Patient Safety Surgical Adverse Events/Complications Report
As a part of the Utah/Missouri Patient Safety Demonstration Project, the Missouri Department of Health and Senior Services developed the Potential Surgical Adverse Events/Complications Report. The report, generated from the Patient Abstract System (PAS) database, is provided to all acute care hospitals to highlight the types of potential surgery-related adverse events observed among hospitalized patients in Missouri acute care hospitals, based on hospital-reported discharge data.
A panel of 29 healthcare experts from around the nation participated in evaluating a list of 1,192 ICD-9-CM codes across three dimensions: 1) medical care causality (e.g., resulting from the medical management and intervention), 2) patient harm and 3) preventability. Following the rating exercise, the list was whittled to 1,003 codes. The codes are currently being evaluated by medical record review for their ability to predict, or point to adverse events due to medical care causation. The codes, grouped into 67 adverse event classifications, were used to select cases for the baseline review conducted in the summer and early fall of 2002. Sixteen categories of the code classification relate to potential surgical adverse events and are the basis of the Potential Surgical Adverse Events Reports. See the Clinical Codes Used for Potential Surgical Adverse Events for a complete list of ICD-9-CM codes by event category.
The report consists of three tables. Table
1 reports hospital-specific occurrence of potential
adverse events/complications for inpatient surgical discharges
for a rolling, four quarter time period. Table
2 reports potential adverse events/complications for
surgical inpatient discharges, for all Missouri acute care
hospitals, for the calendar year 2001. To provide some measures
of surgical patients at-risk for adverse events, statistics
are also provided on the percent of discharges with length
of stay (LOS) greater than 7 days, the percent more than
64 years of age, and the percent who expired. The aggregate
data are also stratified by metro and non-metro hospital
location. Table
3 provides a detailed listing of discharges with potential
adverse events by event category for a given hospital and
provides the first event or trigger ICD-9-CM code that appeared
on the PAS data set. The listing enables hospital examination
of individual cases as necessary to supplement other patient
safety monitoring activities. For a detailed description
of the report and how to interpret it, see the Missouri
Patient Safety Report Guide.
Acute care hospitals are encouraged to examine the report
findings and validate them against internal quality improvement
and patient safety monitoring systems. Analysis of any systemic
factors that may contribute to a pattern of surgical adverse
events should follow. The reports can be of significant
assistance to hospitals that have limited or no access to
comparative data relevant to surgical outcomes and adverse
events. The report can also identify trends in coding that
can positively or negatively affect a given potential adverse
event rate and may point to areas where expanded efforts
are needed to improve patient safety.
On receipt of the report, quality directors or patient safety officers should evaluate their individual rates of potential adverse events considering the state, metro and non-metro rates. Are the rates high or low? Are the rates substantiated or refuted by data tracked within the hospital? Do the rates indicate a need to further evaluate patient safety in a particular area? As information, the reports should generate questions such as these and stimulate further investigation if answers are not readily evident.
As an example, hospital X’s rate of accidental cut, puncture or hemorrhage, ICD-9-CM code 998.2, is 0.9% (Table 1). How does this finding stack up against the hospital’s rate of occurrence for this code? Is this an indicator the hospital follows? Has the code been profiled and tracked by physician over time? Has a trend (type of surgery, surgeon, equipment failure, etc.) been identified or were occurrences felt to be random, within acceptable limits or unpreventable? In some instances, the reports may be a catalyst for further study and implementation of improvement activities to prevent future occurrences and improve patient safety.
Rather than creating additional work, the reports are intended as another source of information for a specialized group of indicators. The reports can help hospitals by increasing awareness of and focusing attention on potential adverse surgical events and patient safety.
For additional information about the reports, contact Carolyn
Link, Project Manager, Utah/Missouri Patient Safety
Demonstration Project, Missouri Department of Health and
Senior Services.
