title: Detecting patient safety indicators: How valid is "foreign body left during procedure" in the Veterans Health Administration?
abstract: BACKGROUND
  The Agency for Healthcare Research and Quality (AHRQ) developed patient safety indicator (PSI) 5, "Foreign body left during procedure," to flag accidental foreign bodies in surgical and medical procedures. This study examined how well this indicator identifies true foreign body events in the Veterans Health Administration (VA).
  
  
  METHODS
  This was a retrospective study within 28 selected VA hospitals from fiscal year 2003 to 2007. Trained abstractors reviewed medical charts flagged by PSI 5 and determined true foreign body cases. We calculated the positive predictive value (PPV) of this indicator and performed descriptive analyses of true positive and false positive cases.
  
  
  RESULTS
  Of the 652,093 eligible cases, 93 were flagged by PSI 5 (0.14 per 1,000). Forty-two were true positives, yielding a PPV of 45% (95% CI 35% to 56%). False positives were due to a foreign body that was present on admission (57%) or coding errors (43%). True foreign bodies were associated with surgical (n = 23) and medical (n = 19) procedures. The most common type of surgical foreign body was a sponge (52%). Overall, approximately 40% of foreign bodies were related to a device failure or malfunction (30% surgical vs 53% medical foreign bodies). Postoperative complications included pain (24%), infection (12%), adhesions (5%), and bowel obstruction (5%).
  
  
  CONCLUSIONS
  The reported rate of foreign body events as detected by PSI 5 is low in the VA, but occurs in both surgical and medical procedures. Despite widespread implementation of surgical counts, quality improvement efforts should focus on novel ways to eliminate this "never event" from operations. Future studies are needed to better understand the preventability of medical procedure-associated foreign bodies and particularly, device failure-related foreign bodies.
authors.affiliation: Center for Organization, Leadership, and Management Research (COLMR), Boston, MA, USA.
authors.forename: Qi
authors.initials: Q
authors.lastname: Chen
authors.forename: Amy K
authors.initials: AK
authors.lastname: Rosen
authors.forename: Marisa
authors.initials: M
authors.lastname: Cevasco
authors.forename: Marlena
authors.initials: M
authors.lastname: Shin
authors.forename: Kamal M F
authors.initials: KM
authors.lastname: Itani
authors.forename: Ann M
authors.initials: AM
authors.lastname: Borzecki
mesh_terms: D000368:Aged; D059019:Clinical Coding / Q000592:standards; D015986:Confounding Factors, Epidemiologic; D003430:Cross-Sectional Studies; D005189:False Positive Reactions; D005260:Female; D005547:Foreign Bodies / Q000150:complications / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D006302:Health Services Research; D006787:Hospitals, Veterans / Q000706:statistics & numerical data*; D006801:Humans; D007297:Inpatients; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D011237:Predictive Value of Tests; D019984:Quality Indicators, Health Care / Q000592:standards* / Q000639:trends; D015203:Reproducibility of Results; D012107:Research Design; D012189:Retrospective Studies; D012307:Risk Factors; D017751:Safety Management / Q000592:standards*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology