Tracking rates of patient safety indicators over time: Lessons from the veterans administration

Amy K. Rosen, Shibei Zhao, Peter Rivard, Susan Loveland, Maria E. Montez-Rath, Anne Elixhauser, Patrick S Romano

Research output: Contribution to journalArticlepeer-review

40 Scopus citations


BACKGROUND: The Patient Safety Indicators (PSIs), developed by the Agency for Healthcare Research and Quality, are useful screening tools for highlighting areas in which quality should be further investigated and providing useful benchmarks for tracking progress. OBJECTIVES: Our objectives were to: 1) provide a descriptive analysis of the incidence of PSI events from 2001 to 2004 in the Veterans Health Administration (VA); 2) examine trends in national PSI rates at the hospital discharge level over time; and 3) assess whether hospital characteristics (eg, teaching status, number of beds, and degree of quality improvement implementation) and baseline safety-related hospital performance predict future hospital safety-related performance. METHODS: We examined changes in risk-adjusted PSI rates at the discharge level, calculated the correlation between hospitals' risk-adjusted PSI rates in 2001 with subsequent years, and developed generalized linear models to examine predictors of hospitals' 2004 risk-adjusted PSI rates. RESULTS: Risk-adjusted rates of 2 of the 15 PSIs demonstrated significant trends over time. Rates of iatrogenic pneumothorax increased over time, whereas rates of failure to rescue decreased. Most PSIs demonstrated consistent rates over time. After accounting for patient and hospital characteristics, hospitals' baseline risk-adjusted PSI rates were the most important predictors of their 2004 risk-adjusted rates for 8 PSIs. CONCLUSIONS: The PSIs are useful tools for tracking and monitoring patient safety events in the VA. Future research should investigate whether trends reflect better or worse care or increased attention to documenting patient safety events.

Original languageEnglish (US)
Pages (from-to)850-861
Number of pages12
JournalMedical Care
Issue number9
StatePublished - Sep 2006


  • Administrative data
  • Adverse events
  • Medical errors
  • Patient safety
  • Quality improvement

ASJC Scopus subject areas

  • Nursing(all)
  • Public Health, Environmental and Occupational Health
  • Health(social science)
  • Health Professions(all)


Dive into the research topics of 'Tracking rates of patient safety indicators over time: Lessons from the veterans administration'. Together they form a unique fingerprint.

Cite this