Chartbook on Patient Safety

Measures of Patient Safety in the Hospital Setting

• Hospitals are a common setting for patient safety events:
  • Many patients admitted to the hospital are in a clinically compromised state.
  • Many care transactions and interventions take place during a hospital stay.
• Measures include:
  • Overall hospital-acquired conditions (HACs).
  • Healthcare-associated infections (HAIs).
  • Procedure-related events.

Overall Hospital-Acquired Conditions

Distribution of hospital-acquired conditions, based on national rates per 1,000 hospital adult discharges, 2010-2013

Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2010-2013; Centers for Disease Control and Prevention, National Healthcare Safety Network, 2010-2013; and Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2010-2011, and 2012 State Inpatient Databases quality analysis file.

Notes: Data are for patients age 18 years and over. Estimates are rounded to the nearest tenth. All Other HACs includes the following: inadvertent femoral artery puncture for catheter angiographic procedures, adverse event associated with hip joint replacement, adverse event associated with knee joint replacement, contrast nephropathy associated with catheter angiography, hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA), hospital-acquired vancomycin-resistant Enterococcus (VRE), hospital-acquired antibiotic-associated C. difficile, mechanical complications associated with central venous catheters, postoperative cardiac events for cardiac and noncardiac surgeries, postoperative pneumonia, iatrogenic pneumothorax, postoperative hemorrhage or hematoma, postoperative respiratory failure, and accidental puncture or laceration.

• Importance: Patient safety events that occur in the hospital setting are not uncommon and are known as HACs.
• Overall Rate: In 2013, the national overall HAC rate was 121 per 1,000 hospital discharges. Adverse drug events (40.3 per 1,000 hospital discharges) accounted for 33.3% of total HACs and pressure ulcers (32.5 per 1,000 hospital discharges) accounted for 26.9% of the total.
• Change Over Time: From 2010 to 2013, the overall rate of hospital-acquired conditions declined from 145 to 121 per 1,000 hospital discharges.

Patient Safety in the Hospital Setting: Healthcare-Associated Infections

• Infections acquired during hospital care—also known as nosocomial infections—are among the most common complications of hospital care.
• HAIs often increase the patient's length of stay in the hospital, risk of mortality, and hospital costs.
  • New infections in critically ill infants and children generally reduce their chances for recovery.
• Antibiotic prophylaxis may prevent or reduce some infections.
• Proper insertion and management of central lines can also lower infection rates significantly.

Measures of Patient Safety in the Hospital Setting: Healthcare-Associated Infections

• Postoperative sepsis per 1,000 adult discharges with an elective operating room procedure.
• Standardized infection ratios for central line-associated bloodstream infections and surgical site infections.
• Bloodstream infections per 1,000 central-line days in neonatal intensive care units.
• Bloodstream infections per 1,000 central-line days in adult intensive care units.

Postoperative Sepsis

Postoperative sepsis per 1,000 adult discharges with an elective operating room procedure, by insurance status and patient race/ethnicity, 2008-2011

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Key: API = Asian or Pacific Islander.

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2008-2011, and AHRQ Quality Indicators, modified version 4.1.

Denominator: All elective hospital surgical discharges for patients age 18 years and over with length of stay of 4 or more days, excluding patients admitted for infection, those with cancer or immunocompromised states, those with obstetric conditions, and admissions specifically for sepsis.

Note: Acute care hospitalizations only. For this measure, lower rates are better. Rates are adjusted by age, sex, age-sex interactions, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers into the hospital. White, Black, and API are non-Hispanic. Hispanic includes all races.

• Overall Rate: In 2011, the postoperative sepsis rate was 16.4 per 1,000 adult discharges with an elective operating room procedure.
• Change Over Time: From 2008 through 2011, the rate of postoperative sepsis did not change overall or for any insurance or racial/ethnic group.
• Groups With Disparities: In 2011, Medicaid and Medicare patients had higher rates of postoperative sepsis compared with those who were privately insured. Asian and Pacific Islander patients, Hispanic patients, and Black patients had higher rates of postoperative sepsis than their White counterparts.

Postoperative Sepsis in California

Postoperative sepsis per 1,000 adult discharges with an elective operating room procedure, by patient language, California, 2009-2011 (combined)

Key: API = Asian and Pacific Islander; languages include Chinese, Hindi, Japanese, Korean, Tagalog, Thai, Vietnamese, Lao, Mandarin, Cantonese, Hmong, Ilocano, Iu Mien, Indonesian, Mon-Khmer, Tonga, Urdu, Burmese, Telugu, Bengali, Tamil, Gujarati, Panjabi, Malayalam, Marathi, Kannada, Chamorro, Fijian, Filipino, Central Khmer, Mongolian, Nepali, Sinhala, and Samoan.

Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, State Inpatient Databases, California, 2009-2011, and AHRQ Quality Indicators, version 4.5 with the use of indication of diagnoses being present on admission and day of procedure.

Denominator: All elective hospital surgical discharges for patients age 18 years and over with length of stay of 4 or more days, excluding patients admitted for infection, those with cancer or immunocompromised states, those with obstetric conditions, and admissions specifically for sepsis.

Note:  Acute care hospitalizations only. For this measure, lower rates are better. Rates are adjusted by age, sex, age-sex interactions, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers into the hospital.

• Groups With Disparities: From January 2009 through December 2011, there were no statistically significant differences in rates of postoperative sepsis in California by language spoken.

Standardized Infection Ratios

Standardized infection ratios for central line-associated bloodstream infections and surgical site infections, 2011-2012

Key: CLABSI = central line-associated bloodstream infection; SSI = surgical site infection; SCIP = Surgical Care Improvement Project.

Source: Centers for Disease Control and Prevention, 2010 and 2011 National and State Healthcare-Associated Infections Standardized Infection Ratio Reports, and 2012 National and State Healthcare Associated Infections Progress Report.

Notes: Acute care hospitalizations only. For this measure, lower numbers are better. A standardized infection ratio of less than one means that hospitals had fewer infections than those of a similar type and size during the January 2006 to December 2008 referent period. For example, a ratio of 0.84 for SSIs means the SSI rate in 2011 was 16% lower than in 2006-2008 for similar hospitals. There were 3,468 facilities that reported CLABSI rates to the National Healthcare Safety Network in 2011 and 3,516 facilities in 2012. SCIP procedures refer to procedures performed on adults. These procedures include abdominal aortic aneurysm repair, peripheral vascular bypass surgery, coronary artery bypass graft with chest and donor site incisions or with chest incision only, other cardiac surgery, colon surgery, rectal surgery, hip arthroplasty, abdominal hysterectomy, knee arthroplasty, and vaginal hysterectomy.

• Overall Rate: In 2012, the overall central line-associated bloodstream infection (CLABSI) standardized infection ratio (SIR) among intensive care units in the 50 States, District of Columbia, and Puerto Rico was 0.56 and the national SIR for surgical site infections (SSIs) following 10 procedures was 0.80.
• Change Over Time: From 2011 to 2012, both CLABSIs and SSIs decreased by about 4% among facilities reporting to the National Healthcare Safety Network (NHSN) in both years.

Change in Standardized Infection Ratios

Change in State-specific hospital SIRs for CLABSI in adults, 2011-2012

Source: Centers for Disease Control and Prevention, 2012 National and State Healthcare-Associated Infections Progress Report.

Notes: Acute care hospitalizations only. For this measure, lower numbers are better. There were 3,468 facilities that reported CLABSI rates to NHSN in 2011 and 3,516 facilities in 2012.

• Geographic Variation: In 2012, two jurisdictions—Alaska and Puerto Rico—had SIRs greater than one, indicating more CLABSIs than hospitals of similar type and size during the referent period (January 2006 to December 2008).
• Change Over Time:
  • Of 52 reporting jurisdictions from 2011 to 2012, 37 had no change in CLABSI SIRs, 11 jurisdictions decreased, and 4 States increased.
  • States that reported a CLABSI SIR decrease from 2011 to 2012 were more likely than the group of States that did not change or that experienced a CLABSI rate increase to have a State mandate at the beginning of 2012 to report CLABSI rates to the NHSN.

Bloodstream Infections in Neonatal Intensive Care Units

Central line-associated bloodstream infections per 1,000 central-line days, by birth weight of child in Level III neonatal intensive care units, 2009-2012

Source: Centers for Disease Control and Prevention, National Healthcare Safety Network, 2006-2012.

Denominator: Infections per 1,000 central-line days.

Note: For this measure, lower rates are better

• Groups With Disparities: In 2012, among patients in the Level III NICU, pooled mean CLABSI rates ranged from a low of 0.6 infections per 1,000 central-line days among neonates born at 1,501 to 2,500 grams to a high of 2.3 infections per 1,000 central-line days among neonates born at less than or equal to 750 grams.

Bloodstream Infections in Adult Intensive Care Units

Central line-associated bloodstream infections per 1,000 central-line days in adult medical vs. medical/surgical intensive care units,by hospital teaching status, 2006-2011

Source: Centers for Disease Control and Prevention, National Healthcare Safety Network, 2006–2012.

Denominator: Infections per 1,000 central-line days.

Note:  Acute care hospitalizations only. For this measure, lower rates are better. Three types of teaching hospitals are defined in the NHSN: major facilities with programs for medical students and postgraduate training, graduate facilities with programs for postgraduate medical training, and undergraduate facilities with programs for medical students only.

• Change Over Time: From 2006-2008 (combined) to 2011, rates of CLABSIs in hospitals decreased 54% among adult medical ICU patients in hospitals with major teaching programs, 33% among adult medical/surgical ICU patients in hospitals with major teaching programs, 42% among adult medical ICU patients in all other (non-major teaching) hospitals, and 40% among adult medical/surgical ICU patients in all other (non-major teaching) hospitals.

Measures of Patient Safety in the Hospital Setting: Procedure-Related Events

• Unadjusted mortality rate (%) 30 days postoperation for colorectal surgeries among U.S. hospitals participating in the American College of Surgeons (ACS)-National Surgical Quality Improvement Program (NSQIP).
• Percentage of adult patients receiving hip joint replacement because of fracture or degenerative conditions who experienced adverse events.
• Percentage of adults with mechanical adverse events associated with central venous catheter placement.

Mortality After Colorectal Surgery

Unadjusted mortality rate (%) 30 days postoperation for colorectal surgeries among ACS-NSQIP participating hospitals in the United States, by hospital teaching status and race/ethnicity, 2008-2013 

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Source: American College of Surgeons (ACS), National Surgical Quality Improvement Program (NSQIP), 2008-2013.

Notes: For this measure, lower rates are better. These data may not represent U.S. hospitals, as participation in ACS NSQIP is voluntary and current participation is weighted when calculating rates; participating hospitals have changed over the 2008-2013 time interval (i.e., some hospitals have dropped out and others have enrolled); and 32% more hospitals participated in 2013 than 2008.Some portion of the variation in raw mortality rate observed over time may be due to these sampling issues. White and Black are non-Hispanic. Hispanic includes all races. 

• Importance: Colon and rectal procedures are ranked among the most harmful procedures, with high rates of postoperative complications, which are often a result of nonadherence to best practices.
• Overall Rate: In 2013, the unadjusted rate of 30-day postoperative mortality for colorectal surgeries was 2.9% among ACS-NSQIP participating hospitals in the United States.
• Change Over Time:
  • From 2008 to 2013, unadjusted rates of 30-day postoperative mortality for colorectal surgery decreased by 34% among nonteaching hospitals and by 30% among teaching hospitals.
  • Rates decreased by 44% among Hispanics, 27% among Blacks, and 33% among Whites.
• Groups With Disparities:
  • Unadjusted rates of 30-day postoperative mortality for colorectal surgery patients were higher in nonteaching hospitals than teaching hospitals across all years except 2012.
  • In 2013, Blacks had higher rates and Hispanics had lower rates compared with Whites.

Adverse Events After Hip Joint Replacement

Adult patients receiving hip joint replacement because of fracture or degenerative conditions who experienced adverse events, by age and sex, 2009-2012

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Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services (CMS), Medicare Patient Safety Monitoring System (MPSMS), 2009–2012.

Note:  For this measure, lower rates are better. The 2012 MPSMS data sample drawn from the CMS Inpatient Quality Reporting Program included medical records from hospitals throughout the United States that reported on at least one of four conditions (acute myocardial infarction, heart failure, pneumonia, and Surgical Care Improvement Project). Hospitals in Puerto Rico, the Virgin Islands, and Maryland were not included in the sample.

• Importance: Hip replacement is most common among older adults, who have an increased risk of adverse events after these surgeries.
• Overall Rate: In 2012, 6.5% of adult patients receiving hip joint replacement because of fracture or degenerative conditions experienced adverse events.
• Change Over Time:
  • From 2009 to 2012, the percentage of adverse events among patients ages 65-74 years who had a hip replacement increased from 5.1% to 6.0%.
  • The percentage decreased among women from 8.3% to 6.8%.
• Groups With Disparities:
  • In 2009, 2010, and 2011, a higher percentage of patients age 85 years and over who received a hip joint replacement experienced an adverse event compared with those ages 65-74 years.
  • In 2012, a higher percentage of patients ages 75-84 years who received a hip joint replacement experienced an adverse event compared with those ages 65-74 years.

Mechanical Adverse Events After Central Venous Catheter Placement

Adults with mechanical adverse events associated with central venous catheter placement, by age and race, 2009-2012

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Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2009-2012.

Denominator: Selected discharges of hospitalized patients age 18 years and over with central venous catheter placement.

Note:  For this measure, lower rates are better. Mechanical adverse events include allergic reaction to the catheter, tamponade, perforation, pneumothorax, hematoma, shearing off of the catheter, air embolism, misplaced catheter, thrombosis of embolism, knotting of the pulmonaryartery catheter, and certain other events. White and Black are non-Hispanic. Data for age 85+ for 2012 did not meet the criteria for statistical reliability.

• Importance: The placement and use of central venous catheters can result in mechanical adverse events, including bleeding, hematoma, perforation, pneumothorax, air embolism, and misplacement, occlusion, shearing, or knotting of the catheter.
• Overall Rate: In 2012, 3.5% of adults with central venous catheter placements experienced an associated mechanical adverse event.
• Change Over Time: From 2009 to 2012, the percentage of adults with central venous catheter placements who had a mechanical adverse event increased for patients ages 65-74 years (from 3.2% to 3.9%) and for patients ages 75-84 years (from 3.1% to 3.7%).
• Groups With Disparities:
  • From 2009 to 2012, the percentage of Black adults with central venous catheter placements who had a mechanical adverse event decreased to 2.7% from 8.5%.
  • The percentage of White adults who had a mechanical adverse event remained between 3% and 4% during this time.

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