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How Often are Potential Patient Safety Events Present on Admission?

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Background: Data fields that capture whether diagnoses are present on admission (POA)—distinguishing comorbidities from potential in-hospital complications—became part of the Uniform Bill for hospital claims in 2007. The AHRQ Patient Safety Indicators (PSIs) were initially developed as measures of potential patient safety problems that use routine administrative data without POA information. The impact of adding POA information to PSIs was examined.

Methods: Data were used from California (CA) and New York (NY) Healthcare Cost and Utilization Project (HCUP) state inpatient databases for 2003, which include POA codes. Analysis was limited to 13 of 20 PSIs for which POA information was relevant, such as complications of anesthesia, accidental puncture, and sepsis.

Results: In New York, 17% of cases revealed suspect POA coding, compared with 1%–2% in California. After suspect records were excluded, 92%–93% of secondary diagnoses in both CA and NY were POA. After incorporating POA information, most cases of decubitus ulcer (86%–89%), postoperative hip fracture (74%–79%), and postoperative pulmonary embolism/deep vein thrombosis (54%–58%) were no longer considered in-hospital patient safety events.

Discussion: Three of 13 PSIs appear not to be valid measures of in-hospital patient safety events, but the remaining 10 appear to be potentially useful measures even in the absence of POA codes.

Document Type: Research Article

Publication date: March 1, 2008

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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