After finding flaws with a federal patient safety metric, researchers at Los Angeles-based UCLA Health are calling for revisions.
In a study published Oct. 12 in the Journal of NeuroInterventional Surgery, UCLA Health researchers outlined their concerns with “PSI 04: Death Rate among Surgical Inpatients with Serious Treatable Complications,” a patient safety indicator from HHS’ Agency of Healthcare Research and Quality.
The “failure-to-rescue” measure tracks deaths from treatable complications in surgical patients, according to a Jan. 8 news release from UCLA Health. Compared to 17 other federal patient safety indicators, PSI 04 had the highest event rate between 2016 and 2019, the study found, indicating flaws in the metric.
The national event rate of PSI 04 for emergent endovascular thrombectomy procedures is 20.5%, according to the study — far higher than the 0.10% median for 17 other PSIs.
“This metric was designed to identify preventable deaths, but when applied to emergency stroke care, it’s flagging unavoidable complications of severe strokes rather than problems with the procedure itself,” Melissa Reider-Demer, DNP, the study’s first author, said in the news release. “The unintended consequence is that hospitals providing excellent stroke care to the sickest patients may appear to have poor safety records.”
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