Detecting adverse events in surgery: Comparing events detected by the Veterans Health Administration Surgical Quality Improvement Program and the Patient Safety Indicators

American Journal of Surgery

Volumn 207, Issue 4, 2014, Pages 584-595

  Mull, Hillary J ^a,b   Borzecki, Ann M ^c,d   Loveland, Susan ^a   Hickson, Kathleen ^c,e   Chen, Qi ^a   Macdonald, Sally ^c   Shin, Marlena H ^a   Cevasco, Marisa ^a,e   Itani, Kamal M F ^a,b,e   Rosen, Amy K ^a,b  

^a VA BOSTON HEALTHCARE SYSTEM   (United States)

^b BOSTON UNIVERSITY SCHOOL OF MEDICINE   (United States)

^c VETERANS AFFAIRS MEDICAL CENTER   (United States)

^d BOSTON UNIVERSITY   (United States)

^e HARVARD MEDICAL SCHOOL   (United States)

Author keywords

Administrative data; Adverse surgical events; Patient Safety Indicators; VA Surgical Quality Improvement Program; Veterans Health Administration

Indexed keywords

ARTICLE; CLINICAL INDICATOR; COMPUTER PROGRAM; CRITERION RELATED VALIDITY; HOSPITALIZATION; HUMAN; MEDICAL RECORD REVIEW; PATIENT SAFETY INDICATOR; POSTOPERATIVE COMPLICATION; PREDICTIVE VALUE; PRIORITY JOURNAL; RETROSPECTIVE STUDY; SENSITIVITY AND SPECIFICITY; VETERANS HEALTH ADMINISTRATION SURGICAL QUALITY IMPROVEMENT PROGRAM;

ADMINISTRATIVE DATA; ADVERSE SURGICAL EVENTS; PATIENT SAFETY INDICATORS; VA SURGICAL QUALITY IMPROVEMENT PROGRAM; VETERANS HEALTH ADMINISTRATION;

HOSPITAL RECORDS; HOSPITALS, VETERANS; HUMANS; INCIDENCE; POSTOPERATIVE COMPLICATIONS; PREDICTIVE VALUE OF TESTS; QUALITY ASSURANCE, HEALTH CARE; QUALITY IMPROVEMENT; SURGICAL PROCEDURES, OPERATIVE; UNITED STATES; UNITED STATES DEPARTMENT OF VETERANS AFFAIRS;

EID: 84897107414     PISSN: 00029610     EISSN: 18791883     Source Type: Journal    
DOI: 10.1016/j.amjsurg.2013.08.031     Document Type: Article

References (42)

1. J. Bruce, E.M. Russell, and J. Mollison et al. The measurement and monitoring of surgical adverse events Health Technol Assess 5 2001 1 194
2. J.A. Morris, Y. Carrillo, and J.M. Jenkins et al. Surgical adverse events, risk management, and malpractice outcome: morbidity and mortality review is not enough Ann Surg 237 2003 844 851
3. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson To Err is Human: Building a Safer Health System 1999 National Academy Press Washington, DC
4. P.J. Pronovost, C.A. Goeschel, and J.A. Marsteller et al. Framework for patient safety research and improvement Circulation 119 2009 330 337
5. A.K. Jha, G.J. Kuperman, and J.M. Teich et al. Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report J Am Med Inform Assoc 5 1998 305 314
6. J.M. Naessens, C.R. Campbell, and J.M. Huddleston et al. A comparison of hospital adverse events identified by three widely used detection methods Int J Qual Health Care 21 2009 301 307
7. S. Olsen, G. Neale, and K. Schwab et al. Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place Qual Saf Health Care 16 2007 40 44
8. L.L. Leape, T.A. Brennan, and N. Laird et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II N Engl J Med 324 1991 377 384
9. S.F. Khuri, J. Daley, and W. Henderson et al. The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care Ann Surg 228 1998 491 507
10. K.M. Itani Fifteen years of the National Surgical Quality Improvement Program in review Am J Surg 198 suppl 2009 S9 18
11. C.L. Davis, J.R. Pierce, and W. Henderson et al. Assessment of the reliability of data collected for the Department of Veterans Affairs National Surgical Quality Improvement Program J Am Coll Surg 204 2007 550 560
12. B.L. Hall, B.H. Hamilton, and K. Richards et al. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals Ann Surg 250 2009 363 376
13. W.G. Henderson, and J. Daley Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg 198 suppl 2009 S19 S27
14. D.L. Davenport, C.W. Holsapple, and J. Conigliaro Assessing surgical quality using administrative and clinical data sets: a direct comparison of the University HealthSystem Consortium Clinical Database and the National Surgical Quality Improvement Program data set Am J Med Qual 24 2009 395 402
15. D.A. Hanauer, M.J. Englesbe, and J.A. Cowan et al. Informatics and the American College of Surgeons National Surgical Quality Improvement Program: automated processes could replace manual record review J Am Coll Surg 208 2009 37 41
16. M.R. Miller, A. Elixhauser, and C. Zhan et al. Patient Safety Indicators: using administrative data to identify potential patient safety concerns Health Serv Res 36 2001 110 132
17. Agency for Healthcare Research and Quality. AHRQ Patient Safety Indicators overview. Available at: http://www.qualityindicators.ahrq.gov/ Modules/psi-overview.aspx. Accessed May 3, 2011.
18. A.K. Rosen, P. Rivard, and S. Zhao et al. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data? Med Care 43 2005 873 884
19. B.J. Weiner, J.A. Alexander, and L.C. Baker et al. Quality improvement implementation and hospital performance on patient safety indicators Med Care Res Rev 63 2006 29 57
20. C. Zhan, and M.R. Miller Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization JAMA 290 2003 1868 1874
21. P. Rivard, A. Elixhauser, and C. Christiansen et al. Testing the association between patient safety indicators and hospital structural characteristics in VA and nonfederal hospitals Med Care Res Rev 67 2010 321 341
22. A.N. West, W.B. Weeks, and J.P. Bagian Rare adverse medical events in VA inpatient care: reliability limits to using patient safety indicators as performance measures Health Serv Res 43 2008 249 266
23. P.S. Romano, H.J. Mull, and P.E. Rivard et al. Validity of selected AHRQ patient safety indicators based on VA National Surgical Quality Improvement Program data Health Serv Res 44 2009 182 204
24. Agency for Healthcare Research and Quality AHRQ quality indicator: National Quality Forum (NQF) endorsed composite and individual measures (June 2010) 2010 Agency for Healthcare Research and Quality Rockville, MD
25. Centers for Medicare and Medicaid Services. Hospital Compare. Available at: http://www.cms.gov/HospitalQualityInits/11-HospitalCompare.asp. Accessed November 16, 2013.
26. K. Henderson, A. Recktenwald, and R. Reichley et al. Clinical validation of the AHRQ postoperative venous thromboembolism patient safety indicator Jt Comm. J Qual Patient Saf 35 2009 370 376
27. G. Utter, J. Cuny, and P. Sama et al. Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator? J Am Coll Surg 211 2010 347 354
28. A.K. Rosen, K.M. Itani, and M. Cevasco et al. Validating the patient safety indicators in the Veterans Health Administration: do they accurately identify true safety events? Med Care 50 2012 74 85
29. R.R. Cima, K.A. Lackore, and S.A. Nehring et al. How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution Surgery 150 2011 943 949
30. Agency for Healthcare Research and Quality AHRQ guide to Patient Safety Indicators version 3.1a 2007 Agency for Healthcare Research and Quality Rockville, MD
31. K.M. McDonald, P.S. Romano, and J.J. Geppert et al. Measures of Patient Safety Based on Hospital Administrative Data: The Patient Safety Indicators 2002 Agency for Healthcare Research and Quality Rockville, MD
32. Agency for Healthcare Research and Quality Patient Safety Indicators Technical Specifications version 4.1 (October 2010) 2010 Agency for Healthcare Research and Quality Rockville, MD
33. VA Office of Information and Technology. VistAWeb Overview. Available at: http://vista.med.va.gov/vistaweb/. Accessed May 3, 2011.
34. VA Information Resource Center. Veterans Health Information Systems and Technology Architecture (VistA), VistA data for research 2012. Available at: http://www.virec.research.va.gov/VistA/Overview.htm. Accessed August 13, 2012.
35. J. Neily, P.D. Mills, and N. Eldridge et al. Incorrect surgical procedures within and outside of the operating room Arch Surg 144 2009 1028 1034
36. P.J. Lavrakas Encyclopedia of Survey Research Methods 2008 Sage Thousand Oaks, CA
37. R.E. Gearing, I.A. Mian, and J. Barber et al. A methodology for conducting retrospective chart review research in child and adolescent psychiatry J Can Acad Child Adolesc Psychiatry 15 2006 126 134
38. G.H. Utter, A.M. Borzecki, and A.K. Rosen et al. Designing an abstraction instrument: lessons from efforts to validate the AHRQ patient safety indicators Jt Comm J Qual Patient Saf 37 2011 20 28
39. Hussey PS, Mattke S, Morse L, et al. Evaluation of the Use of AHRQ and Other Quality Indicators. Program Evaluation: Final Contract Report. AHRQ Publication No. 08-M012-EF. Available at: http://www.ahrq.gov/about/evaluations/ qualityindicators/2007. Accessed November 16, 2013.
40. D.W. Bratzler The Surgical Infection Prevention and Surgical Care Improvement Projects: promises and pitfalls Am Surg 72 2006 1010 1016
41. E.J. Thomas, S.R. Lipsitz, and D.M. Studdert et al. The reliability of medical record review for estimating adverse event rates Ann Intern Med 136 2002 812 816
42. H.C. Polk, J.N. Lewis, and M.K. Ali et al. The complementary value of trained abstractors and surgeons in the more accurate assessment of surgical quality Am J Med Qual 25 2010 444 448