Costs and state-specific rates of thoracic and lumbar vertebroplasty, 2001-2005.

Study Design: Sequential cross-sectional analysis.

Objective: To document vertebroplasty rates and costs.

Summary Of Background Data: Little is known about interstate variation in rates or about nation-wide costs associated with the growing use of percutaneous vertebroplasty.

Improving patient safety by instructional systems design.

Education and training are important elements in patient safety, both as a potential contributing factor to risks and hazards of healthcare associated injury or harm and as an intervention to be used in eliminating or preventing such harm. All too often we have relied on training as the only interventions for patient safety without examining other alternatives or realizing that, in some cases, the training systems themselves are part of the problem. One way to ensure safety by design is to apply established design principles to education and training.

Quality and safety by design.

Rather than continuing to try to measure the width and depths of the quality chasm, a legitimate question is how does one actually begin to close the quality chasm? One way to think about the problem is as a design challenge rather than as a quality improvement challenge. It is time to move from reactive measurement to a more proactive use of proven design methods, and to involve a number of professions outside health care so that we can design out system failure and design in quality of care. Is it possible to actually design in quality and design out failure? A three level conceptual framework design would use the six quality aims laid out in Crossing the quality chasm.

Population-based trends in volumes and rates of ambulatory lumbar spine surgery.

Study Design: Sequential cross-sectional study.

Objectives: To quantify patterns of outpatient lumbar spine surgery.

Summary Of Background Data: Outpatient lumbar spine surgery patterns are undocumented.

Sensemaking of patient safety risks and hazards.

In order for organizations to become learning organizations, they must make sense of their environment and learn from safety events. Sensemaking, as described by Weick (1995), literally means making sense of events. The ultimate goal of sensemaking is to build the understanding that can inform and direct actions to eliminate risk and hazards that are a threat to patient safety.

Racial and ethnic differences in patient assessments of interactions with providers: disparities or measurement biases?

Patient assessment surveys have established a primary role in health care quality measurement as evidence has shown that information from patients can affect quality improvement for practitioners and lead to positive marketwide changes. This article presents findings from the recently released National Healthcare Disparities Report revealing that although most clinical quality and access indicators show superior health care for non-Hispanic whites compared with blacks and Hispanics, blacks and Hispanics assess their interactions with providers more positively than non-Hispanic whites do. The article explores possible explanations for these racial/ethnic differences, including potential pitfalls in survey design that draw biased responses by race/ethnicity.

Patient Safety Indicators: using administrative data to identify potential patient safety concerns.

Objective: To develop Patient Safety Indicators (PSI) to identify potential in-hospital patient safety problems for the purpose of quality improvement.

Data Source/study Design: The data source was 2,400,000 discharge records in the 1997 New York State Inpatient Database. PSI algorithms were developed using systematic literature reviews of indicators and hand searches of the ICD-9-CM code book.

Assessing patient safety in the United States: challenges and opportunities.

Background: In 1999, the US Congress mandated the Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (DHHS), to report annually to the nation about healthcare quality. One chapter in the National Healthcare Quality Report (NHQR) is focused on patient safety.

Objectives: The objectives of this study were to describe the challenges in reporting the national status on patient safety for the first NHQR and discuss emerging opportunities to improve the comprehensiveness and reliability of future reporting.

Challenges in measuring nursing home and home health quality: lessons from the First National Healthcare Quality Report.

Background: The availability of patient assessment data collected by all Medicare- and Medicaid-certified nursing homes (NHs) (the Minimum Data Set [MDS]) and home health agencies (HHAs) (the Outcome and Assessment Information Set [OASIS]) provides an opportunity to measure quality of care in these settings.

Objective: The objective of this study was to examine methodologic issues encountered as these datasets are used to report the nation's health care in the National Healthcare Quality Report (NHQR) at national and state levels.

Findings: Although the reliability of most data elements from MDS and OASIS are considered acceptable in research studies, mixed evidence exists for the reliability and validity of the quality measures themselves.

The first national reports on United States healthcare quality and disparities.

In the Healthcare Research and Quality Act of 1999 (Public Law 106-129), Congress mandated that the Agency for Healthcare Research and Quality (AHRQ) produce annual reports on healthcare quality and disparities in the United States. The National Healthcare Quality Report and the National Healthcare Disparities Report were first released in 2003 by the AHRQ. These reports include broad sets of performance measures to portray the nation's progress toward improving the quality of care provided to all Americans.

The effects of HMO penetration on preventable hospitalizations.

Objective: To examine the effects of health maintenance organization (HMO) penetration on preventable hospitalizations.

Data Source: Hospital inpatient discharge abstracts for 932 urban counties in 22 states from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), hospital data from American Hospital Association (AHA) annual survey, and population characteristics and health care capacity data from Health Resources and Services Administration (HRSA) Area Resource File (ARF) for 1998.

Methods: Preventable hospitalizations due to 14 ambulatory care sensitive conditions were identified using the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators.

Administrative data based patient safety research: a critical review.

Administrative data are readily available, inexpensive, computer readable, and cover large populations. Despite coding irregularities and limited clinical details, administrative data supplemented by tools such as the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) could serve as a screen for potential patient safety problems that merit further investigation, offer valuable insights into adverse impacts and risks of medical errors and, to some extent, provide benchmarks for tracking progress in patient safety efforts at local, state, or national levels.

Hindsight bias, outcome knowledge and adaptive learning.

The ubiquitous nature of hindsight bias is a cause for concern for those engaged in investigations and retrospective analysis of medical error. Hindsight does not equal foresight. Investigations that are anchored to outcome knowledge run the risk of not capturing the complexities and uncertainties facing sharp end personnel and why their actions made sense at the time.

Organizing patient safety research to identify risks and hazards.

Patient safety has become an international priority with major research programmes being carried out in the USA, UK, and elsewhere. The challenge is how to organize research efforts that will produce the greatest yield in making health care safer for patients. Patient safety research initiatives can be considered in three different stages: (1) identification of the risks and hazards; (2) design, implementation, and evaluation of patient safety practices; and (3) maintaining vigilance to ensure that a safe environment continues and patient safety cultures remain in place.

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.

Context: Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact.

Objective: To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization.

Design, Setting, And Patients: The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.

Patient safety events during pediatric hospitalizations.

Objective: Our objective was to describe potential patient safety events for hospitalized children, using the patient safety indicators (PSIs), and examine associations with these events.

Methods: PSI algorithms, developed by researchers at the Agency for Healthcare Research and Quality to identify potential in-hospital patient safety problems using administrative data, were applied to 3.8 million discharge records for children under 19 years from 22 states in the 1997 Healthcare Cost and Utilization Project.