Patient safety indicators of the US Agency for Healthcare Research and Quality49
| Indicator topic | Empirical average* | Drawback |
|---|---|---|
| *Per 1000 population at risk; represents the average performance for a nationwide sample of hospitals. Obtained from AHRQ analysis using the 2000 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for 29 states. Risk adjusted for age, sex, diagnosis related group (DRG), and comorbidity categories. | ||
| Complications of anesthesia | 0.55 | Definition varies; underreporting; unspecific denominator; unknown validity |
| Death in low mortality DRGs | 0.66 | Mixed severity; no published evidence of “explicit process” and “staffing” construct validity |
| Decubitus ulcer | 21.5 | Mixed severity; case mix bias; underreporting; conflicting validity evidence |
| Failure to rescue | 174.24 | May be unpreventable; mixed severity; perverse influence |
| Foreign body left during procedure | 0.09 | Non-specific denominator; rare; needs stratification |
| Iatrogenic pneumothorax | 0.67 | Non-specific denominator; unknown validity |
| Selected infections due to medical care | 1.99 | Perverse influence; underreporting |
| Postoperative hemorrhage or hematoma | 2.06 | Case mix bias; non-specific denominator; needs stratification |
| Postoperative hip fracture | 0.80 | Case mix bias; non-specific denominator |
| Postoperative physiological and metabolic derangement | 0.89 | Definition may vary; no published construct validity evidence |
| Postoperative pulmonary embolism or deep venous thrombosis | 9.19 | Needs stratification; may be underreported |
| Postoperative respiratory failure | 3.59 | Case mix bias; event may be unavoidable |
| Postoperative sepsis | 10.91 | Definition may vary; perverse effects; unclear construct validity |
| Postoperative wound dehiscence | 1.93 | Case mix bias; unclear construct validity evidence |
| Accidental puncture or laceration | 3.29 | Underreporting; may be unpreventable |
| Transfusion reaction | 0.004 | Rare; needs stratification; unknown validity |
| Birth trauma (injury to neonate) | 6.67 | Definition may vary; mixed severity; unclear construct validity |
| Obstetric trauma (Cesarean delivery) | 5.93 | Case mix bias; may be unpreventable; unclear construct validity |
| Obstetric trauma (vaginal delivery with instrument) | 244.08 | Case mix bias; may be unpreventable; unclear construct validity |
| Obstetric trauma (vaginal delivery without instrument) | 86.60 | Case mix bias; may be unpreventable; unclear construct validity |