Table 1.
Mean Annual Adverse Medical Events, Cases at Risk, Smoothed Patient Safety Indicators (PSI) Rates, and Standard Errors for 1997–2005
| PSIs (in Order of Frequency): | (4) Failure to Rescue | (3) Decubitus Ulcer | (15) Accidental Puncture or Laceration | (12) Post operative Pulmonary Embolism or Deep Vein Thrombosis | (7) Selected Infections Due to Medical Care | (11) Post operative Respiratory Failure | (6) Iatrogenic Pneumo thorax | (9) Post operative Hemor rhage or Hematoma | (14) Post operative Wound Dehiscence | (13) Post operative Sepsis | (10) Post operative Physiologic or Metabolic Derangement | (1) Compli cations of Anesthesia | (8) Post operative Hip Fracture |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| For the entire VA* | |||||||||||||
| Adverse events | 3,322.8 | 2,925.0 | 1,210.7 | 1,032.3 | 627.6 | 472.3 | 372.4 | 306.0 | 133.8 | 122.3 | 91.6 | 60.2 | 29.8 |
| Cases at risk | 22,090 | 20,9838 | 45,3532 | 98,100 | 336,662 | 34,844 | 427,209 | 98,321 | 19,889 | 18,834 | 46,265 | 98,881 | 71,293 |
| PSI rate | 1,498.9 | 157.0 | 39.0 | 87.4 | 14.7 | 99.0 | 10.7 | 26.4 | 33.1 | 58.2 | 17.8 | 6.0 | 5.6 |
| Standard error | 23.0 | 3.2 | 0.9 | 3.1 | 0.8 | 5.0 | 0.4 | 1.5 | 3.1 | 7.3 | 1.4 | 0.9 | 0.6 |
| PSI rate/SE | 65.2 | 49.1 | 43.3 | 28.2 | 18.4 | 19.8 | 26.8 | 17.6 | 10.7 | 8.0 | 12.7 | 6.7 | 9.3 |
| Per VISN† | |||||||||||||
| Adverse events | 151.0 | 133.0 | 55.0 | 46.9 | 28.5 | 21.5 | 16.9 | 13.9 | 6.1 | 5.6 | 4.2 | 2.7 | 1.4 |
| Cases at risk | 1,004 | 9,538 | 20,615 | 4,459 | 15,302 | 1,584 | 19,419 | 4,469 | 904 | 856 | 2,103 | 4,495 | 3,241 |
| PSI rate | 1,446.6 | 148.3 | 39.2 | 87.6 | 15.1 | 97.4 | 9.6 | 24.5 | 24.4 | 62.6 | 14.2 | 6.5 | 4.9 |
| Standard error | 105.3 | 15.9 | 4.3 | 14.3 | 3.8 | 20.3 | 1.6 | 5.4 | 7.8 | 33.9 | 5.2 | 4.0 | 2.7 |
| PSI rate/SE | 13.7 | 9.3 | 9.1 | 6.1 | 4.0 | 4.8 | 6.0 | 4.5 | 3.1 | 1.8 | 2.7 | 1.6 | 1.8 |
| Per hospital‡ | |||||||||||||
| Adverse events | 26.2 | 23.0 | 9.4 | 8.4 | 4.9 | 4.1 | 2.9 | 2.5 | 1.2 | 1.1 | 0.8 | 0.5 | 0.2 |
| Cases at risk | 172 | 1,632 | 3,526 | 762 | 2,618 | 271 | 3,322 | 763 | 155 | 146 | 359 | 766 | 554 |
| PSI rate | 1,410.6 | 155.6 | 33.5 | 88.5 | 14.9 | 91.8 | 7.4 | 22.5 | 21.7 | 78.2 | 11.2 | 7.0 | 3.9 |
| Standard error | 192.4 | 43.3 | 9.8 | 30.3 | 9.0 | 31.1 | 2.6 | 7.4 | 8.8 | 70.9 | 6.9 | 7.3 | 4.7 |
| PSI rate/SE | 7.3 | 3.6 | 3.4 | 2.9 | 1.7 | 3.0 | 2.8 | 3.0 | 2.5 | 1.1 | 1.6 | 1.0 | 0.8 |
Note: Mean PSI rates and standard errors are expressed as cases per 10,000 patients at risk.
*
Averaged across all 9 years, 1997–2005.
†
Averaged across all 22 VISNs within each year, then across all 9 years.
‡
Averaged across all hospitals within each year, then across all 9 years.