• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).



• AHRQ quality indicators. Patient safety indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar 10. 107 p.

Does not apply to this measure

This measure is used to assess the number of deaths per 1,000 patients having developed specified complications of care during hospitalization.

Hospitals in the United States provide the setting for some of life's most pivotal events - the birth of a child, major surgery, treatment for otherwise fatal illnesses. These hospitals house the most sophisticated medical technology in the world and provide state-of-the-art diagnostic and therapeutic services. But access to these services comes with certain costs. About 30% of personal health care expenditures in the United States go towards hospital care, and the rate of growth in spending for hospital services has only recently leveled out after several years of increases following a half a decade of declining growth. Simultaneously, concerns about the quality of health care services have reached a crescendo with the Institute of Medicine's series of reports describing the problem of medical errors and the need for a complete restructuring of the health care system to improve the quality of care. Policymakers, employers, and consumers have made the quality of care in U.S. hospitals a top priority and have voiced the need to assess, monitor, track, and improve the quality of inpatient care.

Widespread consensus exists that health care organizations can reduce patient injuries by improving the environment for safety from implementing technical changes, such as electronic medical record systems, to improving staff awareness of patient safety risks. Clinical process interventions also have strong evidence for reducing the risk of adverse events related to a patient's exposure to hospital care. Patient Safety Indicators (PSIs), which are based on computerized hospital discharge abstracts from the AHRQ's Healthcare Cost and Utilization Project (HCUP), can be used to better prioritize and evaluate local and national initiatives. Analyses of these and similar inexpensive, readily available administrative data sets may provide a screen for potential medical errors and a method for monitoring trends over time.

The Death Among Surgical Inpatients with Serious Treatable Complications indicator* is intended to identify patients who die following the development of a complication. The underlying assumption is that good hospitals identify these complications quickly and treat them aggressively.

*The following concerns affect the validity of this indicator:

• Adverse consequences: Use of this indicator may have undesirable effects, such as increasing inappropriate antibiotic use.
• Stratification suggested: This indicator includes some high risk patient groups and stratification is recommended when examining rates.
• Unclear preventability: As compared to other Patient Safety Indicators (PSIs), the conditions included in this indicator may be less preventable by the health system.
• Heterogeneous severity: This indicator includes codes that encompass several levels of severity of a condition that cannot be ascertained by the codes.

Refer to the original measure documentation for further information.

Death; inpatients; serious treatable complications

All surgical discharges, 18 years and older, defined by specific Diagnosis-Related Groups (DRGs) and an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for an operating room procedure, principal procedure within 2 days of admission OR admission type of elective with potential complications of care listed in Death among Surgical definition (e.g., pneumonia, deep vein thrombosis/pulmonary embolism [DVT/PE], sepsis, shock/cardiac arrest, or gastrointestinal [GI] hemorrhage/acute ulcer)

Exclude cases:

• Age 90 years and older
• Neonatal patients in Major Diagnostic Category (MDC) 15
• Transferred to an acute care facility

Note: Additional exclusion criteria are specific to each diagnosis. Refer to the Technical Specifications document for details and for specific DRGs and ICD-9-CM codes.

Discharges with a disposition of "deceased" among cases meeting the inclusion and exclusion rules for the denominator

• A formal consensus procedure involving experts in relevant clinical, methodological, and organizational sciences
• One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Variation in quality for the performance measured

• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).

Current routine use

Internal quality improvement
National reporting
Quality of care research

Hospitals

Physicians

Individual Clinicians

Age 18 to 74 years

Either male or female

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Unspecified

Getting Better

Safety

Users of care only

All surgical discharges, 18 years and older, defined by specific Diagnosis-Related Groups (DRGs) and an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for an operating room procedure, principal procedure within 2 days of admission OR admission type of elective with potential complications of care listed in Death among Surgical definition (e.g., pneumonia, deep vein thrombosis/pulmonary embolism [DVT/PE], sepsis, shock/cardiac arrest, or gastrointestinal [GI] hemorrhage/acute ulcer) (see the "Denominator Inclusions/Exclusions" field)

Patients associated with provider

Inclusions
All surgical discharges, 18 years and older, defined by specific Diagnosis-Related Groups (DRGs) and an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for an operating room procedure, principal procedure within 2 days of admission OR admission type of elective with potential complications of care listed in Death among Surgical definition (e.g., pneumonia, deep vein thrombosis/pulmonary embolism [DVT/PE], sepsis, shock/cardiac arrest, or gastrointestinal [GI] hemorrhage/acute ulcer)

Exclusions
Exclude cases:

• Age 90 years and older
• Neonatal patients in Major Diagnostic Category (MDC) 15
• Transferred to an acute care facility

Note: Additional exclusion criteria are specific to each diagnosis. Refer to the Technical Specifications document for details and for specific DRGs and ICD-9-CM codes.

All cases in the denominator are equally eligible to appear in the numerator

Clinical Condition
Institutionalization
Patient Characteristic
Therapeutic Intervention

Time window is a single point in time

Inclusions
Discharges with a disposition of "deceased" among cases meeting the inclusion and exclusion rules for the denominator

Exclusions
Unspecified

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Institutionalization

Administrative data

Not Individual Case

Adverse Outcome

Unspecified

Rate

Better quality is associated with a lower score

Analysis by high-risk subgroup (stratification on vulnerable populations)
Analysis by subgroup (stratification on patient factors, geographic factors, etc.)
Risk adjustment method widely or commercially available

This indicator includes some high risk patient groups and stratification is recommended when examining rates.

Risk adjustment of the data is recommended using age, sex, modified Diagnosis-Related Group (DRG), and comorbidity categories.

Application of multivariate signal extraction (MSX) to smooth risk adjusted rates is also recommended.

External comparison at a point in time
External comparison of time trends
Internal time comparison

The Patient Safety Indicators (PSIs) were evaluated by the project team using empirical analyses to explore the frequency and variation of the indicators, the potential bias, based on limited risk adjustment, and the relationship between indicators. The data sources used in the empirical analyses were the 1997 Florida State Inpatient Database (SID) for initial testing and development and the 1997 Healthcare Cost and Utilization Project (HCUP) State Inpatient Database for 19 States for the final empirical analyses.

All potential indicators were examined empirically by developing and conducting statistical tests for precision, bias, and relatedness of indicators. Three different estimates of hospital performance were calculated for each indicator:

1. The raw indicator rate was calculated using the number of adverse events in the numerator divided by the number of discharges in the population at risk by hospital.
2. The raw indicator was adjusted to account for differences among hospitals in age, gender, modified Diagnosis-Related Group (DRG), and comorbidities.
3. Multivariate signal extraction methods were applied to adjust for reliability by estimating the amount of "noise" (i.e., variation due to random error) relative to the amount of "signal" (i.e., systematic variation in hospital performance or reliability) for each indicator.

The project team constructed a set of statistical tests to examine the precision, bias, and relatedness of indicators for all accepted Provider-level Indicators, and precision and bias for all accepted Area-level Indicators. It should be noted that rates based on fewer than 30 cases in the numerator or the denominator are not reported.

The project team conducted a structured review of each indicator to evaluate the face validity (from a clinical perspective) of the indicators. The methodology for the structured review was adapted from the RAND/UCLA Appropriateness Method and consisted of an initial independent assessment of each indicator by clinician panelists using an initial questionnaire, a conference call among all panelists, followed by a final independent assessment by clinician panelists using the same questionnaire. The review sought to establish consensual validity, which "extends face validity from one expert to a panel of experts who examine and rate the appropriateness of each item..." The panel process served to refine definitions of some indicators, add new measures, and dismiss indicators with major concerns from further consideration.

Refer to the original measure documentation for additional details.

• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).

Death among surgical inpatients with serious treatable complications (PSI 4).

Agency for Healthcare Research and Quality

Agency for Healthcare Research and Quality (AHRQ)

The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators are in the public domain and the specifications come from multiple sources, including the published and unpublished literature, users, researchers, and other organizations. AHRQ as an agency is responsible for the content of the indicators.

None

National Quality Forum

National Healthcare Disparities Report (NHDR)
National Healthcare Quality Report (NHQR)

This indicator was originally proposed by Silber and colleagues (1992) as a more powerful tool than risk-adjusted mortality rate to detect true differences in patient outcomes across hospitals. The underlying premise was that better hospitals are distinguished not by having fewer adverse occurrences but by more successfully averting death among (i.e., rescuing) patients who experience such complications. More recently, Needleman and Buerhaus (2001) adapted Failure to Rescue to administrative data sets, hypothesizing that this outcome might be sensitive to nurse staffing.

2003 Mar

2008 Mar

This is the current release of the measure.

This measure updates previous versions:

• AHRQ quality indicators. Guide to patient safety indicators [version 3.0a]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2006 May 1. 78 p. (AHRQ Pub; no. 03-R203).
• AHRQ quality indicators. Patient safety indicators: technical specifications [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2007 Mar 12. 107 p.

• AHRQ quality indicators. Guide to patient safety indicators [version 3.1]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ)AHRQ Pub; 2007 Mar 12. 76 p. (AHRQ Pub; no. 03-R203).



• AHRQ quality indicators. Patient safety indicators: technical specifications [version 3.2]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2008 Mar 10. 107 p.

This NQMC summary was completed by ECRI on October 1, 2003. The information was verified by the measure developer on October 29, 2003. This NQMC summary was updated by ECRI on February 7, 2005 and on April 11, 2006. The information was verified by the measure developer on July 31, 2006. This NQMC summary was updated by ECRI Institute on June 12, 2007 and again on October 15, 2008.

No copyright restrictions apply.