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Complete Health Indicator Report of Adverse Events Related to Hospital Inpatient Care

Definition

Rate of adverse events (misadventures, adverse drug events, or other complications of medical and surgical procedures) per 100 hospital discharges.

Numerator

Number of discharges with at least one of 1,003 specified adverse event ICD-9-CM codes.

Denominator

Total number of hospital discharges.

Data Interpretation Issues

Note: These rates are based on a newer, more inclusive set of 1,003 ICD-9-CM codes than the 529 previously codes used for this IBIS indicator. See http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Hougland_26.pdf. For the list of actual 1,003 ICD-9-CM codes by category (Utah Adverse Event Classes, version 2008) see: http://health.utah.gov/psi/ps_grant.htm

Why Is This Important?

Medical injuries, or adverse events, can impose serious harm to individuals and their families including death, disability, and economic burdens. Proper reporting, data collection, and analysis are critical first steps to effective prevention. With the development and improvement of patient safety programs and medical-injury tracking systems in Utah hospitals, an initial increase in reporting of adverse events in hospital discharge data is desired and expected, followed by a decrease as prevention methods improve.

How Are We Doing?

From 1999 through 2012 in Utah, the annual rate of hospital discharges that included at least one of the 1,003 selected adverse event ICD-9-CM codes first increased slightly through 2003 to 29.5%, decreased slightly through 2007, then increased through 2012 to 31.8%. Some subgroups of adverse events do not follow this pattern, however. In 2012, there appears to be a small general increase in all categories of adverse events relative to 2011.

How Do We Compare With the U.S.?

No national measures are available for misadventures, adverse drug events, or other complications of medical and surgical procedures.

What Is Being Done?

In 2001 the Utah Department of Health initiated a Patient Safety program in partnership with the Hospitals and Health Systems Association (UHA), the Utah Medical Association (UMA), and HealthInsight. Current voluntary sentinel event reporting in Utah gives a comparable rate as mandatory sentinel event reporting in Minnesota. Two administrative rules (R380-200, Patient Safety Sentinel Event Reporting, and R380-210, Health Care Facility Patient Safety Program) went into effect in October 2001. These rules focus on reporting of sentinel events, along with associated quality improvement efforts. From 2002 through 2006, about 40 sentinel events were reported per year. In 2007 and 2008 the annual number of sentinel events increased to 80. In 2009, the number of reported sentinel events increased to 101, possibly due to implementation of a web-based reporting system.


Related Indicators

Related Health Care System Factors Indicators:




Graphical Data Views

Rate of Adverse Events per 100 Inpatient Discharges in Utah Acute Care Hospitals, 1999-2012

::chart - missing::
confidence limits

The last few years have been characterized by a general increase in the overall rate of adverse events.
YearRate per 100 DischargesLower LimitUpper Limit
Record Count: 14
199926.626.426.8
200026.926.827.1
200127.427.227.6
200228.528.428.7
200329.529.329.7
200429.329.229.5
20052928.829.2
200627.927.728.1
200727.727.527.8
200828.228.128.4
200929.22929.4
201030.129.930.3
201130.930.731.1
201231.831.631.9

Data Notes

Adverse event ICD-9-CM codes can be in any of up to 9 reported diagnosis code fields and in any of up to 6 reported procedure code fields.   [[br]] [[br]] Note: Any of the specified 1,003 ICD-9-CM codes found in the Utah Adverse Event Classes, version 2008.

Data Source

Utah Inpatient Hospital Discharge Data, Office of Health Care Statistics, Utah Department of Health


Rate of Misadventures per 100 Inpatient Discharges in Utah Acute Care Hospitals, 1999-2012

::chart - missing::
confidence limits

An uptick occurred in 2012 from the previous global low that happened in 2011.
YearRate per 100 DischargesLower LimitUpper Limit
Record Count: 14
19990.430.40.45
20000.460.430.49
20010.470.440.5
20020.490.460.51
20030.430.410.46
20040.430.410.46
20050.450.430.48
20060.440.420.47
20070.390.370.41
20080.360.340.38
20090.360.330.38
20100.360.340.38
20110.320.30.34
20120.340.320.36

Data Notes

Adverse event ICD-9-CM codes can be in any of up to 9 reported diagnosis code fields and in any of up to 6 reported procedure code fields.   [[br]] [[br]] Note: ICD-9-CM codes that indicate an accidental cut, puncture, perforation, or hemorrhage during a procedure; and other misadventures of medical or surgical care that include but are not limited to E870-E876.9, 998.2, 998.4, 998.7 in the Utah Adverse Event Classes, 2008 Version.

Data Source

Utah Inpatient Hospital Discharge Data, Office of Health Care Statistics, Utah Department of Health


Rate of Adverse Drug Events per 100 Inpatient Discharges in Utah Acute Care Hospitals, 1999-2012

::chart - missing::
confidence limits

In 2012, a new global high occurred. This is the result of a continuous upward trend. No decreases have ever occurred since measurement began.
YearRate per 100 DischargesLower LimitUpper Limit
Record Count: 14
19992.982.913.05
20003.0733.14
20013.193.123.26
20023.453.383.53
20033.553.483.62
20043.583.513.65
20053.633.563.7
20063.653.583.72
20073.823.753.89
20083.913.833.98
20094.084.014.16
20104.274.194.34
20114.464.384.54
20124.594.514.67

Data Notes

Adverse event ICD-9-CM codes can be in any of up to 9 reported diagnosis code fields and in any of up to 6 reported procedure code fields.   [[br]] [[br]] Note: ICD-9-CM codes that indicate drug/medication related problems, including but not limited to E930-E949, E850-E858 in the Utah Adverse Event Classes, 2008 Version.

Data Source

Utah Inpatient Hospital Discharge Data, Office of Health Care Statistics, Utah Department of Health


Rate of Other Complications of Medical and Surgical Procedures per 100 Hospital Discharges in Utah Acute Care Hospitals, 1999-2012

::chart - missing::
confidence limits

An increase occurred in 2012, resulting in a new global high. This is a continuation of a general upward trend starting in 2008.
YearRate per 100 DischargesLower LimitUpper Limit
Record Count: 14
199925.225.025.4
200025.525.325.7
200126.025.826.1
200227.026.927.2
200328.027.828.1
200427.727.527.9
200527.327.227.5
200626.226.026.3
200725.925.726.1
200826.426.226.5
200927.327.127.5
201028.127.928.3
201128.928.729.0
201229.729.629.9

Data Notes

Adverse event ICD-9-CM codes can be in any of up to 9 reported diagnosis code fields and in any of up to 6 reported procedure code fields.   [[br]] [[br]] Note: ICD-9-CM codes for surgical and medical adverse events, excluding codes for misadventures and adverse drug events.

Data Source

Utah Inpatient Hospital Discharge Data, Office of Health Care Statistics, Utah Department of Health

References and Community Resources

Utah Patient Safety Initiative website: health.utah.gov/psi Contact Iona Thraen, Patient Safety Director, Utah Department of Health, 801-273-6643

More Resources and Links

Evidence-based community health improvement ideas and interventions may be found at the following sites:

Additional indicator data by state and county may be found on these Websites:

Medical literature can be queried at the PubMed website.

For an on-line medical dictionary, click on this Dictionary link.

Page Content Updated On 10/07/2014, Published on 10/20/2014
The information provided above is from the Department of Health's Center for Health Data IBIS-PH web site (http://ibis.health.state.gov). The information published on this website may be reproduced without permission. Please use the following citation: " Retrieved Tue, 19 June 2018 8:36:33 from Department of Health, Center for Health Data, Indicator-Based Information System for Public Health Web site: http://ibis.health.state.gov ".

Content updated: Tue, 20 Dec 2016 15:48:06 MST