DefinitionRate of adverse events (misadventures, adverse drug events, or other complications of medical and surgical procedures) per 100 hospital discharges.
NumeratorNumber of discharges with at least one of 1,003 specified adverse event ICD-9-CM codes.
DenominatorTotal number of hospital discharges.
Data Interpretation IssuesNote: 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:
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.