Agency for Healthcare Research and Quality Patient Safety Indicators

The Agency for Healthcare Research and Quality (AHRQ) is a federal agency for research on health care quality, costs, outcomes and patient safety. AHRQ has created software that screens billing records for adverse events (potentially preventable complications) that patients sometimes experience while receiving medical care. University Hospitals tracks and analyzes these events (called patient safety indicators, or PSIs) in an effort to prevent future occurrences.

How PSIs are measured and evaluated

The indicators use administrative data and try to measure potentially preventable complications for patients who received their initial care and experienced complications during the same hospitalization period.

  • Post Operative Hemorrhage or Hematoma : Unexpected bleeding after surgery

  • Post Operative Pulmonary Embolism or DVT (serious blood clots after surgery): When patients stay still for a long time after some types of surgery, they’re more likely to develop a serious blood clot in the veins of the legs, thighs, or pelvis. This is especially true for patients who are very frail or sick. A blood clot can also break off and travel to other parts of the body. If a blood clot gets into a patient’s lung, it’s a serious problem that can cause death. Some patients may get blood clots even though doctors order treatments to prevent them. However, if a hospital has a higher rate of serious blood clots after surgery, it may be a sign that doctors and nurses aren’t doing enough to prevent them.

  • Post Operative Respiratory Failure (breathing failure after surgery): This refers to patients who were unable to breathe after surgery without the help of a ventilator (a machine that helps someone breathe).

    If patients have breathing problems after surgery, doctors usually order special treatment (respiratory therapy) to make sure they get enough oxygen into their bloodstream. Even so, some patients may not be able breathe on their own, especially if they were very frail or sick to begin with. However, if a hospital has a higher rate of breathing failure among its surgical patients, it may be a sign that it isn’t providing high-quality and effective care.

Agency for Healthcare Research and Quality Patient Safety Indicators
UH Case Medical Center Academic Medical Center Mean
Post Operative Hemorrhage or Hematoma 3.659/1,000 patients 3.89/1,000 patients
Post Operative Pulmonary Embolism or DVT 8.993/1,000 patients 9.18/1,000 patients
Post Operative Respiratory Failure 11.815/1,000 patients 11.40/1,000 patients

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