LESSONS FOR NURSING FROM THE AHRQ PATIENT SAFETY INDICATOR VALIDATION PILOT PROJECT

2.50
Hdl Handle:
http://hdl.handle.net/10755/157402
Type:
Presentation
Title:
LESSONS FOR NURSING FROM THE AHRQ PATIENT SAFETY INDICATOR VALIDATION PILOT PROJECT
Abstract:
LESSONS FOR NURSING FROM THE AHRQ PATIENT SAFETY INDICATOR VALIDATION PILOT PROJECT
Conference Sponsor:Western Institute of Nursing
Conference Year:2010
Author:Zrelak, Patricia, PhD
P.I. Institution Name:UC Davis Medical Center
Title:Nurse Researcher
Contact Address:2103 Stockton Blvd., Suite 2224, Sacramento, CA, 95817, USA
Co-Authors:Jeff Geppert; Patrick Romano; Garth Utter; Ruth Baron; Banafsheh Sadeghi
PURPOSES/AIMS: A descriptive analysis of potential nursing-associated opportunities identified by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) Validation Pilot Project.
RATIONALE/CONCEPTUAL BASIS/BACKGROUND: The PSIs were developed in 2003 by the University of California-Stanford Evidence-based Practice Center, under contract to ARHQ. The PSIs are a set of tools intended to help identify potentially preventable adverse events that occur during hospitalization. These indicators are based on International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures, using readily available and inexpensive administrative discharge data.
METHODS:
- Retrospective cross-sectional study of hospitalization records flagged as having a PSI event under study.
- Chart review tools were developed for each PSI that targeted the ascertainment of the flagged event, associated risk factors, evaluation, treatment, and related outcomes.
- Voluntary/uncompensated samples of US hospitals were identified through the AHRQ Quality Indicator (QI) technical support listserve.
- A modified version of the AHRQ PSI windows software was used to extract a probability sample of records that met PSI criteria to generate desired sample size locally (30) and nationally (240 per indicator).
- For the first five indicators, data collected included 2nd quarter 2006 through 1st quarter 2007. The second set of indicators includes data from 2008*.
- Abstractors were trained via web-based teleconferences.
- Positive Predictive Values were calculated and adjusted for hospital clustering effect along with descriptive analysis of opportunities for quality improvement including those thought specific to nursing care.
RESULTS: Select findings per PSI with potential impacts for nursing care are as follows:
Selected infections due to Medical Care (Central Line Associated Bloodstream Infection):
- Lack of documentation of catheter type (12%), insertion/removal dates, symptomology (no documented cases of chills), infectious source, culture results and preventive interventions.
- Site selection: non-tunneled sites included femoral (11%), subclavian (25%), internal jugular (34%), and PICC (30%).
Postoperative Sepsis:
- Non-specific documentation regarding recognition, suspected source, and related interventions.
Postoperative DVT and/or PE:
- Missing and/or delayed prophylaxis including ambulation.
- False positive upper extremity DVT were associated with PICCs.
Iatrogenic Pneumothorax:
- Majority due to central catheters placed without radiologic adjuncts.
Postoperative Respiratory Failure*:
- A leading cause was unspecified, aspiration and ventilator associated pneumonia.
- Poor documentation of early ambulation and weaning protocol use.
Postoperative Physiological and Metabolic Derangement*:
- Subcutaneous insulin/pump use in immediate post-op period in type I diabetics.
- Nephrotoxic medication use in patients with chronic kidney disease (100%).
- Poor documentation of ionic contrast type/amount.
- Primary cause of postoperative renal failure was a decrease in effective/relative blood volume.
Results for the more medically oriented indicators (Foreign Body Left in During Procedure*, Postoperative Hemorrhage and Hematoma*, Accidental Puncture and Laceration, and Postoperative Wound dehiscence*) appear less specific to nursing care beyond risk identification and surveillance.
IMPLICATIONS: Several PSIs may be influenced by nursing associated care and may provide an additional source of inexpensive and readily available information on the quality of nursing care. However, additional research is needed.
* Still under study.

Repository Posting Date:
26-Oct-2011
Date of Publication:
17-Oct-2011
Sponsors:
Western Institute of Nursing

Full metadata record

DC FieldValue Language
dc.typePresentationen_GB
dc.titleLESSONS FOR NURSING FROM THE AHRQ PATIENT SAFETY INDICATOR VALIDATION PILOT PROJECTen_GB
dc.identifier.urihttp://hdl.handle.net/10755/157402-
dc.description.abstract<table><tr><td colspan="2" class="item-title">LESSONS FOR NURSING FROM THE AHRQ PATIENT SAFETY INDICATOR VALIDATION PILOT PROJECT</td></tr><tr class="item-sponsor"><td class="label">Conference Sponsor:</td><td class="value">Western Institute of Nursing</td></tr><tr class="item-year"><td class="label">Conference Year:</td><td class="value">2010</td></tr><tr class="item-author"><td class="label">Author:</td><td class="value">Zrelak, Patricia, PhD</td></tr><tr class="item-institute"><td class="label">P.I. Institution Name:</td><td class="value">UC Davis Medical Center</td></tr><tr class="item-author-title"><td class="label">Title:</td><td class="value">Nurse Researcher</td></tr><tr class="item-address"><td class="label">Contact Address:</td><td class="value">2103 Stockton Blvd., Suite 2224, Sacramento, CA, 95817, USA</td></tr><tr class="item-email"><td class="label">Email:</td><td class="value">pazrelak@ucdavis.edu</td></tr><tr class="item-co-authors"><td class="label">Co-Authors:</td><td class="value">Jeff Geppert; Patrick Romano; Garth Utter; Ruth Baron; Banafsheh Sadeghi</td></tr><tr><td colspan="2" class="item-abstract">PURPOSES/AIMS: A descriptive analysis of potential nursing-associated opportunities identified by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator (PSI) Validation Pilot Project. <br/>RATIONALE/CONCEPTUAL BASIS/BACKGROUND: The PSIs were developed in 2003 by the University of California-Stanford Evidence-based Practice Center, under contract to ARHQ. The PSIs are a set of tools intended to help identify potentially preventable adverse events that occur during hospitalization. These indicators are based on International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnoses and procedures, using readily available and inexpensive administrative discharge data. <br/>METHODS: <br/>- Retrospective cross-sectional study of hospitalization records flagged as having a PSI event under study.<br/>- Chart review tools were developed for each PSI that targeted the ascertainment of the flagged event, associated risk factors, evaluation, treatment, and related outcomes.<br/>- Voluntary/uncompensated samples of US hospitals were identified through the AHRQ Quality Indicator (QI) technical support listserve.<br/>- A modified version of the AHRQ PSI windows software was used to extract a probability sample of records that met PSI criteria to generate desired sample size locally (30) and nationally (240 per indicator).<br/>- For the first five indicators, data collected included 2nd quarter 2006 through 1st quarter 2007. The second set of indicators includes data from 2008*.<br/>- Abstractors were trained via web-based teleconferences.<br/>- Positive Predictive Values were calculated and adjusted for hospital clustering effect along with descriptive analysis of opportunities for quality improvement including those thought specific to nursing care.<br/>RESULTS: Select findings per PSI with potential impacts for nursing care are as follows: <br/>Selected infections due to Medical Care (Central Line Associated Bloodstream Infection): <br/>- Lack of documentation of catheter type (12%), insertion/removal dates, symptomology (no documented cases of chills), infectious source, culture results and preventive interventions.<br/>- Site selection: non-tunneled sites included femoral (11%), subclavian (25%), internal jugular (34%), and PICC (30%).<br/>Postoperative Sepsis: <br/>- Non-specific documentation regarding recognition, suspected source, and related interventions.<br/>Postoperative DVT and/or PE: <br/>- Missing and/or delayed prophylaxis including ambulation.<br/>- False positive upper extremity DVT were associated with PICCs.<br/>Iatrogenic Pneumothorax: <br/>- Majority due to central catheters placed without radiologic adjuncts.<br/>Postoperative Respiratory Failure*: <br/>- A leading cause was unspecified, aspiration and ventilator associated pneumonia. <br/>- Poor documentation of early ambulation and weaning protocol use.<br/>Postoperative Physiological and Metabolic Derangement*: <br/>- Subcutaneous insulin/pump use in immediate post-op period in type I diabetics.<br/>- Nephrotoxic medication use in patients with chronic kidney disease (100%).<br/>- Poor documentation of ionic contrast type/amount. <br/>- Primary cause of postoperative renal failure was a decrease in effective/relative blood volume.<br/>Results for the more medically oriented indicators (Foreign Body Left in During Procedure*, Postoperative Hemorrhage and Hematoma*, Accidental Puncture and Laceration, and Postoperative Wound dehiscence*) appear less specific to nursing care beyond risk identification and surveillance. <br/>IMPLICATIONS: Several PSIs may be influenced by nursing associated care and may provide an additional source of inexpensive and readily available information on the quality of nursing care. However, additional research is needed. <br/>* Still under study.<br/><br/></td></tr></table>en_GB
dc.date.available2011-10-26T19:50:27Z-
dc.date.issued2011-10-17en_GB
dc.date.accessioned2011-10-26T19:50:27Z-
dc.description.sponsorshipWestern Institute of Nursingen_GB
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