Surgeon-reported complications vs AHRQ PSIs for identifying adverse events

Editor's Note

Surgeon-reported complications in morbidity and mortality (M&M) conferences and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are complementary approaches for identifying adverse events and informing quality improvement efforts, this study finds.

Of 6,563 surgical hospitalizations analyzed, 647 (9.9%) had at least one complication identified by either the M&M process or PSIs or both.

Most complications identified by M&M alone were excluded by PSI criteria, as intended, but 11 true PSI events (ie, false negatives) were identified only by M&M.

Pressure ulcers and central venous catheter-related blood stream infections were detected only by PSIs and not reported at M&M conferences.

Both case-finding processes should be used to inform quality improvement efforts, the researchers say.