: 65 and Over vs. 18-44: Adults with postoperative pulmonary embolism or deep vein thrombosis per 1,000 surgical hospital discharges.

Slide 11

Text Description is below the image.

Measures of Patient Safety

  • Summary of information on patient safety from the National Healthcare Quality and Disparities Report.
  • Individual measures of patient safety, overall and by age, sex, race, ethnicity, income, education, insurance, birth weight, health status, and presence of various health conditions.
  • Measures of patient safety by setting:
    • Hospitals.
    • Nursing homes.
    • Home health.
    • Ambulatory care.
    • All settings: Infrastructure.

Slide 12

Text Description is below the image.

Patient Safety in the Hospital Setting

  • Hospitals are a common setting for patient safety events:
    • Many patients admitted to the hospital are in a clinically compromised state.
    • Care often includes the use of invasive devices and procedures, increasing patients' risk for infection and harm.
  • Measures include:
    • Overall hospital-acquired conditions (HACs).
    • Healthcare-associated infections (HAIs).
    • Procedure-related events.
    • Adverse drug events.

Slide 13

Text Description is below the image.

Distribution of hospital-acquired conditions, based on national rates per 1,000 adult hospital discharges, 2010-2015

Image: Chart shows distribution of hospital-acquired conditions, based on national rates per 1,000 adult hospital discharges:

Hospital-Acquired Conditions 2010 2011 2012 2013 2014 2015
Total 145 142 132 121 121 115
Pressure Ulcers 40.3 40.4 39.4 32.5 30.9 36.3
Adverse Drug Events 49.5 48.7 41.9 40.3 41.4 35.1
Catheter-Associated Urinary Tract Infections 12.2 11.3 10.6 8.8 7.6 8.2
Falls 7.9 7.8 7.2 7.2 7.9 6.7
Lower Frequency HACs 8.1 7.3 7.4 6.9 6.7 6.0
All Other HACs 27.3 26.7 25.7 25.1 26.6 23.0

Source:Agency for Healthcare Research and Quality (AHRQ), Medicare Patient Safety Monitoring System (MPSMS); Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; Centers for Disease Control and Prevention, National Healthcare Safety Network., 2010-2015.
Denominator: Adult hospital discharges, age 18 and over.

Notes: Lower Frequency HACs (<3/1,000 discharges) include central line-associated bloodstream infections, venous thromboembolisms, surgical site infections, obstetric adverse events, and ventilator-associated pneumonia. All Other Hospital-Acquired Conditions includes: inadvertent femoral artery puncture for catheter angiographic procedures, adverse events associated with hip joint replacement, adverse events associated with knee joint replacement, contrast nephropathy associated with catheter angiography, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), C. difficile, mechanical complications associated with central venous catheters, postoperative cardiac events for cardiac and noncardiac surgeries, postoperative pneumonia, iatrogenic pneumothorax, postoperative hemorrhage or hematoma, postoperative respiratory failure, and accidental puncture or laceration.

For more information on methods, go to https:// www.ahrq.gov/professionals/quality-patient-safety/pfp/index.html. The 2015 data on this graph reflect interim results. Prior analysis suggest that the (pending) final data should be very similar.

  • Importance: Hospital-acquired conditions (HACs) are conditions that patients did not have upon hospital admission, but which developed during the patient's hospital stay. They can lead to poor patient outcomes and increased spending on health care. HACs are often preventable.
  • Overall Rate:
    • In 2015, the overall HAC rate was 115 per 1,000 hospital discharges.
    • Adverse drug events (35.1 per 1,000 hospital discharges) accounted for 30.5% of total HACs and pressure ulcers (36.3 per 1,000 hospital discharges) accounted for 31.6% of the total.
    • Data on disparities seen within some specific individual measures appear in subsequent slides.
  • Trends:
    • From 2010 through 2015, the overall rate of hospital-acquired conditions declined 20.7%, from 145 to 115 per 1,000 hospital discharges.
    • Among the most frequent HACs, the rate of pressure ulcers decreased the most between 2010 and 2014, dropping from 40.3 per 1,000 discharges (more than 1.3 million events) to 30.9 per 1,000 discharges (about 1 million events). However, these events increased in 2015 to a level of 36.3 per 1,000 discharges (approximately 1.2 million events).
    • During that same period, adverse drug events decreased from a rate of 49.5 per 1,000 discharges (more than 1.6 million events) to 35.1 per 1,000 discharges (fewer than 1.2 million events). The physician-diagnosed catheter-associated urinary tract infection rate (based on MPSMS definitions) seen across various inpatient unit types decreased from 12.2 to 8.2 per 1,000 discharges (400,000 and 270,000 events, respectively).
    • Among the lower frequency HACs, central line-associated bloodstream infections had the greatest percentage decrease in rate (91%) between 2010 and 2015. The rates of venous thromboembolism, surgical site infections, and specific obstetric events also decreased, falling by 76%, 16%, and 10% respectively.

Slide 14

Text Description is below the image.

Healthcare-Associated Infections

  • Infections acquired during a hospital stay are among the most common complications of hospital care (AHRQ, 2016).
  • On any given day, about 1 in 25 hospital patients has at least one healthcare-associated infection (HAI) (CDC, 2016a).
  • HAIs often increase the patient's length of stay in the hospital, risk of mortality, and hospital costs.
  • New infections in critically ill infants, children, and other patients generally reduce their chances for recovery.

Note:

Slide 15

Text Description is below the image.

Measures of Patient Safety in the Hospital Setting: HAIs

  • Standardized infection ratios (SIRs) for central line-associated bloodstream infections, surgical site infections, NHSN-defined catheter-associated urinary tract infections (CAUTIs), and C. difficile infections.
  • NHSN-defined CAUTI per 1,000 urinary catheter-days in critical care units:
    • By hospital type.
    • By critical care unit type.
  • Change in SIRs for NHSN-defined CAUTIs.

Slide 16

Text Description is below the image.

Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2009-2014, catheter-associated urinary tract infections, 2010-2014, and C. difficile infections, 2012-2014

Image: Chart shows infection ratios for central line-associated bloodstream infections and surgical site infections, catheter-associated urinary tract infections, and C. difficile infections:

Year CLABSI, All SSI, Combined SCIP Procedures C. difficile,
Facility-wide
CAUTI, All
2009 0.854 0.981    
2010 0.677 0.927   0.937
2011 0.591 0.838   0.930
2012 0.562 0.868 0.963 1.025
2013 0.536 0.814 0.888 1.050
2014 0.495 0.827 0.924 1.000

Key: CLABSI = central line-associated bloodstream infection; SSI = surgical site infection; SCIP = Surgical Care Improvement Project; CAUTI = catheter-associated urinary tract infection; C. difficile = laboratory-identified hospital-onset Clostridium difficile infection.
Source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, 2014 National and State Healthcare Associated Infections: Progress Report, and National Healthcare Safety Network, 2009–2014.

Notes: For this measure, lower numbers are better. Acute care hospitalizations only. CAUTI and C. difficile exclude neonatal intensive care units.

  • Background:
    • SIR is described in Slide 13.
    • NHSN data are predominantly from intensive care units, although general medical/surgical inpatient wards and other non-critical care locations are also represented. The numbers of units/facilities reporting to NHSN roughly quadrupled from 2009 to 2014.
    • A central line-associated bloodstream infection (CLABSI) is a laboratory-confirmed bloodstream infection (LCBI) where a central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement being Day 1 and the line was also in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then removed, the date of event of the LCBI must be the day of discontinuation or the next day to be a CLABSI (CDC, 2017). CLABSI data also include neonatal intensive care units but exclude long-term acute care hospitals and inpatient rehabilitation facilities.
    • SCIP procedures are those performed on adults. Procedures include abdominal aortic aneurysm repair, peripheral vascular bypass surgery, coronary artery bypass graft with both chest and donor site incisions or with chest incision only, other cardiac surgery, colon surgery, rectal surgery, hip arthroplasty, abdominal hysterectomy, knee arthroplasty, and vaginal hysterectomy.
    • Hospital-onset C. difficile infections are detected on the 4th day or later after admission to an inpatient location within the facility.
  • Overall Rate: In 2014, the overall SIR for CLABSIs seen in intensive care units (including neonatal intensive care units) and general hospital wards in acute care hospitals in the 50 States, District of Columbia, and Puerto Rico was 0.50. This means that roughly 50% fewer CLABSIs were observed in 2014 than were predicted based on patient and hospital characteristics seen in the 2006-2008 referent period. The CLABSI SIR decreased more than 40% in 6 years, going from 0.85 in 2009 to 0.50 in 2014.
    • The overall SIR for CAUTIs in 2014 was 1.00.
    • The overall SIR for SSIs following 10 common procedures in adults was 0.83, and the overall SIR for C. difficile was 0.92.
  • Trends:
    • The CLABSI SIR decreased more than 40% between 2009 and 2014.
    • The SSI SIR decreased 16% between 2009 and 2014.
    • The C. difficile SIR decreased 4% between 2012 and 2014.
    • Between 2010 and 2014, there was no statistically significant change in the CAUTI SIR.

Slide 17

Catheter-associated urinary tract infections per 1,000 urinary catheter days in critical care units, by hospital type, 2009-2014, and by critical care unit type, 2013

Image: Charts show catheter-associated urinary tract infections per 1,000 urinary catheter days in critical care units:

Left Chart (Hospital type):

Year Medical/Surgical -
All Other
Medical -
Major Teaching
Medical/Surgical -
Major Teaching
Medical -
All Other
2009 1.26 2.30 2.28 2.02
2010 1.30 2.40 2.20 1.90
2011 1.35 2.57 2.17 1.57
2012 1.44 2.94 2.44 1.69
2013 1.52 3.48 2.66 2.04
2014 1.58 3.30 2.70 2.00

Source: Centers for Disease Control and Prevention, National Healthcare Safety Network, 2009-2014.
Denominator: Infections per 1,000 urinary catheter days.
Note: For this measure, lower rates are better. Acute care hospitalizations only; excludes neonatal intensive care units.

Right Chart (Critical care unit type):

  • Burn - 4.8.
  • Neurologic - 4.5.
  • Trauma - 4.3.
  • Pediatric Medical - 3.4.
  • Respiratory - 2.1.

Source: Dudeck, et al. National Healthcare Safety Network report, data summary for 2013, Device-associated module. Am J Infect Control 2015 Mar;43(3):206-21.
Denominator: Infections per 1,000 urinary catheter days.
Note: For this measure, lower rates are better. Acute care hospitalizations only; excludes neonatal intensive care units.

  • Background: Compared with other hospital-acquired infections, CAUTI rates are more highly variable among units in the same hospital (Dudeck et al., 2015). ICU patients differ from non-ICU patients in their underlying health status, their risks of contracting CAUTIs, and the consequences of CAUTIs that occur. CAUTI rates and the rates at which they have changed over time also differ between these two types of settings.
  • Overall Rates:
    • In 2014, the pooled mean rates of CAUTI in critical care units were 3.3 infections per 1,000 urinary catheter days for medical ICUs in major teaching hospitals, 2.7 for medical/surgical ICUs in major teaching hospitals, 2.0 for medical ICUs in all other acute care hospitals, and 1.6 for medical/surgical ICUs in all other acute care hospitals.
    • In 2013, acute care hospital patients in Burn, Neurologic, and Trauma critical care units had CAUTI rates of 4.8, 4.5, and 4.3 per 1,000 urinary catheter days, respectively. Patients in Pediatric Medical and in Respiratory critical care units had CAUTI rates of 3.4 and 2.1 per 1,000 urinary catheter days, respectively.

Slide 18

Text Description is below the image.

Change from 2013 to 2014 in Statewide SIRs for CAUTI

Image: Map of the United States is color-coded by state to show increase, decrease, or no change in standardized infection ratios from 2013 to 2014.

Key: CAUTI = catheter-associated urinary tract infection; NHSN = National Healthcare Safety Network.
Source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, 2014 National and State Healthcare Associated Infections: Progress Report.

Notes: For this measure, lower numbers are better. Changes in SIRs are categorized as "no change" if they are not statistically significant. Acute care hospitalizations only. Excludes neonatal intensive care units. For this measure, District of Columbia and Puerto Rico are treated as States.

  • Geographic Variation for 2014 (data not shown): In 2014, 16 of 52 reporting States (including State-equivalent jurisdictions) had statewide SIRs greater than 1, indicating that, on average, their hospitals had more CAUTIs than hospitals of similar type and size had reported during the 2009 referent period. That year, 19 States had statewide SIRs less than 1, indicating that, on average, their hospitals had fewer CAUTIs than hospitals of similar type and size had reported during the 2009 referent period. The remaining 17 States had SIRs of 1, indicating that their hospitals had roughly the same number of CAUTIs as hospitals of similar type and size had reported during the 2009 referent period.
  • Trends: Of the 52 reporting States, 37 had no change in CAUTI SIRs from 2013 to 2014, while 14 SIRs decreased, and 1 increased.

Slide 19

Text Description is below the image.

Toolkit for Reducing Central Line-Associated Bloodstream Infections in Hospitals

  • Purpose: To help hospitals prevent central line-associated bloodstream infections (CLABSIs) and improve safety culture.
  • Method: Implementing evidence-based, practical resources and concepts from the Comprehensive Unit-based Safety Program.
  • Intended User: Hospital facilities.
  • Available Tools: •Checklists, preventable incidence calculators, audit forms, event report templates.
  • Impact:
    • Through use of the CUSP toolkit and CLABSI tools, more than 100 intensive care units in Michigan have nearly eliminated CLABSIs.
    • Nationwide, the use of this toolkit has helped more than 1,000 hospitals reduce rates of CLABSI by 41% in aggregate. Go to http://www.ahrq.gov/workingforquality/pias/mhhakcpia.htm.
  • Link: https://www.ahrq.gov/professionals/education/curriculum-tools/clabsitools/index.html

Slide 20

Text Description is below the image.

Toolkit for Reducing Catheter-Associated Urinary Tract Infections in Hospitals

  • Purpose: To help hospitals prevent catheter-associated urinary tract infections (CAUTIs) and improve safety culture.
  • Method: Implementing evidence-based, practical resources and concepts from the Comprehensive Unit-based Safety Program.
  • Intended User: Hospital facilities.
  • Available Tools: Guides, checklists, webinars, learning modules, data interpretation guides.
  • Potential Measures of Effectiveness:
    • Number of symptomatic CAUTIs attributable to each unit by month.
    • Days since last CAUTI.
  • Link: http://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/cauti-hospitals/Index.html

Slide 21

Text Description is below the image.

Procedure-Related Events

  • More than 40 million operative procedures are performed in the United States each year.
  • Postoperative adverse events are not uncommon and increase both hospitalization length and cost (AHRQ, 2013).
  • Measures include:
    • Inpatient sepsis per 1,000 adult discharges with an elective operating room procedure.
    • Obstetric trauma per 1,000 vaginal deliveries.
    • Percentage of adult patients receiving hip joint replacement due to fracture or degenerative conditions who experienced adverse events.
    • Risk-adjusted mortality at 30 postoperative days for colorectal surgery performed in adults.

Slide 22

Text Description is below the image.

Inpatient sepsis per 1,000 adult discharges with an elective operating room procedure, by sex and insurance status, 2008-2014

Image: Charts show inpatient sepsis per 1,000 adult discharges with an elective operating room procedure:

Left Chart (Sex):

Year Total Male Female
2008 15.6 17.9 13.8
2009 16.2 18.7 14.2
2010 16.6 18.3 15.3
2011 16.4 18.8 14.5
2012 13.8 14.9 13.2
2013 14.3 16.0 13.0
2014 16.7 18.75 15.26

Right Chart (Insurance Status):

Year Medicaid Medicare Private Uninsured
2008 20.4 16.0 14.6 9.6
2009 19.4 16.8 14.8 13.9
2010 21.9 16.9 14.9 15.7
2011 20.9 16.7 15.1 16.1
2012 19.2 14.7 11.1 12.7
2013 19.2 14.5 12.1 13.8
2014 20.04 16.54 15.29 23.51

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008-2014, and AHRQ Quality Indicators, version 4.4.
Denominator: All elective hospital surgical discharges for patients age 18 years and over with length of stay of 4 or more days, excluding patients admitted for infection, those with cancer or immunocompromised states, those with obstetric conditions, and admissions specifically for sepsis.

Notes: For this measure, lower rates are better. Rates are adjusted by age, sex, age-sex interactions, comorbidities, major diagnostic category, diagnosis-related group, and transfers into the hospital. Cases captured by this measure are those with a secondary discharge diagnosis of sepsis. Such cases could have had sepsis present on admission (POA) because the POA exclusion criterion was not universally available and was therefore not applied. The ‘uninsured category” also includes self-pay and “no charge” patients.

  • Cases of sepsis diagnosed before surgery or cases resulting from infections acquired but not diagnosed before surgery could not necessarily be excluded. However, such cases should be rare among elective surgical patients not meeting the exclusion criteria noted above.
  • Overall Rate: In 2014, the inpatient sepsis rate was 16.7 per 1,000 adult discharges with an elective operating room procedure.
  • Groups With Disparities:
    • In 2014, the rate of inpatient sepsis was lower for female patients than for male patients.
    • Also in 2014, the rate of inpatient sepsis was worse for patients with Medicaid or no insurance that for patients with private insurance.
    • From 2008 to 2014, there were no statistically significant changes in the gap between males and females.
    • From 2008 to 2014, the gap between privately insured patients and uninsured patients worsened.

Slide 23

Text Description is below the image.

Obstetric trauma per 1,000 vaginal deliveries

Image: Charts show obstetric trauma per 1,000 instrument-assisted vaginal deliveries:

Left Chart (Obstetric Trauma, by Instrument Assistance):

  Instrument Assisted Without Instrument
2000 196.4 39.2
2001 187.9 35.3
2002 179.4 33.7
2003 176.5 32.1
2004 171.3 30.0
2005 160.0 28.5
2006 153.7 25.6
2007 142.9 23.9
2008 146.3 23.8
2009 142.9 22.3
2010 140.8 22.9
2011 133.2 21.8
2012 127.3 20.7
2013 127.7 19.6
2014 119 18.7

Right Chart (Obstetric Trauma for Deliveries Without Instrument Assistance, by Ethnicity and Age, 2014):

  • White, 20.3.
  • Black - 10.0.
  • Hispanic - 13.8.
  • API - 35.8.
  • 10-14 - 27.1.
  • 15-17 - 22.1.
  • 18-24 - 15.3.
  • 25-34 - 21.3.
  • 35-54 - 15.6.

Key: API=Asian or Pacific Islander

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Disparities Analytic Files, 2000–2014.

Denominator: Vaginal deliveries, identified by DRG or Medicare Severity-DRG code. In the case of instrument-assisted delivery, the population was additionally identified with any listed International Classification of Diseases, Ninth Revision procedure codes for instrument-assisted delivery.

Notes: For this measure, lower rates are better. Consistent with the AHRQ Patient Safety Indicators software, obstetric trauma must involve 3rd or 4th degree lacerations of the perineum. Rates are adjusted by age using U.S. hospitalizations for 2010 as the standard population.

  • Importance: Obstetric trauma occurring to the mother during childbirth can extend a patient’s hospital stay after giving birth, may cause additional procedures to be performed, and may lead to poorer health outcomes for both the mother and child (Hines & Jiang, 2012). Vaginal deliveries that involve instruments, such as forceps and vacuums, are more likely to result in obstetric trauma, such as third and fourth degree lacerations of the perineum.
  • Overall Rate: In 2014, the rate of obstetric trauma was 119.0 for instrument-assisted vaginal deliveries and 18.7 per 1,000 vaginal deliveries without instrument assistance.
  • Trends: From 2000 to 2014, obstetric trauma rates improved for vaginal deliveries both with and without instrument assistance.
  • Groups With Disparities:
    • In 2014, the rate of obstetric trauma for vaginal deliveries without instrument assistance was worse for Asians and Pacific Islanders (APIs) (35.8 per 1,000 vaginal deliveries) compared with Whites (20.3 per 1,000 vaginal deliveries).
    • In 2014, the rate of obstetric trauma for deliveries without instrument assistance was better for Blacks (10.0 per 1,000 vaginal deliveries) and Hispanics (13.8 per 1,000 vaginal deliveries) than for Whites (20.3 per 1,000 vaginal deliveries).
    • In 2014, the obstetric trauma rate for vaginal deliveries without instrument assistance was worse for patients ages 10-14 years (27.1%), 15-17 years (22.1%), and 25-34 years (21.3%) compared with patients ages 18-24 (15.3%) and 35 to 54 (15.6%).

Slide 24

Text Description is below the image.

Obstetric trauma per 1,000 instrument-assisted vaginal deliveries, by State, United States, 2014

Image: Map of the United States is color-coded by state to show obstetric trauma per 1,000 instrument-assisted vaginal deliveries.

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Disparities Analytic Files, 2014, and AHRQ Quality Indicators, version 4.4.
Denominator: Vaginal deliveries, identified by DRG or Medicare Severity-DRG code, with any-listed International Classification of Diseases, Ninth Revision procedure code for instrument-assisted delivery.

Notes: For this measure, lower rates are better. Consistent with the AHRQ Patient Safety Indicators software, obstetric trauma must involve 3rd or 4th degree lacerations of the perineum. Rates are adjusted by age using U.S. hospitalizations for 2010 as the standard population. Missing refers to HCUP nonparticipants or States with data not meeting criteria for statistical reliability, data quality, or confidentiality.

  • The HCUP Disparities Analytic Files used in this and the preceding slide are limited to data from States (and hospitals within those States) meeting specified criteria for consistent coding of race/ethnicity. States listed as “missing” in this slide include several that did not meet these criteria in 2014.
  • Overall Rate: In 2014, the national average was 119.0 obstetric trauma events occurring per 1,000 instrument-assisted vaginal deliveries.
  • Differences by State: Interquartile ranges follow:
    • First quartile (lowest): 79.6-109.0 (CA, FL, KY, LA, MD, NJ, NM, TN, VT).
    • Second quartile (second lowest): 110.2-124.0 (AR, GA, IN, NV, NC, OK, SC, SD).
    • Third quartile (second highest): 124.8-139.6 (CO, CT, IL, MN, MO, NY, OR, VA, WV, WI).
    • Fourth quartile (highest): 140.0-173.8 (AZ, IA, KS, NE, ND, RI, WA, WY).
    • In 2014, Vermont had the lowest obstetric trauma rate at 79.6 events per 1,000 instrument-assisted vaginal deliveries; Nebraska had the highest rate at 173.8.

Slide 25

Text Description is below the image.

Adult patients receiving hip joint replacement due to fracture or degenerative conditions who experienced adverse events, by age and gender, 2010-2014

Image: Charts show adult patients receiving hip joint replacement due to fracture or degenerative conditions who experienced adverse events:

Left Chart (Age):

Age 2010 2011 2012 2013 2014
Total 7.8 7.7 6.5 4.9 4.5
65-74 4.3 6.0 6.0 5.1 3.9
75-84 8.0 9.1 10.7 6.7 7.6
85+ 18.3 15.3 9.3   8.8

Right Chart (Gender):

Sex 2010 2011 2012 2013 2014
Male 5.8 7.2 6.0 3.3 3.3
Female 9.0 8.0 6.8 5.9 5.5

Source: Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare & Medicaid Services (CMS), Medicare Patient Safety Monitoring System (MPSMS), 2010-2014.
Denominator: All patients age 18 years and over in the MPSMS sample who had a surgical procedure performed to replace a hip joint due to degenerative conditions or a fractured hip.

Notes: For this measure, lower percentages are better. Hospitals in Puerto Rico, the Virgin Islands, and Maryland were not included in the annual samples. Samples were drawn from the CMS Hospital Inpatient Quality Reporting program and consist of medical records for discharges following hip arthroplasty procedures as defined by the Surgical Care Improvement Project. Rates for patients age 85 years and over in 2013 and for ages 18-64 years old for all years are not shown because the data did not meet the criteria for statistical reliability, data quality, or confidentiality.

  • Importance: Hip replacement is most common among older adults, who have an increased risk of adverse events after these procedures.
  • Overall Percentage: In 2014, 4.5% of patients receiving a hip joint replacement due to fracture or degenerative conditions experienced adverse events.
  • Trends:
    • From 2010 to 2014, there was an overall decrease in the frequency of adverse events among patients who had a hip joint replacement due to fracture or degenerative conditions.
    • From 2010 to 2014, the percentage of patients experiencing adverse events decreased for females who had a hip joint replacement due to fracture or degenerative conditions.
  • Groups With Disparities:
    • In 2014, there were no statistically significant differences by age or gender in the percentage of hip replacement patients who had adverse events.
    • From 2010 to 2014, there were no statistically significant changes in the gap between patients ages 75-84 and those ages 65-74 in adverse event frequencies. Similarly, there were no statistically significant changes in disparities between male and female patients.

Slide 26

Text Description is below the image.

Risk-adjusted mortality rate within 30 days post-operation for adults undergoing colorectal surgery in ACS NSQIP participating hospitals in the United States, by race/ethnicity and hospital teaching status, 2008-2015

Image: Charts show risk-adjusted mortality rate within 30 days postoperation for adults undergoing colorectal surgery in ACS NSQIP participating hospitals in the United States:

Left Chart (Race/ethnicity):

Race/Ethnicity 2008 2009 2010 2011 2012 2013 2014 2015
Total 4.3 4.2 3.7 3.6 3.1 3.1 3.1 3.0
Hispanic 3.7 3.1 3.7 2.8 2.8 2.4 2.6 2.7
Black 5.1 5.1 4.5 4.1 3.8 3.7 3.6 3.5
Other 3.1 3.7 2.3 3.1 2.6 2.6 2.6 2.3
White 4.3 4.2 3.7 3.6 3.0 3.0 3.0 2.9

Right Chart (Hospital teaching status):

Hospital Type 2008 2009 2010 2011 2012 2013 2014 2015
Nonteaching 4.0 4.1 3.7 3.3 3.2 3.2 3.2 3.0
Teaching 4.0 4.0 3.6 3.5 3.0 3.0 3.0 2.9

Source: American College of Surgeons (ACS), National Surgical Quality Improvement Program (NSQIP), 2008-2015.
Denominator: Adults age 18 years and over.
Note: For this measure, lower percentages are better. The participation in the ACS NSQIP is voluntary and current participation is weighted when calculating rates. Participating hospitals have changed over time; 209 hospitals participated in 2008 and 578 hospitals participated in 2015. Other includes Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander. White, Black, and Other are non-Hispanic. Hispanic includes all races.

  • Importance: Colorectal procedures have high rates of postoperative complications. Nonadherence to evidence-based best practices is associated with an increased risk of these complications (Arriaga, et al., 2009).
  • Overall Rate: In 2015, the risk-adjusted mortality rate was 3.0% among patients undergoing colorectal surgeries at ACS NSQIP participating hospitals.
  • Trends: From 2008 to 2015, 30-day postoperative mortality after colorectal surgery improved. The rate also improved for both White patients and Black patients.
  • Groups With Disparities:
    • In 2015, the percentage of colorectal surgery patients with 30-day postoperative mortality was worse for Blacks (3.5%) compared with Whites (2.9%). The percentage of patients with 30-day postoperative mortality was better for Asians, American Indians or Alaska Natives, and Native Hawaiians or Other Pacific Islanders, combined (2.3%), compared with Whites (2.9%).

Slide 27

Text Description is below the image.

Adverse Drug Events

  • An estimated 400,000 preventable ADEs occur each year in U.S hospitals, generating additional costs of $3.5 billion in 2006 dollars (IOM, 2007).
  • The three initial targets of the HHS National Action Plan for Adverse Drug Event Prevention are:
    • Anticoagulants and related bleeding.
    • Diabetes agents and related hypoglycemia.
    • Opioids and accidental overdose, oversedation, and respiratory depression.

Notes:

  • An adverse drug event (ADE) is an injury—including physical harm, mental harm, or loss of function—resulting from medical intervention involving a drug.
  • For more information, go to the Patient Safety Primer: Medication Errors at https://psnet.ahrq.gov/primers/primer/23/medication-errors.

Slide 28

Text Description is below the image.

Measures of Patient Safety in the Hospital Setting: Adverse Drug Events

  • Percentage of hospitalized adult patients who received a hypoglycemic agent and had an adverse drug event.
  • Percentage of hospitalized adult patients who had an anticoagulant-related adverse drug event to warfarin.

Slide 29

Text Description is below the image.

Hospitalized adult patients who received a hypoglycemic agent who had adverse drug events with hypoglycemic agents, by race/ethnicity, and by renal disease or diabetes status, 2010-2014

Image: Charts show hospitalized adult patients who received a hypoglycemic agent who had adverse drug events with hypoglycemic agents:

Left Chart (Race/ethnicity):

Race/Ethnicity 2010 2011 2012 2013 2014
Total 10.2 10.2 8.7 8.5 8.8
Hispanic 11.7 12.1 9.1 8.9 7.7
Asian 9.8 13.0 14.0 11.6 9.4
Black 12.7 13.0 10.3 11.1 10.2
White 9.5 9.3 8.1 8.0 8.8

Right Chart (Renal disease or diabetes status):

Disease Status 2010 2011 2012 2013 2014
Renal Disease 13.8 14.2 12.0 12.2 12.0
No Renal Disease 7.9 7.6 6.6 5.6 6.2
Diabetes 11.3 11.1 9.5 9.2 9.4
No Diabetes 5.0 5.6 4.8 4.6 5.6

Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2010-2014.

Notes: For this measure, lower percentages are better. Hypoglycemic agents received by patients age 18 and over during a hospital stay include insulin, oral hypoglycemic, or both. White, Black, and Asian are non-Hispanic. Hispanic includes all races.

  • Importance: Hypoglycemic agents, which are ingested orally, are typically used in patients with type 2 diabetes to control blood sugar levels. In some cases, diabetic patients use hypoglycemic agents together with insulin. The risk of chronic kidney disease increases twofold for people with diabetes, and renal impairment can increase the risk for adverse events related to hypoglycemic agents.
  • Overall Percentage: In 2014, 8.8% of hospital patients receiving hypoglycemic agents had an adverse drug event.
  • Trends:
    • The overall percentage of adverse drug events associated with hypoglycemic agents improved from 2010 to 2014.
    • From 2010 to 2014, the percentage of adverse drug events associated with hypoglycemic agents improved for patients with diabetes and for those with and without renal disease.
    • From 2010 to 2014, the percentage of patients experiencing an adverse drug event with hypoglycemic agents improved for Whites and Blacks.
  • Groups With Disparities:
    • In 2014, the percentage of hospital patients who had adverse drug events with hypoglycemic agents was higher for those with renal disease (12.0%) than for those without renal disease (6.2%).
    • Also in 2014, the percentage of hospital patients who had adverse drug events with hypoglycemic agents was higher for those with diabetes (9.4%) than for those without diabetes (5.6%).
    • From 2010 to 2014, there were no statistically significant changes in the gap between minority groups and Whites in the percentage of patients who had adverse drug events associated with hypoglycemic agents. Similarly, there were no statistically significant changes in the gap between those with renal disease and those without.

Slide 30

Text Description is below the image.

Hospitalized adult patients with an anticoagulant-related adverse drug event with warfarin, by obesity and cerebrovascular disease status, 2010-2014

Image: Charts show hospitalized adult patients with an anticoagulant-related adverse drug event with warfarin:

Left Chart (Obesity):

  2010 2011 2012 2013 2014
Total 5.5 6.1 5.4 5.0 4.8
Obese 5.4 5.7 4.4 4.7 5.4
Not Obese 5.5 6.3 5.9 5.3 4.5

Right Chart (Cerebrovascular disease status):

  2010 2011 2012 2013 2014
Cerebrovascular disease 7.7 8.4 7.3 7.1 5.2
No cerebrovascular disease 4.9 5.6 5.0 4.5 4.7

Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2010–2014.
Denominator: Patients 18 and over who received warfarin and had their international normalized ratio measured during their hospital stay.

Notes: For this measure, lower percentages are better. Adverse events occurring the day of hospital arrival were excluded.

  • Importance: Blood clots in arteries and veins can cause a blockage of blood flow and lead to strokes and heart attacks. Survivors of stroke have an increased risk of another stroke, and individuals who are obese are at higher risk of blood clots. Anticoagulants, such as warfarin, reduce this risk but pose an increased risk of bleeding.
  • Overall Percentage: In 2014, 4.8% of adults using warfarin experienced an anticoagulant-related adverse drug event.
  • Trends: From 2010 to 2014, there were no statistically significant changes in the overall percentage of hospital patients with an adverse drug event related to warfarin.
  • Groups With Disparities:
    • In 2014, there were no statistically significant differences by obesity status or cerebrovascular disease status in the percentage of hospital patients who had an adverse drug event related to warfarin.
    • From 2010 to 2014, there were no statistically significant changes in the gap between obese patients and patients who were not obese in the percentage of patients who had a drug event related to warfarin. Similarly, there were no statistically significant changes in the gap between those with cerebrovascular disease and those without cerebrovascular disease.

Slide 31

Text Description is below the image.

Patient Safety in the Home Health Setting

  • Home health agencies provide services to beneficiaries who are homebound and need skilled nursing care or therapy.
  • Approximately 12 million individuals receive home health care from more than 33,000 providers for causes including acute illness, long-term health conditions, permanent disability, or terminal illness (NAHCH, 2010).
  • Improvements among home health patients can reflect the quality of care from home health agencies.
  • Measures include:
    • Home health care patients whose surgical wounds improved or healed, 2010-2015.
    • Home health patients with improvements in their ability to take medications orally, 2010-2015.
    • Interstate variation in rates of improvement in home health patients’ ability to take medications correctly by mouth, 2010-2015.

Slide 32

Text Description is below the image.

Home health care patients whose surgical wounds improved or healed, 2010-2015

Image: Chart shows home health care patients whose surgical wounds improved or healed:

  • 2010 - 80.
  • 2011 - 88.
  • 2012 - 89.
  • 2013 - 89.
  • 2014 - 89.4.
  • 2015 - 89.8.

2013 Achievable Benchmark: 94.2%.

Source: Centers for Medicare & Medicaid Services, Home Health Compare, 2010-2015.
Denominator: Number of home health episodes during the measurement period in which the patient of any age had a surgical wound and the episode ended with the patient discharged from home health care.

Notes:

  • Importance: Normal wound healing after an operation is an important marker of good care. The home health team should regularly change wound dressing and teach the patient about wound care.
  • Overall Percentage:
    • In 2015, the percentage of home health patients with improvement in their surgical wounds was close to 90% (89.8%).
  • Achievable Benchmark:
    • The 2013 top 5 State achievable benchmark for improvement in surgical wounds was 94.2%. The States and State-equivalent jurisdictions that have contributed to this benchmark are Idaho, Massachusetts, Mississippi, Puerto Rico, and South Carolina.
    • Based on current trends, the total population of home health patients with improvement in or healing of surgical wounds is estimated to reach the benchmark in 2017.

Slide 33

Text Description is below the image.

Home health care patients who got better at taking their drugs correctly by mouth, 2010-2015

Image: Chart shows home health care patients who got better at taking their drugs correctly by mouth:

  • 2010 - 43.
  • 2011 - 47.
  • 2012 - 49.
  • 2013 - 52.
  • 2014 - 53.
  • 2015 - 56.1.

2013 Achievable Benchmark: 60.7%.

Source: Centers for Medicare & Medicaid Services, Home Health Compare, 2010-2015.
Denominator: Number of home health care episodes in which a patient of any age was unable to take oral medications independently at the start of the episode that ended during the measurement period.

Notes:

  • Importance: Taking medications correctly is important to the health status and quality of life of individuals living in the community. The home health team can help teach a patient ways to organize drugs and take them properly.
  • Overall Percentages:
    • In 2015, the percentage of home health patients with improvement in their ability to take medications orally was 56.3%, compared with 46% in 2010..
  • Achievable Benchmark:
    • In 2013, the achievable benchmark for improvement in taking drugs correctly by mouth was 60.7%. The States that contributed to the achievable benchmark are Iowa, Massachusetts, New Jersey, North Dakota, and South Carolina.
    • Based on current trends, the total population of home health patients with improvement in their ability to take drugs correctly by mouth is estimated to reach the benchmark in 2017.

Slide 34

Text Description is below the image.

Relative change from 2010 to 2015 in how often patients got better at taking their drugs correctly by mouth, by State

Image: Map of the United States color-coded by state shows overall trends in the percentage of home health patients with improvement in their ability to take medications orally.

Source: Centers for Medicare & Medicaid Services, Home Health Compare, 2010-2015.
Denominator: Number of home health care episodes in which a patient of any age was unable to take oral medications independently at the start of the episode that ended during the measurement period.

Notes:

  • Overall: This map shows overall trends from 2010 to 2015 across 52 State-equivalent jurisdictions in relative increases in the percentage of home health patients with improvement in their ability to take medications orally. Increasing rates of change are preferable, although a State that performed well in 2010 would have less room for improvement. From 2010 to 2015, the relative rate of change across States ranged from 0.0% to 48.7%.
  • Differences by State:
    • First quartile (lowest amount of change): 0.0%-19.57% (AK, CA, DC, FL, GA, IL, LA, MA, NV, NH, NY, PR, TX).
    • Second quartile (second lowest amount of change): 19.78%-25.60% (AZ, CT, DE, HI, ME, MS, NM, OR, PA, RI, SC, TN, VA).
    • Third quartile (second highest amount of change): 25.61%-31.71% (AL, IN, KS, KY, MI, MO, MT, NJ, ND, UT, WA, WI, WY).
    • Fourth quartile (highest amount of change): 32.10%-48.65% (AR, CO, ID, IA, MD, MN, NE, NC, OH, OK, SD, VT, WV).
    • The change from 2010 to 2015 in the percentage of home health patients with improvement in their ability to take medications orally was lowest for patients in the District of Columbia (0.0% increase) and highest for Idaho (48.65% increase).
    • Most of the States in the Midwest and Mountain regions improved the most (in the 3rd or 4th quartiles).

Slide 35

Text Description is below the image.

Patient Safety in the Ambulatory Setting

  • Although patient safety initiatives frequently focus on inpatient hospital events, adverse effects of medical care may be identified and treated in outpatient settings.
  • Adverse effects of medical care can follow care or procedures in hospitals, emergency departments, physician offices, or other settings.
  • For more information, go to the Patient Safety Primer: Patient Safety in Ambulatory Care at https://psnet.ahrq.gov/primers/primer/16/patient-safety-in-ambulatory-care.

Slide 36

Text Description is below the image.

Measures of Patient Safety in the Ambulatory Setting

  • Patient safety and quality issues in outpatient medical offices, relative to safety culture.
  • Adults age 65 years and over who received potentially inappropriate prescription medications during the calendar year.
  • Percentage of hemodialysis patients with vascular catheter in use for 90 days or longer.
  • Events reported by ambulatory surgical facilities in Pennsylvania, by type and harm.

Slide 37

Text Description is below the image.

Patient safety and quality issues reported in outpatient medical offices, by frequency, November 2013–November 2015 combined

Image: Chart shows patient safety and quality issues by frequency of occurrence in outpatient medical offices:

Issue Daily or Weekly Occurrence Monthly Occurrence
Pharmacy contacts office to clarify or correct a prescription 27.0 12.0
Patient unable to get visit in 48 hours for an acute problem 15.0 7.0
Medication list not updated at last visit 11.0 7.0
Results from lab or imaging test not available when needed 9.0 10.0
Information exchange problems with pharmacies 12.0 8.0
Information exchange problems with other offices 9.0 11.0
Information exchange problems with outside labs or imaging centers 9.0 10.0

Source: AHRQ Medical Office Survey on Patient Safety Culture 2016 User Comparative Database Report, 2013-2015. http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/medical-office/2016/mosurvey2016pt1.pdf

Notes: For this measure, less frequent occurrences during the year are better. Office staff were asked how often these problems occurred over the past year. Not shown are response categories for "Several times over the past year" and "Not at all" (n=1,385 medical offices). Medical offices could submit their survey data to the Medical Office database in October and November 2015 for the 2016 Medical Office SOPS Comparative Database.

  • Importance: Most health care takes place in the outpatient (ambulatory care) setting. Lack of access to care and lack of access to timely and accurate medical information and test results may contribute to patient safety events such as missed or delayed diagnoses, medication errors, failure to order appropriate diagnostic or laboratory tests, incorrect interpretation of tests, and inadequate followup on results.
  • Overall Percentage:
    • More than one-quarter (27%) of medical offices participating in the AHRQ Medical Office Survey on Patient Safety Culture from November 2013 to November 2015 reported daily or weekly occurrences of being contacted by the pharmacist for clarification or correction of a prescription.
    • In terms of daily or weekly issues, medical offices were next most likely to report patients being unable to get an appointment within 48 hours for an acute or serious problem (15%), medical office having an information exchange problem with pharmacies (12%), and patients not having their medication list updated during their visit (11%).

Slide 38

Text Description is below the image.

Patient safety and quality issues reported in outpatient medical offices, by patient safety culture score quartile, November 2013–November 2015 combined

Image: Chart shows patient safety and quality issues by frequency of occurrence in outpatient medical offices:

Issue Offices in PSC Quartile 1
(Bottom)
Offices in PSC Quartile 2 Offices in PSC Quartile 3 Offices in PSC Quartile 4
(Top)
Pharmacy contacts office to clarify or correct a prescription 37.0 27.9 25.4 18.0
Patient unable to get visit in 48 hours for an acute problem 22.5 16.0 14.0 7.9
Medication list not updated at last visit 18.9 11.0 8.4 3.9
Results from lab or imaging test not available when needed 16.5 8.6 7.4 4.5
Information exchange problems with pharmacies 18.3 12.6 10.3 4.5
Information exchange problems with other offices 13.7 9.7 8.2 3.9
Information exchange problems with outside labs or imaging centers 12.8 9.6 8.7 4.4

Key: PSC = patient safety culture. An office's patient safety culture score is the average of the percent positive scores across all 10 composites in the Medical Office culture survey. The range of patient safety culture scores by quartile are: <65.4% for quartile 1; 65.4%-74.2% for quartile 2; 74.3%-83.2% for quartile 3; and >83.2% for quartile 4.
Source: Westat analysis of the AHRQ 2016 Medical Office Survey on Patient Safety Culture Database, 2013-2015.

Notes: Office staff were asked how often these problems occurred over the past year. Response categories include: Daily, Weekly, Monthly, Several times over the past year, and Not at all (n = 1,385 medical offices). Medical offices could submit their survey data to the Medical Office database in October and November 2015 for the 2016 Medical Office SOPS Comparative Database.

  • Importance: As medical offices aim to improve their performance, there is growing recognition of the importance of establishing a culture of patient safety.
  • Overall Percentage:
    • Patient safety and quality issues were less likely to be reported as occurring on a daily or weekly basis among medical offices with the highest patient safety culture (PSC) scores (PSC quartile 4) compared with medical offices with the lowest scores (PSC quartile 1).
    • The difference in frequency of reporting daily or weekly issues by medical offices with the lowest PSC scores compared with offices with the highest scores was more than fourfold for medication lists not being updated and information exchange problems with pharmacies; more than threefold for lab and imaging test results not being available and information exchange problems with other offices; and more than twofold for the other issues.

Slide 39

Text Description is below the image.

Adults age 65 and over who received at least 1 of 33 potentially inappropriate prescription medications for older adults in the calendar year, by sex and perceived health status, 2003–2014

Image: Charts show adults age 65 years and over who received potentially inappropriate prescription medications during the calendar year:

Left Chart (Sex):

Year Total Male Female
2003 18.5 13.5 22.3
2004 16.7 12.8 19.7
2005 17.7 14.4 20.2
2006 15.9 12.5 18.5
2007 15.5 12.0 18.1
2008 13.9 11.1 16.0
2009 13.4 10.7 15.4
2010 13.9 10.8 16.3
2011 12.9 10.5 14.9
2012 12.5 9.9 14.7
2013 11.4 9.5 13.0
2014 11.7 10.1 13.1

Right Chart (Perceived health status):

Year Excellent / Very Good / Good Fair / Poor
2003 16.7 24.5
2004 14.4 23.9
2005 15.8 23.6
2006 13.7 23.3
2007 13.6 21.8
2008 12.1 20.1
2009 11.5 19.5
2010 12.2 20.0
2011 11.6 18.2
2012 11.2 17.9
2013 10.5 15.2
2014 9.9 18.5

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2014.

Notes: For this measure, lower percentages are better. Prescription medications received include all prescribed medications initially purchased or otherwise obtained as well as any refills. For more information on inappropriate medications, see the American Geriatrics Society 2012 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012 Apr;60(4):616-31.

  • Importance: Some drugs that are prescribed for older patients are known to be potentially harmful for this age group.
  • Overall Percentage: In 2014, the percentage of adults age 65 years and over who received potentially inappropriate prescription medications was 11.7%.
  • Trends: From 2003 to 2014, the percentage of adults age 65 years and over who received potentially inappropriate prescription medications improved overall, for both sexes, and for people with excellent/very good/good health status and people with fair/poor health status.
  • Groups With Disparities:
    • In all years, the percentage of patients receiving potentially inappropriate medications was higher among females than males. This gap has not narrowed significantly over time.
    • In all years from 2003 to 2014, the percentage of patients receiving potentially inappropriate medications was higher among people with fair/poor health status compared with people with excellent/good health status. This gap has not narrowed significantly over time.

Slide 40

Text Description is below the image.

Hemodialysis patients age 18 years and over who had central venous catheters used for vascular access for more than 90 days, by State, July 2015-June 2016

Image: Map of the United States color-coded by state shows percentage of hemodialysis patients with central venous catheters used for vascular access for 90 days or longer.

Source: Centers for Medicare & Medicaid Services, Dialysis Facility Compare, July 1, 2015-June 30, 2016.
Denominator: Adult end stage renal failure patients on hemodialysis for more than 90 days in the period of July 1, 2015 through June 30, 2016.

Notes: For this measure, lower percentages are better. American Samoa, Guam, Northern Mariana Islands, and Virgin Islands are not shown on the map.

  • Importance: In hemodialysis patients, central venous catheters (CVCs) are frequently used for vascular access until a fistula or graft is ready for use. Compared with other forms of vascular access for hemodialysis, CVC use is associated with higher rates of infection and other adverse events (Pisoni, et. al., 2015). To decrease the likelihood of adverse events, CVCs should be used for 90 days or less.
  • Overall Percentage: Nationally, among adult end stage renal failure patients on any form of hemodialysis for 90 or more days during the observation period of July 1, 2015, through June 30, 2016, an average of 10% used CVCs for more than 90 days.
  • Differences by State: Percentages for State-equivalent jurisdictions and U.S. territories were provided as whole numbers (with multiple tied values). Therefore, the quartiles have varying numbers of States, and ranges are approximate.
    • First (lowest) quartile: 0%-9% (AL, AS, AZ, CO, CT, DC, DE, GA, HI, ID, KS, MP, OR, SC, UT, VI, WA).
    • Second (next to lowest) quartile: 10% (CA, GU, KY, LA, MS, MO, NV, NM, NC, TX, WY).
    • Third (next to highest) quartile: 11%-12% (AK, FL, IL, ME, MD, MA, MI, MN, NJ, ND, OH, PA, RI, SD).
    • Fourth (highest) quartile: 13%-20% (AR, IN, IA, MT, NE, NH, NY, OK, PR, TN, VA, VT, WV, WI).
    • Kansas and the U.S. Virgin Islands had the lowest nonzero percentages of dialysis patients using CVCs 90 days or longer (7%). At 20%, Puerto Rico had the highest percentage of long-term CVC use.

Slide 41

Patient safety events reported from ambulatory surgical facilities in Pennsylvania, by event type, 2005-2015 (combined)

Image: Pie chart shows distribution of reports by event type:

  • Falls - 2.6%.
  • Medication Error - 2.4%.
  • Error Related to Procedure/Treatment/Test - 18.3%.
  • Adverse Drug Reaction - 2.1%.
  • Complication of Procedure/Treatment/Test - 34.4%.
  • Skin Integrity - 3.5%.
  • Equipment/Supplies/Devices - 2.4%.
  • Other/Miscellaneous - 34.3%.

Source: Pennsylvania Patient Safety Authority, Pennsylvania Patient Safety Reporting System, January 1, 2005-December 31, 2015.

Notes: Transfusion and patient self-harm each account for less than 1% of patient safety events. Event categories refer to those in the Agency for Healthcare Research and Quality Common Formats.

  • Importance: Surgical procedures are frequently and increasingly performed in ambulatory settings. In 2010, ambulatory surgery cases in the United States totaled 18.7 million and accounted for almost two-thirds of all operations. Understanding the frequency of various types of events and the level of harm associated with each can aid providers and policymakers in setting priorities for improving safety in these settings. The Pennsylvania Patient Safety Authority analyzed patient safety events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) between 2005 and 2015. The chart shows the distribution of reports by event type.
  • Common Types of Events:
    • Pennsylvania ambulatory surgical facilities (ASFs) reported a total of 44,718 patient safety events between January 1, 2005, and December 31, 2015.
    • The three most commonly reported event types were Complication of Procedure, Treatment, or Test (34.4%), Other/Miscellaneous (34.3%), and Error Related to Procedure, Treatment, or Test (18.3%).
    • The top three areas within the Complication of Procedure, Treatment, or Test event type category for ASFs were return to the operating room, healthcare-acquired infections, and IV complications.
    • During this 11-year time period, more than 15,300 events reported were classified in the "Other/Miscellaneous" category. This category captures events that may not fit into the PA-PSRS taxonomy (e.g., inappropriate discharge, electric shock to patient), as well as events that fit into the existing PA-PSRS taxonomy but are not reported in the appropriate category. The latter situation may occur because the reporter is unfamiliar with the full PA-PSRS event type taxonomy.

Slide 42

Patient safety events reported from ambulatory surgical facilities in Pennsylvania, by event type and harm, 2005-2015 (combined)

Image: Chart shows number of patient safety events reports by harm and event type:

  Unsafe Condition Near- Miss Patient Event, No Harm Patient Event, Harm
Error Related to Procedure/Treatment/Test 1,063 1,274 5,294 553
Complication of Procedure/Treatment/Test 159 148 6,083 8,976
Equipment/Supplies/Devices 145 211 649 62
Fall 25 35 930 158
Skin Integrity 79 20 1,197 288
Adverse Drug Reaction 5 32 692 193
Other/Miscellaneous 1,989 2,362 7,939 3,054
Medication Error 38 100 914 32

Source: Pennsylvania Patient Safety Authority, Pennsylvania Patient Safety Reporting System, January 1, 2005-December 31, 2015.

Notes: Transfusions and patient self-harm accounted for fewer than 10 events. Event/harm categories refer to those in the Agency for Healthcare Research and Quality Common Formats. Unsafe condition is defined as any circumstance that increases the probability of a patient safety event. A near-miss is defined as a patient safety event that did not reach the patient. The AHRQ Common Formats refers to any event that reaches the patient, whether harm results or not, as an incident.

  • Importance: Surgical procedures are frequently and increasingly performed in ambulatory settings. In 2010, ambulatory surgery cases in the U.S. totaled 18.7 million and accounted for almost two-thirds of all operations. Understanding the frequency of various types of events and the level of harm associated with each can aid providers and policymakers in setting priorities for improving safety in these settings. The Pennsylvania Patient Safety Authority analyzed patient safety events reported through the Pennsylvania Patient Safety Reporting System between 2005 and 2015. The chart shows the number of reports by level of harm and event type.
  • Common Types of Event and Harm:
    • Events that reached the patient—with or without harm—were the most frequently reported overall.
    • Between 2005 and 2015, the event type accounting for the largest share of reported events involving harm or death was Complication of Procedure, Treatment, or Test.

Slide 43

Text Description is below the image.

Innovations Related to Ambulatory Surgery Facility Cancellations and Transfers

  • Issue: Comorbidities and lack of screening criteria place ambulatory surgery patients at risk for day-of-surgery (DOS) cancellations and medical complications that may require unexpected transfers to acute care inpatient facilities.
  • Intervention: Between December 2012 and June 2013, nurses at 11 freestanding ambulatory surgery facilities in Northeastern Pennsylvania used an evidence-based checklist to perform preoperative screening and assessments. Optional additions to the checklist included:
    • Calling patients preoperatively to review procedure-related responsibilities (e.g., colonoscopy preparation).
    • Using health literacy principles to enhance patient understanding of procedure-related activities.
  • Outcomes: Use of nursing-based preoperative screening and assessment led to fewer DOS cancellations with no significant reduction in transfers to acute care inpatient facilities.

Notes:

  • Background: This intervention was motivated in part by analyses of patient safety events reported by ambulatory surgery facilities through the Pennsylvania Patient Safety Reporting System. The results indicated that 43% of event reports related to preoperative screening or assessment from June 2004 to December 2008 involved patient harm (i.e., reported as a Serious Event), most often a complication requiring transfer to an acute care setting. In addition, a lack of screening or assessment processes was identified as contributing to day-of-surgery (DOS) cancellations. DOS cancellations may directly affect patient safety and result in delayed care. They can also lead to interruptions and distractions in the surgical schedule and in daily workflow.
  • Intervention Results: For DOS cancellations, there was a statistically significant relative reduction of 9.7%, going from 29.6/1,000 completed procedures in the pre-intervention phase (July-November 2012) to 26.8/1,000 during the intervention phase (December 2012-June 2013). This reduction included transportation-related DOS cancellations, protocol-related DOS cancellations, and no-show DOS cancellations. While unexpected DOS transfers to acute care inpatient facilities fell from 1.21 to 1.03 transfers per 1,000 ambulatory surgery center admissions, this 14.7% relative reduction was not statistically significant.
  • Resources:

Slide 44

Text Description is below the image.

Patient Safety Infrastructure

  • Efforts to improve patient safety have been accompanied by various infrastructure enhancements.
  • One example of continued growth and maturation is shown by AHRQ’s Patient Safety Organizations, which can aggregate data across providers to identify patterns of hazards from care delivery and accelerate learning.

Slide 45

Text Description is below the image.

Patient Safety Organizations

  • Patient safety organizations (PSOs) aim to reduce preventable adverse events, near misses, and unsafe conditions in all health care settings.
  • PSOs provide an environment for health care providers to voluntarily report, discuss, and learn from patient safety events and quality analyses on a privileged and confidential basis.
  • Measures include:
    • Number of patient safety event reports submitted to CHPSO (formerly the California Hospital Patient Safety Organization).
    • Trend in reports of high-harm events relative to all patient safety events submitted to CHPSO.

Note:

Slide 46

Text Description is below the image.

Patient Safety Organizations: AHRQ Common Formats

  • AHRQ Common Formats provide a standardized method for PSOs, health care providers, and other organizations to collect and report patient safety events.
    • Data element standards are important for aggregating and analyzing events across providers.
  • AHRQ Common Formats have been developed for a variety of settings of care:
    • Hospitals.
    • Nursing facilities.
    • Community pharmacies.

Note:

Slide 47

Text Description is below the image.

Mining PSO Event Data To Increase Reporting and Reduce Patient Harm

Image: Patient Safety Event Reports from PSO members are gathered into CHPSO and used to generate Annual Reports and examples of Lessons Learned and Actions Taken. These documents are captioned: "Partnering on data analysis to improve perinatal safety in California."

Key: CHPSO = California Hospital Patient Safety Organization.

Notes:

  • Background: CHPSO is a component of the Hospital Quality Institute. CHPSO provides an example of how PSOs can mine the data they collect from members to improve patient safety and encourage reporting.
  • Uses of Patient Safety Event Reports:
    • CHPSO generates patient safety dashboards that feed back a variety of event-related metrics (e.g., event types, harm, top drug classes involved) for each member provider compared with all members. Members share this information internally with safety, quality, and risk management teams and with their board of directors. The dashboard also encourages event reporting to have more reliable data.
    • CHPSO makes learning from aggregated event report information available to the general public through its annual report. The publicly available annual report showcases patterns of event reports for all member hospitals, as well as PSO and member actions to improve safety based on the analyses. For example, a recent annual report presented evidence that medication errors involving Vancomycin were often associated with testing and monitoring.
    • CHPSO leverages their database for high-priority research in their home State. The Hospital Quality Institute received funding from the California HealthCare Foundation to mine CHPSO data in order to identify vulnerabilities in perinatal care and cesarean deliveries. Findings are of value to hospitals and insurers, as recent policy changes link rates to participation in the State health insurance exchange.

Slide 48

Text Description is below the image.

CHPSO Event Reporting and Harm (June 2007–December 2015)

Image: Line graph shows CHPSO Event Reporting and Harm: Source: Communication with CHPSO, July 2016.

Notes: "Total reports reviewed" refers to the number of patient safety event reports submitted to CHPSO, including those in which the degree of patient harm is unknown. "All harm" refers to the number of patient safety event reports submitted to CHPSO in which the degree of patient harm is known. "High harm" refers to the number of patient safety event reports submitted to CHPSO with severe harm or death.

  • Background:
    • Two cornerstones of health care quality and safety improvement programs in the United States are reporting events and reducing patient harm from events.
    • The California Hospital Patient Safety Organization (CHPSO) uses a measure, the harm ratio, that encourages reporting of patient safety events. It reflects the ratio of patient safety event reports with high harm to all event reports where the degree of harm is known and is calculated for PSO members individually and in aggregate.
    • High-harm events, when they occur, tend to get reported because they are very visible and required or incentivized by various regulatory and accrediting agencies. However, reporting of unsafe conditions, near-misses, and lower harm events is very important because the information can shed light on mechanisms for preventing events from reaching the patient and causing harm.
  • Overall Trends:
    • The number of patient safety event reports submitted to CHPSO has steadily increased over time from 5,673 reports of events that occurred in July 2007 to 10,357 reports of events that occurred in December 2015. The drop in volume for events that occurred after May 2015 is attributed to the lag in time for submitting events.
    • In July 2007, more than 4% of event reports involved high harm to the patient. This number declined to less than 1% by December 2015, indicating that the number of non-high-harm events reported had more than quadrupled compared with high-harm events during the 10 years.

Slide 49

Text Description is below the image.

References

Slide 50

Text Description is below the image.

References

  • Centers for Disease Control and Prevention. Urinary Tract Infections (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection [USI]) Events. Device-associated module. 2016b. http://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf. Accessed July 19, 2017.
  • Dudeck MA, Edwards JR, Allen-Bridson K, et al. National Healthcare Safety Network report, data summary for 2013, Device-associated Module. Am J Infect Control 2015;43(3):206-21. http://doi.org/10.1016/j.ajic.2014.11.014. Accessed July 19, 2017.
  • Hines AL, Jiang HJ. Rates of obstetric trauma, 2009. Healthcare Cost and Utilization Project, Statistical Brief #129. Rockville, MD: Agency for Healthcare Research and Quality; April 2012. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb129.pdf. Accessed July 19, 2017.
  • Institute of Medicine. Preventing Medication Errors: Quality Chasm Series. 2007. http://www.nap.edu/catalog/11623/preventing-medication-errors-quality-chasm-series. Accessed July 19, 2017.
  • National Association for Home Care & Hospice. Basic Statistics About Home Care. Updated 2010. http://www.nahc.org/assets/1/7/10hc_stats.pdf (403 KB). Accessed July 19, 2017.
  • Pisoni RL, Zepel L, Port FK, et al. Trends in U.S. vascular access use, patient preferences, and related practices: an update from the U.S. DOPPS practice monitor with international comparisons. Am J Kidney Dis 2015;65(6):905-15.
Page last reviewed September 2017
Page originally created March 2016
Internet Citation: Chartbook on Patient Safety: Slide Presentation. Content last reviewed September 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/chartbooks/patientsafety/patientsafety-slides.html