BACKGROUND/RATIONALE:
Ensuring patient safety has become a high priority for all health care systems. Little is known, however, about the number of patient safety events that typically occur during a hospitalization. Administrative data are known to be a practical method for identifying in-hospital complications, and may therefore also be useful as a method for identifying patient safety events. In this study, we assess the feasibility of using administrative data from the Department of Veterans Affairs to calculate Patient Safety Indicators, known as PSIs, that were developed by the Agency for Healthcare Research and Quality (AHRQ) and modified by the Evidence-based Practice Center at Stanford University. The VA is an ideal setting in which to explore this because it contains rich clinical information on patients as well as documented information on patients' utilization.

OBJECTIVE(S):
Our specific objectives were to assess the ability of VA administrative data to identify potential instances of compromised patient safety in the inpatient acute care setting, to determine the construct validity of PSIs based on VA inpatient data, to validate PSIs using other VA quality data (National Surgical Quality Improvement Program, NSQIP), to identify factors that explain variation in PSI rates, to compare VA and non-VA PSI rates, and to explore variation in safety practices across VA facilities with low vs. high PSI rates.

METHODS:
We developed algorithms and other methods to adapt VA Patient Treatment File (PTF) data for use with PSI software. We obtained NSQIP data and developed methods to match NSQIP and PTF data for assessment of PSI sensitivity and specificity. We used hierarchical Poisson and Bayesian methods to control for statistical artifacts of the inherently low rates of PSI events when comparing event rates across VA facilities. We obtained American Hospital Association and VA NQIS (National Quality Improvement Survey) data and analyzed facility-level predictors of variation in PSI rates. We worked with AHRQ to set up comparable VA and non-VA databases in order to compare PSI rates. We developed an interview protocol, recruited four VA facilities for site visits, and initiated site visits to explore variation in safety practices.

FINDINGS/RESULTS:
A paper on adapting VA administrative data for use with PSIs apperared in an AHRQ compendium on patient safety early in 2005. A paper evaluating use of the PSIs on VA data appeared in Medical Care September 2005. Preliminary study results were presented to the VA National Center for Patient Safety in Fall of 2004. Extensive analysis of the statistical properties of the VA PSI rates and associated variables supported our propositions that VA administrative data are a rich source of information on safety and quality, and that they can be used to identigy potenial instances of compromised patient safety. Hospitalizations with PSI events are consistenly associated with greater lengths of stay, higher estimated costs, and higher mortality rates, compared to hospitalizations without PSI events. We identified 0,974 PSI events in the VA nationwide in FY '01 and 12,165 in FY '04. Observed PSI rates per 1,000 discharges ranged from 0.007 ro "transfusion reaction" to 126.75 for "failure torescue" in FY'04. Comparisons of VA and non-VA risk-adjusted PSI rates showed that VA rates were slightly higher for 10 out of 15 relevant PSIs. Hospitalizations with PSI events had greater lengths of stay, higher mortality, and higher costs than those without PSI events. We found meaningful variation in rates across VA facilities and VISNs for most PSIs. Certain surgical PSIs have moderately high levels of sensitivity when compared with NSQIP.

IMPACT:
These findings may affect the VA’s future patient safety initiatives at the national, VISN, and/or facility levels.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Rivard PE, Rosen AK, Carroll JS. Enhancing patient safety through organizational learning: Are patient safety indicators a step in the right direction? Health services research. 2006 Aug 1; 41(4 Pt 2):1633-53. [view]
2. Rosen AK, Rivard P, Zhao S, Loveland S, Tsilimingras D, Christiansen CL, Elixhauser A, Romano PS. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data? Medical care. 2005 Sep 1; 43(9):873-84. [view]
3. Tsilimingras D, Rosen AK, Berlowitz DR. Patient safety in geriatrics: a call for action. The journals of gerontology. Series A, Biological sciences and medical sciences. 2003 Sep 1; 58(9):M813-9. [view]
4. Nelson A, Weaver FM. Promoting evidence-based practice in spinal cord injury/disorders health care. SCI nursing : a publication of the American Association of Spinal Cord Injury Nurses. 2004 Jul 1; 21(3):129-135. [view]
5. Reker DM, Rosen AK, Hoenig H, Berlowitz DR, Laughlin J, Anderson L, Marshall CR, Rittman M. The hazards of stroke case selection using administrative data. Medical care. 2002 Feb 1; 40(2):96-104. [view]
6. Rosen AK, Zhao S, Rivard P, Loveland S, Montez-Rath ME, Elixhauser A, Romano PS. Tracking rates of Patient Safety Indicators over time: lessons from the Veterans Administration. Medical care. 2006 Sep 1; 44(9):850-61. [view]
7. Rivard PE, Luther SL, Christiansen CL, Shibei Zhao, Loveland S, Elixhauser A, Romano PS, Rosen AK. Using patient safety indicators to estimate the impact of potential adverse events on outcomes. Medical care research and review : MCRR. 2008 Feb 1; 65(1):67-87. [view]
8. Singer S, Meterko M, Baker L, Gaba D, Falwell A, Rosen AK. Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey. Health services research. 2007 Oct 1; 42(5):1999-2021. [view]

Reports

1. Rivard PE, Elwy AR, Loveland S, Zhao S, Tsilimingras D, Elixhauser A, Romano PS, Rosen AK. Applying Patient Safety Indicators (PSIs) Across Health Care Systems: Achieving Data Comparability. Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb 1. Report No.: 050021. [view]

Conference Presentations

1. Shimada SL, Montez-Rath ME, Loveland SA, Zhao S, Kressin NR, Rosen AK. Are Minorities at Higher Risk of Patient Safety Events in the VA? Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 3; Orlando, FL. [view]
2. Shimada SL, Montez-Rath ME, Loveland SA, Zhao S, Kressin NR, Rosen AK. Are Minorities at Higher Risk of Patient Safety Events in the VA? Poster session presented at: VA HSR&D National Meeting; 2007 Feb 16; Arlington, VA. [view]
3. Loveland S, Rosen AK. Can Readmissions Serve as a Quality Indicator? Poster session presented at: VA HSR&D National Meeting; 2009 Feb 14; Baltimore, MD. [view]
4. Rivard P, Zhao S, Loveland S, Christiansen C, Elixhauser A, Rosen A. Estimating Increased Mortality, Cost and Length of Stay Associated with Safety Events: An Application of Patient Safety Indicators in the Veterans Health Administration. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 4; San Diego, CA. [view]
5. Christiansen CL, Elixhauser A, Loveland SA, Rivard PE, Zhou S, Rosen AK. How Do VA Hospitals Compare to Non-VA Hospitals on Rates of Patient Safety Events? Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
6. Rosen AK, Rivard PE, Zhao S, Tsilimingras D, Loveland SA, Christiansen CL, Henderson W, Khuri S, Elixhauser A, Romano PS. Identification of Patient Safety Events from VA Administrative Data: Is It Valid. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA. [view]
7. Rivard P, Parker V, Rosen AK. Moving Patient Safety Improvement Practices to the Next Level: Closing the Organizational Learning Loop. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 3; Orlando, FL. [view]
8. Zhao S, Elwy R, Loveland S, Tsilimingras D, Elixhauser A, Romano P, Rivard P, Rosen A. Patient Safety Indicators: Comparing Rates in the VA and Non-VA Settings. Paper presented at: VA HSR&D National Meeting; 2004 Mar 17; Washington, DC. [view]
9. Christiansen CL, Rivard PE, Zhao S, Loveland S, Tsilimingras D, Rosen AK. Using Patient Safety Indicators to Identify VA Outlier Hospitals: A Picture is Worth 1000 Statistics. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
10. Christiansen C, Rivard P, Tsilimingra D, Zhao S, Loveland S, Rosen A. Using Patient Safety Indicators to Identify VA Outlier Hospitals: A Picture is Worth 1000 Statistics. Paper presented at: AcademyHealth Annual Research Meeting; 2005 Feb 1; Boston, MA. [view]
11. Tsilimingras D, Romano P, Christiansen C, Henderson W, Khuri S, Elixhauser A, Rivard P, Loveland S, Zhao S, Rosen A. Validating AHRQ Patient Safety Indicators with NSQIP Postoperative Adverse Events. Paper presented at: AcademyHealth Annual Research Meeting; 2005 Jun 26; Boston, MA. [view]

DRA: Health Systems Science
DRE: none
Keywords: Adverse events, Organizational issues, Safety
MeSH Terms: none