New AHRQ Internet tool checks patient safety

The Agency for Healthcare Research and Quality (AHRQ) in Rockville, MD, has developed a new web-based tool that can help hospitals enhance their patient safety performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care. Hospitals then investigate to determine whether the problems detected were caused by potentially preventable medical errors or have some other explanations.

"The first step in reducing the nation’s toll of medical errors is to identify when they occur and why, and then develop strategies to improve patient safety. This goal is central to efforts to combat this problem," said Health and Human Services Secretary Tommy G. Thompson, who announced the AHRQ Patient Safety Indicators at the recent National Patient Safety Foundation Fifth Annual Congress in Washington, DC.

The Patient Safety Indicators — at — are part of a major AHRQ program to improve the safety of patients in hospitals, outpatient care, and other medical settings.

The program also includes research to develop ways to prevent medical errors and a web-based medical journal that showcases patient safety lessons drawn from actual cases of medical errors.

The Patient Safety Indicators tool contains a set of measures that use secondary diagnosis codes to detect 26 types of adverse events, such as complications of anesthesia, blood clots in the legs or lungs following surgery, fracture following surgery, and four types of birth-related injuries.

Six of these indicators can be calculated as a hospital-level or an area-level indicator. Area-level indicators use principal and secondary diagnosis codes to capture all cases of potentially preventable complications that occur within a specific geographic area and include foreign bodies left during a procedure, hospital-acquired pneumonia, infection from medical care, technical difficulty with a procedure, and reaction to blood transfusion. Evaluating these indicators by geographic region can help policy-makers and providers identify differences in the occurrence of health care complications by individual counties or Metropolitan Statistical Areas.

Although the indicators were developed primarily for hospitals to use in their quality improvement programs, other kinds of organizations will find the tool useful. For example, hospital associations can show member hospitals how they perform for each indicator when compared with their peer group, the state as a whole, or other comparable states.

The Patient Safety Indicators were developed and validated by the AHRQ-funded UCSF-Stanford Evidence-based Practice Center with the help of eight panels of clinicians nominated by 21 professional societies, including the American College of Physicians-American Society of Internal Medicine, American College of Surgeons, American College of Cardiology, and the American College of Obstetricians and Gynecologists.

The tool can be downloaded free of charge from AHRQ’s web site, but it requires the use of SAS or SPSS software, which are commercially available statistical programs. For technical questions on the content and use of the Patient Safety Indicators, contact AHRQ at