title: Using patient safety indicators to estimate the impact of potential adverse events on outcomes.
abstract: The authors estimated the impact of potentially preventable patient safety events, identified by Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs), on patient outcomes: mortality, length of stay (LOS), and cost. The PSIs were applied to all acute inpatient hospitalizations at Veterans Health Administration (VA) facilities in fiscal 2001. Two methods-regression analysis and multivariable case matching- were used independently to control for patient and facility characteristics while predicting the effect of the PSI on each outcome. The authors found statistically significant (p < .0001) excess mortality, LOS, and cost in all groups with PSIs. The magnitude of the excess varied considerably across the PSIs. These VA findings are similar to those from a previously published study of nonfederal hospitals, despite differences between VA and non-VA systems. This study contributes to the literature measuring outcomes of medical errors and provides evidence that AHRQ PSIs may be useful indicators for comparison across delivery systems.
authors.affiliation: VA Boston Healthcare System, USA.
authors.forename: Peter E
authors.initials: PE
authors.lastname: Rivard
authors.forename: Stephen L
authors.initials: SL
authors.lastname: Luther
authors.forename: Cindy L
authors.initials: CL
authors.lastname: Christiansen
authors.lastname: Shibei Zhao
authors.forename: Susan
authors.initials: S
authors.lastname: Loveland
authors.forename: Anne
authors.initials: A
authors.lastname: Elixhauser
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Romano
authors.forename: Amy K
authors.initials: AK
authors.lastname: Rosen
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D036262:Empirical Research; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D008297:Male; D008485:Medical Audit; D019300:Medical Errors / Q000517:prevention & control; D008875:Middle Aged; D011785:Quality Assurance, Health Care / Q000379:methods*; D019984:Quality Indicators, Health Care; D017751:Safety Management / Q000592:standards*; D014481:United States