National Healthcare Quality Report, 2013
Chapter 4: Text Descriptions
Figure 4.1. Distribution of hospital acquired conditions, based on national rates per 1,000 hospital adult discharges, 2011
| Hospital Acquired Condition | Percent |
|---|---|
| Adverse Drug Events | 34.2% |
| Catheter-Associated Urinary Tract Infections | 8.0% |
| Central Line-Associated Bloodstream Infections | 0.4% |
| Falls | 5.4% |
| Obstetric Adverse Events | 1.8% |
| Pressure Ulcer | 28.4% |
| Surgical Site Infection | 1.8% |
| Ventilator-Associated Pneumonia | 0.8% |
| Venous Thromboembolism | 0.3% |
| All Other HACs | 18.9% |
Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2011; Centers for Disease Control and Prevention, National Healthcare Security Network, 2010-2012; and Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP), Nationwide Inpatient Sample and AHRQ Quality Indicators, version 4.1, 2011.
Note: Data are for patients 18 years of age and over. Estimates are rounded to the nearest tenth.
Figure 4.2. Postoperative sepsis per 1,000 adult discharges with an elective operating room procedure, by age and hospital bed size, 2008-2010
| 2008 | 2009 | 2010 | |
|---|---|---|---|
| 18-44 (per 1,000) | 11.4 | 10.5 | 10.2 |
| 45-64 (per 1,000) | 12.1 | 13.0 | 14.3 |
| 65+ (per 1,000) | 17.5 | 18.5 | 17.7 |
| Total (per 1,000) | 14.6 | 15.3 | 15.4 |
| <100 Beds (per 1,000) | 12.3 | 15.4 | 17.4 |
| 100-299 Beds (per 1,000) | 14.8 | 16.2 | 14.5 |
| 300-499 Beds (per 1,000) | 15.3 | 16.4 | 16.2 |
| 500+ Beds (per 1,000) | 14.4 | 13.4 | 15.0 |
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2008-2010.
Denominator: All elective hospital surgical discharges, age 18 and over, with length of stay of 4 or more days, excluding patients admitted for infection, patients with cancer or immunocompromised states, patients with obstetric conditions, and admissions specifically for sepsis.
Note: For this measure, lower rates are better. Rates are adjusted by age, gender, age-gender interactions, comorbidities, major diagnostic category (MDC), diagnosis-related group (DRG), and transfers into the hospital. When reporting by age, the adjustment is by gender, comorbidities, MDC, DRG, and transfers into the hospital.
2008 Achievable Benchmark: 8.7
Figure 4.3. Adult surgery patients with postoperative catheter-associated urinary tract infection, by age and renal disease status, 2009-2011
| 2009 | 2010 | 2011 | |
|---|---|---|---|
| <65 | 1.6% | 1.9% | 1.6% |
| 65-74 | 3.3% | 3.4% | 2.9% |
| 75-84 | 4.7% | 5.1% | 4.6% |
| 85+ | 5.0% | 6.3% | 5.6% |
| Total | 3.1% | 3.6% | 3.1% |
| Renal Disease—Yes | 5.5% | 6.3% | 5.3% |
| Renal Disease—No | 2.5% | 2.7% | 2.4% |
Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2009-2011.
Denominator: Selected discharges of hospitalized patients age 18 and over having major surgery and meeting specific criteria for each measure.
Note: For this measure, lower rates are better.
Figure 4.4. Standardized infection ratios for central line-associated bloodstream infection and surgical site infections in adults, 2009-2011
| Year | CLABSI All | SSI Combined SCIP Procedures |
|---|---|---|
| 2006-2008 | 1 | 1 |
| 2009 | 0.8 | 0.9 |
| 2010 | 0.7 | 0.9 |
| 2011 | 0.6 | 0.8 |
Source: 2009-2011 national and State healthcare-associated infections standardized infection ratio report using the National Healthcare Safety Network (NHSN) data.
Note: For this measure, lower numbers are better. This SIR compares the number of infections reported to NHSN in 2011 with the number of infections predicted based on 2006-2008 national historic data. Because the 2006-2008 data are used as a baseline, that period is reported as 1.000. There were 1,603 facilities that reported CLABSI rates to NHSN in 2009, 2,389 facilities in 2010, and 3,468 facilities in 2011. SCIP procedures refers to Surgical Care Improvement Project procedures performed on adults. These procedures include abdominal aortic aneurysm repair, peripheral vascular bypass surgery, coronary artery bypass graft with both chest and donor site incisions or with chest incision only, other cardiac surgery, colon surgery, rectal surgery, hip arthroplasty, abdominal hysterectomy, knee arthroplasty, and vaginal hysterectomy.
Figure 4.5. Change in State-specific hospital SIRs for CLABSIs in adults, 2010-2011**
| Decrease | No Change |
|---|---|
| Alabama* | Alaska |
| Arizona | Colorado* |
| Arkansas* | Connecticut* |
| California* | Georgia |
| Delaware* | Idaho |
| Florida | Iowa |
| Hawaii | Kansas |
| Illinois* | Kentucky |
| Indiana | Louisiana |
| Maryland* | Maine |
| Mississippi | Massachusetts* |
| Missouri | Michigan |
| Nebraska | Minnesota |
| Nevada* | Montana |
| Ohio | New Hampshire* |
| South Carolina* | New Jersey* |
| Tennessee* | New Mexico |
| Vermont | New York* |
| -- | North Carolina |
| -- | Oklahoma* |
| -- | Oregon* |
| -- | Pennsylvania* |
| -- | Tennessee |
| -- | Texas* |
| -- | Virginia* |
| -- | Washington* |
| -- | West Virginia* |
| -- | Wisconsin |
| -- | District of Columbia* |
* Indicates existence of state mandate to report CLABSI to NHSN at beginning of 2011
** Fewer than five facilities reporting in Utah, Wyoming, and South Dakota
Figure 4.6. Bloodstream infections per 1,000 central-line days in neonates and older children, by birth weight of child in Level III neonatal ICU and by type of pediatric ICU, 2009-2011
| 2009 | 2010 | 2011 | |
|---|---|---|---|
| ≤750 g (per 1,000) | 3.4 | 2.6 | 2.5 |
| 751-1000 g (per 1,000) | 2.7 | 2.2 | 2.0 |
| 1001-1500 g (per 1,000) | 1.9 | 1.3 | 1.3 |
| 1501-2500 g (per 1,000) | 1.5 | 1.0 | 0.9 |
| >2500 g (per 1,000) | 1.3 | 0.8 | 0.9 |
| Pediatric Cardiothoracic ICU (per 1,000) | 2.5 | 2.1 | 1.6 |
| Pediatric Medical ICU (per 1,000) | 2.6 | 1.9 | 1.4 |
| Pediatric Medical / Surgical ICU (per 1,000) | 2.2 | 1.8 | 1.8 |
Key: ICU = intensive care unit.
Source: Centers for Disease Control and Prevention, National Healthcare Safety Network, 2009-2011.
Denominator: Number of central-line days.
Note: For this measure, lower rates are better.
Figure 4.7. Composite: Mechanical adverse events associated with central venous catheter placement in adults, by age, 2009-2011
| Age | 2009 | 2010 | 2011 |
|---|---|---|---|
| Total | 3.9% | 3.3% | 4% |
| 18-64 | 4.4% | 3.5% | 4.2% |
| 65-74 | 3.2% | 3.4% | 3.6% |
| 75-84 | 3.1% | 2.9% | 3.6% |
| 85+ | 5.9% | 2.9% | 4.5% |
Source: Agency for Healthcare Research and Quality and Centers for Medicare & Medicaid Services, Medicare Patient Safety Monitoring System, 2009-2011.
Denominator: Selected discharges of hospitalized patients age 18 and over with central venous catheter placement.
Note: For this measure, lower rates are better. Mechanical adverse events include allergic reaction to the catheter, tamponade, perforation, pneumothorax, hematoma, shearing off of the catheter, air embolism, misplaced catheter, thrombosis or embolism, knotting of the pulmonary artery catheter, and certain other events.
Figure 4.8. Obstetric trauma with 3rd or 4th degree laceration per 1,000 vaginal deliveries without instrument assistance, by age and insurance, 2004-2010
| Age / Insurance | 2004 | 2005 | 2006 | 2007 | 2008 | 2009 | 2010 |
|---|---|---|---|---|---|---|---|
| Total (per 1,000) | 30.0 | 28.5 | 25.6 | 23.8 | 23.7 | 22.2 | 22.8 |
| 10-14 (per 1,000) | 50.5 | 40.3 | 46.2 | 37.8 | 32.7 | 36.7 | 38.5 |
| 15-17 (per 1,000) | 34.6 | 34.3 | 27.9 | 28.3 | 26.0 | 23.9 | 27.8 |
| 18-24 (per 1,000) | 26.7 | 26.3 | 23.5 | 21.5 | 21.3 | 19.3 | 19.6 |
| 25-34 (per 1,000) | 33.0 | 30.5 | 27.6 | 25.9 | 26.2 | 24.9 | 25.5 |
| 35-54 (per 1,000) | 24.9 | 24.6 | 22.0 | 20.6 | 19.4 | 18.8 | 19.4 |
| Private (per 1,000) | 36.0 | 34.0 | 32.0 | 30.0 | 29.0 | 28.0 | 31.0 |
| Medicare (per 1,000) | 19.0 | 27.0 | 25.0 | 17.0 | 17.0 | 12.0 | 15.0 |
| Medicaid (per 1,000) | 20.0 | 20.0 | 17.0 | 16.0 | 16.0 | 15.0 | 14.0 |
| Other insurance (per 1,000) | 34.0 | 27.0 | 27.0 | 23.0 | 24.0 | 21.0 | 19.0 |
| Uninsured (per 1,000) | 25.0 | 25.0 | 23.0 | 24.0 | 21.0 | 20.0 | 18.0 |
Key: Private indicates private health insurance as the payment sources; uninsured indicates self-pay, uninsured, or no charge as the payment source.
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project, Nationwide Inpatient Sample and AHRQ Quality Indicators, modified version 4.1, 2004-2010.
Denominator: All patients hospitalized for vaginal delivery without indication of instrument assistance.
Note: For this measure, lower rates are better. Rates are adjusted by age. Rates by age are not age adjusted.
2008 Achievable Benchmark: 17.8
Figure 4.9. Nursing home residents experiencing various adverse events, by sex and age, 2011
| Sex / Age | Pressure Ulcers—Short Stay | Restraints—Long Stay | UTI—Long Stay |
|---|---|---|---|
| Male | 2.2% | 2.5% | 6.4% |
| Female | 1.6% | 2.4% | 8.9% |
| 0-64 | 1.2% | 2.4% | 5.8% |
| 65-74 | 1.5% | 2.0% | 7.4% |
| 75-84 | 1.9% | 2.6% | 8.6% |
| 85+ | 2.4% | 2.5% | 8.7% |
Source: Centers for Medicare & Medicaid Services, Minimum Data Set 3.0, 2011.
Denominator: For pressure ulcers, the denominator was short-stay residents, who are defined as residents whose cumulative stay was less than or equal to 100 days. For restraints and urinary tract infections, the denominator was long-stay residents, who are defined as residents whose cumulative stay was greater than 100 days.
Note: For these measures, lower rates are better. Measures were calculated as follows: Pressure ulcers: Percentage of short-stay residents for whom a look-back scan indicates one or more new or worsening stage II-IV pressure ulcers. Restraints: Percentage of long-stay residents who are physically restrained on a daily basis. UTI: Percentage of long-stay residents with a urinary tract infection within the 30 days prior to assessment.
Figure 4.10. Home health patients with improvement in their surgical site wounds, by age, 2010-2011
| Age | 2010 | 2011 |
|---|---|---|
| 0-64 | 83.0% | 84.7% |
| 65-74 | 86.1% | 88.2% |
| 75-84 | 87.0% | 89.4% |
| 85+ | 88.2% | 90.4% |
Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2010-2011.
Denominator: The number of home health episodes during the measurement period in which the patient had a surgical wound and the episode ended with the patient discharged from home health care.
Figure 4.11. Home health patients with improvements in their ability to take medications orally, by age, 2010-2011
| Age | 2010 | 2011 |
|---|---|---|
| 0-64 | 51.5% | 53.1% |
| 65-74 | 56.5% | 57.3% |
| 75-84 | 47.4% | 48.4% |
| 85+ | 35.9% | 37.0% |
Source: Centers for Medicare & Medicaid Services, Outcome and Assessment Information Set, 2010-2011.
Denominator: Number of home health episodes of care in which a patient was unable to take oral medications independently at the start of the episode that ended during the measurement period.
Figure 4.12. Ambulatory care visits due to adverse effects of medical care, per 1,000 people, by age and sex, 2006-2009
| Age / Sex | 2006-2007 | 2007-2008 | 2008-2009 |
|---|---|---|---|
| 0-17 (per 1,000) | 13.8 | 16.6 | 11.9 |
| 18-44 (per 1,000) | 22.9 | 27.3 | 23.3 |
| 45-64 (per 1,000) | 44.0 | 56.0 | 43.1 |
| 65 and over (per 1,000) | 93.9 | 105.2 | 83.6 |
| Total (per 1,000) | 34.6 | 41.7 | 33.2 |
| Male (per 1,000) | 25.8 | 32.8 | 25.0 |
| Female (per 1,000) | 43.1 | 50.2 | 41.0 |
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2006-2009.
Denominator: U.S. Census Bureau estimated civilian noninstitutionalized population as of July 1 of each data year.
Note: For this measure, lower rates are better. Ambulatory care includes visits to office-based physicians, hospital outpatient departments, and hospital emergency departments.
Figure 4.13. Adults age 65 and over who received potentially inappropriate prescription medications in the calendar year, by age and perceived health status, 2002-2010
| Year | 65-69 | 70-74 | 75-79 | 80+ | Total | Excellent / Very Good / Good |
Fair / Poor |
|---|---|---|---|---|---|---|---|
| 2002 | 16.2% | 20.6% | 19.8% | 20.8% | 19.3% | 16.8% | 26.8% |
| 2003 | 18.4% | 19.1% | 17.2% | 18.9% | 18.5% | 16.6% | 24.5% |
| 2004 | 16.4% | 16.3% | 18.8% | 15.8% | 16.7% | 14.4% | 23.9% |
| 2005 | 18.4% | 18.2% | 19.6% | 15.0% | 17.7% | 15.8% | 23.6% |
| 2006 | 15.5% | 15.1% | 15.2% | 17.1% | 15.8% | 13.5% | 23.2% |
| 2007 | 15.2% | 15.9% | 15.7% | 15.1% | 15.4% | 13.6% | 21.6% |
| 2008 | 12.8% | 13.6% | 16.6% | 11.8% | 13.4% | 11.8% | 19.1% |
| 2009 | 14.1% | 13.9% | 13.7% | 12.0% | 13.4% | 11.5% | 19.5% |
| 2010 | 13.9% | 13.9% | 14.5% | 13.4% | 13.9% | 12.2% | 20.0% |
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2010.
Denominator: Civilian noninstitutionalized population age 65 and over.
Note: For this measure, lower rates are better. Prescription medications received include all prescribed medications initially purchased or otherwise obtained, as well as any refills.
Figure 4.14. Median hospital 30-day risk-standardized readmission rate for certain conditions in adults, 2006-2010
| Year | AMI | Heart Failure | Pneumonia |
|---|---|---|---|
| 2006 | 19.9% | 24.4% | 18.0% |
| 2007 | 20.0% | 24.7% | 18.3% |
| 2008 | 19.9% | 24.9% | 18.2% |
| 2009 | 19.7% | 24.7% | 18.4% |
| 2010 | 19.4% | 24.6% | 18.4% |
Key: AMI = acute myocardial infarction.
Source: Medicare Hospital Quality Chartbook, 2010, 2011, and 2012.
Denominator: Expected number of readmissions for each disease type given the hospital's case mix.
Note: For this measure, lower rates are better. Readmission rates presented for 2006 do not include Veterans Affairs hospitals. Rates after 2006 include these hospitals.
Figure 4.15. Malpractice claims by type of error and harm, 2004-2010 combined
| Type of Error | Death | Disability |
|---|---|---|
| Diagnosis | 39.3% | 33.8% |
| Treatment | 24.3% | 18.3% |
| Surgery | 11.3% | 21.5% |
| Obstetrics | 5.5% | 14.7% |
| Medication | 7.1% | 3.6% |
| Other | 12.5% | 8.2% |
Source: 1986-2010 National Practitioner Data Bank analysis as reported in Saber Tehrani, et al., 2013.
Figure 4.16. Diagnosis-related-error claims: frequency and harm by setting of care, 2004-2010 combined
| Diagnosis-Related Error Claim | Inpatient | Outpatient |
|---|---|---|
| Diagnosis-Related Error Claims That Resulted in Death | 48.4% | 36.9% |
Source: 1986-2010 National Practitioner Data Bank analysis as reported in Saber Tehrani, et al., 2013
Figure 4.17. Pennsylvania patient safety reports by event type and harm, 2012
| Event Type | Events With Harm | Events With No Harm |
|---|---|---|
| Complications of Procedure / Treatment / Test | 44% | 14% |
| Other / Miscellaneous | 16% | 9% |
| Falls | 14% | 15% |
| Skin Integrity | 10% | 15% |
| Errors related to Procedure / Treatment / Test | 8% | 22% |
| Adverse Drug Reactions (not a medication error) | 4% | 2% |
| Medication Errors | 3% | 19% |
| Equipment / Supplies / Devices | 1% | 2% |
| Transfusions | 0% | 2% |
Source: Pennsylvania Patient Safety Reporting System, 2012.
Note: Only hospital and ambulatory surgical facility data are presented. Values for bar segments less than 5% are not shown.
Figure 4.18. Average patient safety culture composite percent positive response, 2012
| Patient Safety Culture Composite | % Positive Response |
|---|---|
| Nonpunitive Response to Error | 44% |
| Handoffs & Transitions | 45% |
| Staffing | 56% |
| Teamwork Across Units | 58% |
| Communication Openness | 62% |
| Frequency of Events Reported | 63% |
| Feedback & Communication About Error | 64% |
| Overall Perceptions of Patient Safety | 66% |
| Management Support for Patient Safety | 72% |
| Organizational Learning—Continuous Improvement | 72% |
| Supv / Mgr Expectations & Actions Promoting Patient Safety | 75% |
| Teamwork Within Units | 80% |
Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: User Comparative Database Report, 2012.
Figure 4.19. Average percent positive for nonpunitive response to error and respondents reporting no events in the past 12 months, by geographic region, 2012
| Geographic Region | Nonpunitive Response to Error | Respondents Reporting No Events |
|---|---|---|
| West North Central | 47% | 51% |
| Mountain | 46% | 55% |
| East South Central | 45% | 56% |
| West South Central | 45% | 59% |
| Mid-Atlantic | 44% | 54% |
| South Atlantic | 44% | 56% |
| East North Central | 42% | 54% |
| Pacific | 42% | 51% |
| New England | 39% | 56% |
Source: Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture: User Comparative Database Report, 2012.
Figure 4.20. Root cause analyses completed within 45 days at VHA facilities, FY 2006-2011
| Fiscal Year | Percent RCAs Completed within 45 days |
|---|---|
| FY06 | 44.5% |
| FY07 | 51.2% |
| FY08 | 85.4% |
| FY09 | 95.7% |
| FY10 | 97.7% |
| FY11 | 97.7% |
Source: Department of Veterans Affairs, 2012 VHA Facility Quality and Safety Report.
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