Using patient safety indicators to estimate the impact of potential adverse events on outcomes

Med Care Res Rev. 2008 Feb;65(1):67-87. doi: 10.1177/1077558707309611.


The authors estimated the impact of potentially preventable patient safety events, identified by Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs), on patient outcomes: mortality, length of stay (LOS), and cost. The PSIs were applied to all acute inpatient hospitalizations at Veterans Health Administration (VA) facilities in fiscal 2001. Two methods-regression analysis and multivariable case matching- were used independently to control for patient and facility characteristics while predicting the effect of the PSI on each outcome. The authors found statistically significant (p < .0001) excess mortality, LOS, and cost in all groups with PSIs. The magnitude of the excess varied considerably across the PSIs. These VA findings are similar to those from a previously published study of nonfederal hospitals, despite differences between VA and non-VA systems. This study contributes to the literature measuring outcomes of medical errors and provides evidence that AHRQ PSIs may be useful indicators for comparison across delivery systems.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Empirical Research
  • Female
  • Hospitals, Veterans
  • Humans
  • Male
  • Medical Audit
  • Medical Errors / prevention & control
  • Middle Aged
  • Quality Assurance, Health Care / methods*
  • Quality Indicators, Health Care*
  • Safety Management / standards*
  • United States