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<h1 class="page__title title" id="page-title">Chartbook on Patient Safety</h1> <h2>National Healthcare Quality and Disparities Report: Chartbook on Patient Safety</h2>
</div>
<div class="field field-name-ahrq-generic-body field-type-text-long field-label-hidden"><div class="field-items"><div class="field-item even"><h4>Patient Safety Infrastructure</h4>
<ul>
<li>Efforts to improve patient safety have led to various infrastructure enhancements.
<ul>
<li>National Practitioner Data Bank, a clearinghouse for information on medical malpractice payments and adverse actions against health care providers.</li>
<li>Culture of patient safety, recognized as important for reducing adverse events, and surveys to monitor the culture.</li>
<li>Patient Safety Organizations, designed to create a protected space in which providers can learn from adverse events without fear of legal action.</li>
</ul>
</li>
</ul>
<h4>Patient Safety Infrastructure: National Practitioner Data Bank</h4>
<ul>
<li>Medical malpractice actions are one way to flag potential medical errors.</li>
<li>Medical Malpractice Payment Reports (MMPRs) are submitted to the National Practitioner Data Bank by medical malpractice payers:
<ul>
<li>Report of a monetary exchange made for the benefit of a physician, dentist, or other health care provider.</li>
<li>Result of a settlement or judgment of a written complaint or claim based on that provider's delivery of or failure to deliver health care services.</li>
</ul>
</li>
</ul>
<h4>Medical Malpractice Payment Reports</h4>
<p><strong>Number of Medical Malpractice Payment Reports, by health care setting, 2004-2013</strong></p>
<p><img alt="Line graph showing number of Medical Malpractice Payment Reports, by health care setting, 2004-2013. Go to table below for details." src="pts-fig23.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 90%;">
<tr>
<th scope="col">&#160;</th>
<th scope="col"><strong>2004</strong></th>
<th scope="col"><strong>2005</strong></th>
<th scope="col"><strong>2006</strong></th>
<th scope="col"><strong>2007</strong></th>
<th scope="col"><strong>2008</strong></th>
<th scope="col"><strong>2009</strong></th>
<th scope="col"><strong>2010</strong></th>
<th scope="col"><strong>2011</strong></th>
<th scope="col"><strong>2012</strong></th>
<th scope="col"><strong>2013</strong></th>
</tr>
<tr>
<td scope="row">Total</td>
<td align="center">15,537</td>
<td align="center">17,241</td>
<td align="center">15,788</td>
<td align="center">14,486</td>
<td align="center">14,113</td>
<td align="center">13,855</td>
<td align="center">13,237</td>
<td align="center">12,868</td>
<td align="center">12,418</td>
<td align="center">12,708</td>
</tr>
<tr>
<td scope="row">Inpatient</td>
<td align="center">6,146</td>
<td align="center">7,060</td>
<td align="center">6,544</td>
<td align="center">5,985</td>
<td align="center">5,540</td>
<td align="center">5,421</td>
<td align="center">5,121</td>
<td align="center">4,883</td>
<td align="center">4,479</td>
<td align="center">4,592</td>
</tr>
<tr>
<td scope="row">Outpatient</td>
<td align="center">6,595</td>
<td align="center">7,549</td>
<td align="center">6,881</td>
<td align="center">6,608</td>
<td align="center">6,583</td>
<td align="center">6,587</td>
<td align="center">6,404</td>
<td align="center">6,347</td>
<td align="center">6,156</td>
<td align="center">5,932</td>
</tr>
<tr>
<td scope="row">Other</td>
<td align="center">2,796</td>
<td align="center">2,632</td>
<td align="center">2,363</td>
<td align="center">1,893</td>
<td align="center">1,990</td>
<td align="center">1,847</td>
<td align="center">1,712</td>
<td align="center">1,638</td>
<td align="center">1,783</td>
<td align="center">2,184</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source:</strong> National Practitioner Data Bank Public Use Data File, Health Resources and Services Administration, Bureau of Health Professions, Division of Practitioner Data Banks, 2004-2013.<br><br />
<strong>Note: </strong>Other includes MMPRs related to unknown settings and a combination of inpatient and outpatient settings. Number of Medical Malpractice Payment Reports, by health care setting,&#160;</p>
<ul>
<li><strong>Change Over Time:</strong> From 2004 to 2013, the number of MMPRs per year decreased by 18%, from 15,537 in 2004 to 12,708 in 2013.</li>
<li><strong>Differences Between Settings:</strong>
<ul>
<li>Of 142,288 MMPRs from 2004 to 2013, more related to care in the outpatient setting (65,621) than in the inpatient setting (55,761).</li>
<li>Diagnosis-related and treatment-related errors were the most frequent types of error, each accounting for 27% of reports. Medication errors accounted for only 5% of MMPRs (data not shown).</li>
</ul>
</li>
</ul>
<h4>Variation in Medical Malpractice Payment Reports</h4>
<p><strong>Number of Medical Malpractice Payment Reports, by patient sex, type of error, and harm, 2004-2013 (combined)</strong></p>
<p><img alt="Bar chart showing number of Medical Malpractice Payment Reports, by patient sex, type of error, and harm, 2004-2013 (combined). Go to table below for details." src="pts-fig24.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 80%;">
<tr>
<th scope="col">&#160;</th>
<th scope="col">Death</th>
<th scope="col">Disability</th>
</tr>
<tr>
<td scope="row">Male</td>
<td align="center">20,092</td>
<td align="center">18,374</td>
</tr>
<tr>
<td scope="row">Female</td>
<td align="center">19,638</td>
<td align="center">20,880</td>
</tr>
<tr>
<td scope="row">Obstetric</td>
<td align="center">2,170</td>
<td align="center">5,643</td>
</tr>
<tr>
<td scope="row">Medication</td>
<td align="center">2,919</td>
<td align="center">1,405</td>
</tr>
<tr>
<td scope="row">Surgery</td>
<td align="center">4,446</td>
<td align="center">8,481</td>
</tr>
<tr>
<td scope="row">Other</td>
<td align="center">5,020</td>
<td align="center">3,219</td>
</tr>
<tr>
<td scope="row">Treatment</td>
<td align="center">9,810</td>
<td align="center">7,241</td>
</tr>
<tr>
<td scope="row">Diagnosis</td>
<td align="center">15,471</td>
<td align="center">13,352</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source: </strong>National Practitioner Data Bank Public Use Data File, Health Resources and Services Administration, Bureau of Health Professions, Division of Practitioner Data Banks, 2004-2013.<br><br />
<strong>Note: &#160;</strong>MMPRs missing patient sex data (n=555), injury data (n=61,309), and other data (n=1,790) were excluded from the results above. "Disability” includes outcomes resulting in significant permanent injury, major permanent injury, quadriplegia, brain damage, or lifelong care. Categories for error related to diagnosis, treatment, surgery, medication, and obstetrics are defined by corresponding malpractice allegation groups in the National Practitioner Data Bank Public Use File. The "Other " category includes error related to anesthesia, IV and blood products, monitoring, equipment/product, behavioral health, and other malpractice allegation groups in the National Practitioner Data Bank Public Use File.</p>
<ul>
<li><strong>Groups With Disparities:</strong>
<ul>
<li>In 2004-2013, more MMPRs were related to female patients (40,518) than male patients (38,466). The harm outcome of disability accounted for a larger share of MMPRs involving female patients than MMPRs involving male patients, while a greater percentage of MMPRs involving males documented the harm outcome of death.</li>
</ul>
</li>
<li><strong>Differences in Type of Error and Harm:</strong>
<ul>
<li>In 2004-2013, MMPRs related to diagnosis, treatment, and medication were more likely to document death than disability as the harm outcome. MMPRs related to surgery and obstetrics were more likely to document disability than death.</li>
</ul>
</li>
</ul>
<h4>Patient Safety Infrastructure: Culture</h4>
<ul>
<li>High-reliability organizations—those that perform high-risk work but achieve low rates of adverse events—establish "cultures of safety" (Chassin and Loeb, 2013).</li>
<li>The culture is characterized by:
<ul>
<li>Shared dedication to making work safe.</li>
<li>Nonpunitive reporting and communication about errors.</li>
<li>Collaboration and teamwork across disciplines.</li>
<li>Adequate resources to prevent adverse events.</li>
</ul>
</li>
<li>A patient safety practice widely encouraged by experts is teamwork training. One model—Crew Resource Management (CRM)—applies an array of nontechnical skills (e.g., communication techniques), which are also known as "safety behaviors." These are used in concert with the technical and knowledge requirements of safety-sensitive jobs to develop high-reliability teams.</li>
</ul>
<h4>Measures of Patient Safety Culture</h4>
<ul>
<li>Average percent positive responses on the AHRQ Hospital Survey on Patient Safety Culture.</li>
<li>Average percent positive responses on the AHRQ Medical Office Survey on Patient Safety Culture.</li>
<li>Average percent positive responses for patient safety culture composite (Sexton, et al., 2006) among participants in the National Center for Patient Safety (NCPS) High Reliability Team training.</li>
<li>Percent change from baseline in observed annual mortality rate per 1,000 procedures, by medical team training status of Veterans Health Administration facility.</li>
</ul>
<h4>Hospital Patient Safety Culture Survey Results</h4>
<p><strong>Average percent positive responses for patient safety culture composite from hospitals, 2012 and 2014</strong></p>
<p><img alt="Bar chart showing average percent positive responses for patient safety culture composite from hospitals, 2012 and 2014. Go to table below for details." src="pts-fig25.jpg"><br><br />
&#160;</p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 90%;">
<tr>
<th scope="col" width="70%">&#160;</th>
<th scope="col" width="15%"><strong>2012</strong></th>
<th scope="col" width="15%"><strong>2014</strong></th>
</tr>
<tr>
<td scope="row">Nonpunitive Response to Error</td>
<td align="center">44%</td>
<td align="center">44%</td>
</tr>
<tr>
<td scope="row">Handoffs &#38; Transitions</td>
<td align="center">45%</td>
<td align="center">47%</td>
</tr>
<tr>
<td scope="row">Staffing</td>
<td align="center">56%</td>
<td align="center">55%</td>
</tr>
<tr>
<td scope="row">Teamwork Across Units</td>
<td align="center">58%</td>
<td align="center">61%</td>
</tr>
<tr>
<td scope="row">Communication Openness</td>
<td align="center">62%</td>
<td align="center">62%</td>
</tr>
<tr>
<td scope="row">Frequency of Events Reported</td>
<td align="center">63%</td>
<td align="center">66%</td>
</tr>
<tr>
<td scope="row">Feedback &#38; Communication About Error</td>
<td align="center">64%</td>
<td align="center">67%</td>
</tr>
<tr>
<td scope="row">Overall Perceptions of Patient Safety</td>
<td align="center">66%</td>
<td align="center">66%</td>
</tr>
<tr>
<td scope="row">Management Support for Patient Safety</td>
<td align="center">72%</td>
<td align="center">72%</td>
</tr>
<tr>
<td scope="row">Organizational Learning—Continuous Improvement</td>
<td align="center">72%</td>
<td align="center">73%</td>
</tr>
<tr>
<td scope="row">Supv/Mgr Expectations &#38; Actions Promoting Patient Safety</td>
<td align="center">75%</td>
<td align="center">76%</td>
</tr>
<tr>
<td scope="row">Teamwork Within Units</td>
<td align="center">80%</td>
<td align="center">81%</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source: </strong>Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture user comparative database report, 2012 (<a href="/professionals/quality-patient-safety/patientsafetyculture/hospital/2012/index.html">http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2012/index.html</a>) and 2014 (<a href="https://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2014/index.html">http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2014/index.html</a>).<br><br />
<strong>Note: &#160;</strong>Hospital staff voluntarily assessed the culture of safety in their facilities. Percent positive is the percentage of positive responses (e.g., Agree) to positively worded items (e.g., People support one another in this unit) or negative responses (e.g., Disagree) to negatively worded items (e.g., We have problems in this unit).</p>
<ul>
<li><strong>Change Over Time:</strong>
<ul>
<li>Seven of 12 composites of questions about patient safety culture demonstrated a slightly higher percentage of positive responses from hospital staff in 2014 compared with 2012.</li>
<li>One composite, staffing, received a lower percent positive response by hospital staff in 2014 than in 2012.</li>
<li>Four composites (Management Support for Patient Safety, Overall Perceptions of Patient Safety, Communication Openness, and Nonpunitive Response to Error) demonstrated similar percent positive responses in the 2 years.</li>
</ul>
</li>
<li><strong>Areas of Strength and Weakness:</strong>
<ul>
<li>Teamwork Within Units had the highest percent positive responses.</li>
<li>Handoffs and Transitions and Nonpunitive Response to Error had the lowest percent positive responses.</li>
</ul>
</li>
</ul>
<h4>Medical Office Patient Safety Culture Survey Results</h4>
<p><strong>Average percent positive responses for patient safety culture composite from medical offices, by composite, 2012</strong></p>
<p><img alt="Bar chart showing average percent positive responses for patient safety culture composite from medical offices, by composite, 2011. Go to table below for details." src="pts-fig26.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 90%;">
<tr>
<th scope="col" width="80%">&#160;</th>
<th scope="col" width="20%"><strong>% Positive Response</strong></th>
</tr>
<tr>
<td scope="row">Work Pressure and Pace</td>
<td align="center">46</td>
</tr>
<tr>
<td scope="row">Office Processes and Standardization</td>
<td align="center">64</td>
</tr>
<tr>
<td scope="row">Communication Openness</td>
<td align="center">64</td>
</tr>
<tr>
<td scope="row">Communication About Error</td>
<td align="center">66</td>
</tr>
<tr>
<td scope="row">Owner / Managing Partner / Leadership Support for Patient Safety</td>
<td align="center">67</td>
</tr>
<tr>
<td scope="row">Staff Training</td>
<td align="center">73</td>
</tr>
<tr>
<td scope="row">Overall Perceptions of Patient Safety and Quality</td>
<td align="center">76</td>
</tr>
<tr>
<td scope="row">Organizational Learning</td>
<td align="center">77</td>
</tr>
<tr>
<td scope="row">Patient Care Tracking and Followup</td>
<td align="center">82</td>
</tr>
<tr>
<td scope="row">Teamwork</td>
<td align="center">84</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source:</strong> AHRQ, Medical Office Survey on Patient Safety Culture user comparative database report, 2012 (<a href="/professionals/quality-patient-safety/patientsafetyculture/medical-office/2012/index.html">http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2012/index.html</a>).<br><br />
<strong>Note: &#160;</strong>Staff in medical offices with at least three providers voluntarily assessed the culture of safety in their offices.</p>
<ul>
<li><strong>Overall Rate:</strong> The highest percent positive responses were for composites of questions about teamwork and patient care (84% and 82%, respectively), and the composite on work pressure and pace had the lowest percent positive responses (46%).</li>
</ul>
<h4>Variation in Medical Office Patient Safety Culture Survey Results</h4>
<p><strong>Average percent positive responses for patient safety culture composite from medical offices, by specialty for all composites combined, 2012</strong></p>
<p><img alt="Average percent positive responses for patient safety culture composite from medical offices, by specialty for all composites combined, 2012. Cardiology, 72%; Hematology, 69%; OB/GYN, 73%; Pediatrics, 73%; Primary Care, 71%." src="pts-fig27.jpg"></p>
<p>&#160;</p>
<p><strong>Source:</strong> AHRQ, Medical Office Survey on Patient Safety Culture user comparative database report, 2012 (<a href="/professionals/quality-patient-safety/patientsafetyculture/medical-office/2012/index.html">http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2012/index.html</a>).<br><br />
<strong>Note: &#160;</strong>Staff in medical offices with at least three providers voluntarily assessed the culture of safety in their offices.</p>
<ul>
<li><strong>Differences by Specialty:</strong> No clear patterns emerged across specialties (Cardiology, Hematology, OB/GYN, Pediatrics, Primary Care) on the patient safety culture composites in 2012.</li>
</ul>
<h4>High Reliability Team Training</h4>
<p><strong>Average percent positive responses for patient safety culture composite among participants in the NCPS High Reliability Team training, comparing baseline with 6 and 11 months, 2009</strong></p>
<p><img alt="Bar chart showing average percent positive responses for patient safety culture composite among participants in the NCPS High Reliability Team training, comparing baseline with 6 and 11 months, 2009. Go to table below for details." src="pts-fig28.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 90%;">
<tr>
<th scope="col" width="40%">&#160;</th>
<th scope="col" width="20%"><strong>Baseline (n=368; 11 units)</strong></th>
<th scope="col" width="20%"><strong>6 Months (n=207; 10 units)</strong></th>
<th scope="col" width="20%"><strong>11 Months (n=189; 7 units)</strong></th>
</tr>
<tr>
<td scope="row">It is difficult to speak up if I perceive a problem with patient care</td>
<td align="center">60</td>
<td align="center">20</td>
<td align="center">15</td>
</tr>
<tr>
<td scope="row">The physicians and nurses here work together as a well-coordinated team</td>
<td align="center">48</td>
<td align="center">53</td>
<td align="center">62</td>
</tr>
<tr>
<td scope="row">It is easy for personnel here to ask questions when there is something that they do not understand</td>
<td align="center">71</td>
<td align="center">73</td>
<td align="center">82</td>
</tr>
<tr>
<td scope="row">I have the support I need from personnel to care for patients</td>
<td align="center">54</td>
<td align="center">60</td>
<td align="center">71</td>
</tr>
<tr>
<td scope="row">Disagreements in this clinical area are resolved appropriately (not who's right, but what's best for pt)</td>
<td align="center">46</td>
<td align="center">52</td>
<td align="center">68</td>
</tr>
<tr>
<td scope="row">Nurse input about patient care is well received</td>
<td align="center">57</td>
<td align="center">68</td>
<td align="center">72</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source: </strong>Sculli GL, Fore AM, West P, et al. Spotlight on safety: nursing crew resource management: a followup report from the Veterans Health Administration. <em>J Nurs Adm </em>2013;43(3):122-6.<br><br />
<strong>Note: &#160;</strong>Statistically significant (p&#60;0.05), comparing baseline with end-of-study percent positive response rates. For the first five measures, higher rates are better. For the last measure, lower rates are better.</p>
<ul>
<li><strong>Change Over Time:</strong> The NCPS Clinical Team Training Programs at the Veterans Health Administration have used CRM since its inception in 1999. Among team training participants in 2009, staff perception of teamwork had increased nearly 1 year later. The average percent positive response to 10 of 12 composites of questions, including those in the chart, showed statistically significant improvement.</li>
</ul>
<h4>Mortality Rate by Medical Team Training Status</h4>
<p><strong>Percent change from baseline in observed annual mortality rate per 1,000 procedures, by medical team training status of facility, 2006-2008 (combined)</strong></p>
<p><img alt="Percent change from baseline in observed annual mortality rate per 1,000 procedures, by medical team training status of facility, 2006-2008 (combined). Go to table below for details." src="pts-fig29.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 80%;">
<tr>
<th scope="col">&#160;</th>
<th scope="col"><strong>Baseline</strong></th>
<th scope="col"><strong>End of Training Program</strong></th>
</tr>
<tr>
<td scope="row">Trained Staff</td>
<td align="center">17</td>
<td align="center">14</td>
</tr>
<tr>
<td scope="row">Nontrained Staff</td>
<td align="center">15</td>
<td align="center">14</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source: </strong>Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. <em>JAMA</em> 2010;304(15):1693-700.<br><br />
<strong>Note: </strong>Statistically significant (p&#60;0.05), comparing baseline with end-of-study mortality rates. For this measure (mortality), lower rates are better.</p>
<ul>
<li><strong>Change Over Time:</strong> The NCPS Clinical Team Training Programs at the Veterans Health Administration have used CRM since its inception in 1999. In the 2006-2008 period, facilities participating in team training experienced a statistically significant reduction in the annual mortality rate (18% relative decrease), compared with a nonsignificant relative reduction (7%) among untrained facilities.</li>
</ul>
<h4>Patient Safety Infrastructure: Patient Safety Organizations</h4>
<ul>
<li>Patient safety organizations (PSOs) enable health care providers to voluntarily report, discuss, and learn from patient safety events and quality analyses on a privileged and confidential basis.</li>
<li>PSOs aim to reduce preventable adverse events, near-misses, and unsafe conditions in all health care settings.</li>
<li>Measures related to PSOs include:
<ul>
<li>Distribution of Patient Safety Organizations by category of event reports collected.</li>
<li>Reduction in surgical site infections among Vascular Quality Initiative Centers that expanded from sporadic to routine chlorhexidine use.</li>
</ul>
</li>
</ul>
<p>PSOs were established under the Patient Safety and Quality Improvement Act of 2005.</p>
<h4>Patient Safety Organizations</h4>
<p><strong>Distribution of Patient Safety Organizations by category of event reports collected, 2013</strong></p>
<p><img alt="Pie chart showing distribution of Patient Safety Organizations by category of event reports collected, 2013. Go to table below for details." src="pts-fig30.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 80%;">
<tr>
<td scope="row" width="80%">All categories</td>
<td align="center" width="20%">10 (24%)</td>
</tr>
<tr>
<td scope="row">Multiple categories, but not all</td>
<td align="center">22 (54%)</td>
</tr>
<tr>
<td scope="row">Blood or blood product only</td>
<td align="center">1 (2%)</td>
</tr>
<tr>
<td scope="row">Device only</td>
<td align="center">1 (2%)</td>
</tr>
<tr>
<td scope="row">Fall only</td>
<td align="center">1 (2%)</td>
</tr>
<tr>
<td scope="row">Medication and/or other substance only</td>
<td align="center">2 (5%)</td>
</tr>
<tr>
<td scope="row">Anesthesia only</td>
<td align="center">2 (5%)</td>
</tr>
<tr>
<td scope="row">Other category only</td>
<td align="center">2 (5%)</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source: </strong>Agency for Healthcare Research and Quality, Patient Safety Organization Profile, Calendar Year 2013.<br><br />
<strong>Note: </strong>Only self-reporting PSOs that received at least one patient safety report were included in this figure. PSOs can collect reports on more than one type of event. Percentages do not add to 100 due to rounding.</p>
<ul>
<li><strong>Overall Rate:</strong> More than three-quarters of PSOs that received at least one patient safety event report in 2013 received reports in multiple or all event categories. Four of every five of these PSOs also received reports on quality.</li>
</ul>
<h4>Reduction in Surgical Site Infections Among Facilities With Routine Chlorhexidine Use</h4>
<p><strong>Reduction in surgical site infections among Vascular Quality Initiative Centers that improved to routine chlorhexidine use, 2011 and 2013</strong></p>
<p><img alt="Bar chart showing reduction in surgical site infections among Vascular Quality Initiative Centers that improved to routine chlorhexidine use, 2011 and 2013. Go to table below for details." src="pts-fig31.jpg"></p>
<table border="1" cellspacing="0" cellpadding="3" style=" width: 80%;">
<tr>
<th scope="col">&#160;</th>
<th scope="col"><strong>2011</strong></th>
<th scope="col"><strong>2013</strong></th>
</tr>
<tr>
<td scope="row">Chlorhexidine Use</td>
<td align="center">15%</td>
<td align="center">95%</td>
</tr>
<tr>
<td scope="row">Rate of Surgical Site Infections</td>
<td align="center">5.5%</td>
<td align="center">1.5%</td>
</tr>
</table>
<p>&#160;</p>
<p><strong>Source: </strong>Vascular Quality Initiative® data, 2011-2013.</p>
<ul>
<li><strong>Overall Rate:</strong> The Society for Vascular Surgery PSO identified skin preparation using iodine—rather than chlorhexidine disinfectant—as one of three factors that predicted a higher likelihood of SSI in patients receiving a lower extremity bypass operation. Provider behavior changed as a result of receiving performance reports on the factors that increase SSI. Overall use of chlorhexidine increased and the majority of centers that rarely or selectively used chlorhexidine began to use it routinely. Among centers that improved chlorhexidine usage to routine use, the rate of SSIs decreased from 5.5% to 1.5% between 2011 and 2013.</li>
</ul>
<p><a href="/research/findings/nhqrdr/2014chartbooks/patientsafety/index.html">Return to Contents</a></p>
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Page last reviewed <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2015-04-01T00:00:00-04:00">April 2015</span> <br />Page originally created April 2015 </div>
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Internet Citation: National Healthcare Quality and Disparities Report: Chartbook on Patient Safety. Content last reviewed April 2015. Agency for Healthcare Research and Quality, Rockville, MD. https://archive.ahrq.gov/research/findings/nhqrdr/2014chartbooks/patientsafety/ps-measures6.html<div class="citation-flag"> </div> </div> <!--</div>--> <div class="footnote"> <p> The information on this page is archived and provided for reference purposes only.</p> </div> <p>&nbsp;</p> </div> </div></td> </tr> </tbody> </table> </td> </tr> </tbody> </table> </div>
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