Center for Organization, Leadership, and Management Research (COLMR), Boston, MA, USA.
J Am Coll Surg. 2011 Jun;212(6):977-83. doi: 10.1016/j.jamcollsurg.2011.02.003. Epub 2011 Apr 13.
The Agency for Healthcare Research and Quality (AHRQ) developed patient safety indicator (PSI) 5, "Foreign body left during procedure," to flag accidental foreign bodies in surgical and medical procedures. This study examined how well this indicator identifies true foreign body events in the Veterans Health Administration (VA).
This was a retrospective study within 28 selected VA hospitals from fiscal year 2003 to 2007. Trained abstractors reviewed medical charts flagged by PSI 5 and determined true foreign body cases. We calculated the positive predictive value (PPV) of this indicator and performed descriptive analyses of true positive and false positive cases.
Of the 652,093 eligible cases, 93 were flagged by PSI 5 (0.14 per 1,000). Forty-two were true positives, yielding a PPV of 45% (95% CI 35% to 56%). False positives were due to a foreign body that was present on admission (57%) or coding errors (43%). True foreign bodies were associated with surgical (n = 23) and medical (n = 19) procedures. The most common type of surgical foreign body was a sponge (52%). Overall, approximately 40% of foreign bodies were related to a device failure or malfunction (30% surgical vs 53% medical foreign bodies). Postoperative complications included pain (24%), infection (12%), adhesions (5%), and bowel obstruction (5%).
The reported rate of foreign body events as detected by PSI 5 is low in the VA, but occurs in both surgical and medical procedures. Despite widespread implementation of surgical counts, quality improvement efforts should focus on novel ways to eliminate this "never event" from operations. Future studies are needed to better understand the preventability of medical procedure-associated foreign bodies and particularly, device failure-related foreign bodies.
医疗保健研究与质量署（AHRQ）开发了患者安全指标（PSI）5，“手术过程中遗留异物”，以标记手术和医疗程序中的意外异物。本研究考察了该指标在退伍军人健康管理局（VA）中识别真正异物事件的效果。
这是一项在 2003 年至 2007 年期间从 28 家选定的 VA 医院进行的回顾性研究。经过培训的摘要员审查了 PSI 5 标记的医疗图表，并确定了真正的异物病例。我们计算了该指标的阳性预测值（PPV），并对真正阳性和假阳性病例进行了描述性分析。
在 652,093 例合格病例中，有 93 例被 PSI 5 标记（每 1,000 例 0.14 例）。其中 42 例为真正的阳性，阳性预测值为 45%（95%置信区间为 35%至 56%）。假阳性归因于入院时存在的异物（57%）或编码错误（43%）。真正的异物与手术（n=23）和医疗（n=19）程序有关。最常见的手术异物是海绵（52%）。总体而言，大约 40%的异物与设备故障或故障有关（30%的手术异物与 53%的医疗异物）。术后并发症包括疼痛（24%）、感染（12%）、粘连（5%）和肠梗阻（5%）。
VA 中通过 PSI 5 检测到的异物事件报告率较低，但发生在手术和医疗程序中。尽管广泛实施了手术计数，但质量改进工作应侧重于消除这种“不应发生的事件”的新方法。需要进一步研究以更好地了解与医疗程序相关的异物，特别是与设备故障相关的异物的可预防性。
