Chunliu Zhan

U.S. Department of Health and Human Services, Washington, D. C., DC, United States

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Publications (29)124.75 Total impact

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    ABSTRACT: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.
    Medical care 02/2009; 47(3):364-9. · 3.24 Impact Factor
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    ABSTRACT: A study was conducted to explore the value and limitations of voluntary medical error reports and to learn about common errors in warfarin use. Voluntary reports of 8,837 inpatient errors and 820 outpatient errors in warfarin use submitted by 445 hospitals and 192 outpatient facilities participating in MEDMARX, a voluntary medication error reporting system, from 2002 to 2004, were gathered. Overall, errors occurred most often during transcription/documentation (35%) and administration (30%) in hospitals, and during prescribing (31%) and dispensing (39%) in outpatient settings. Dosing errors were the most common type. In hospitals, more than 50% of reported errors were initiated by nurses, and 50% were intercepted by nurses, whereas in outpatient settings, about 50% of reported errors occurred in pharmacies and 50% were intercepted by pharmacists. About 17% of inpatient and 13% of outpatient warfarin errors resulted in changes in patient care, and 42% of inpatient and 62% of outpatient errors resulted in procedural changes. Cascade analysis and textual descriptions further located specific, correctible safety lapses. Voluntary medical error reporting systems can, to some extent, provide meaningful and actionable information to guide patient safety improvement, but their usefulness is limited because of a lack of details, incomplete reporting, underreporting, and various reporting biases.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 02/2008; 34(1):36-45.
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    ABSTRACT: Use of cardiac devices has been increasing rapidly along with concerns over their safety and effectiveness. This study used hospital administrative data to assess cardiac device implantations in the United States, selected perioperative outcomes, and associated patient and hospital characteristics. We screened hospital discharge abstracts from the 1997-2004 Healthcare Cost and Utilization Project Nationwide Inpatient Samples. Patients who underwent implantation of pacemaker (PM), automatic cardioverter/defibrillator (AICD), or cardiac resynchronization therapy pacemaker (CRT-P) or defibrillator (CRT-D) were identified using ICD-9-CM procedure codes. Outcomes ascertainable from these data and associated hospital and patient characteristics were analyzed. Approximately 67,000 AICDs and 178,000 PMs were implanted in 2004 in the United States, increasing 60% and 19%, respectively, since 1997. After FDA approval in 2001, CRT-D and CRT-P reached 33,000 and 7,000 units per year in the United States in 2004. About 70% of the patients were aged 65 years or older, and more than 75% of the patients had 1 or more comorbid diseases. There were substantial decreases in length of stay, but marked increases in charges, for example, the length of stay of AICD implantations halved (from 9.9 days in 1997 to 5.2 days in 2004), whereas charges nearly doubled (from $66,000 in 1997 to $117,000 in 2004). Rates of in-hospital mortality and complications fluctuated slightly during the period. Overall, adverse outcomes were associated with advanced age, comorbid conditions, and emergency admissions, and there was no consistent volume-outcome relationship across different outcome measures and patient groups. The numbers of cardiac device implantations in the United States steadily increased from 1997 to 2004, with substantial reductions in length of stay and increases in charges. Rates of in-hospital mortality and complications changed slightly over the years and were associated primarily with patient frailty.
    Journal of General Internal Medicine 02/2008; 23 Suppl 1:13-9. · 3.28 Impact Factor
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    ABSTRACT: Deep vein thrombosis and pulmonary embolism (DVT/PE) are common complications after surgery and are associated with substantial excess mortality and length of stay. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes recorded in hospital claims have been used to identify and study DVT/PE, but the validity of this method is not well studied. Identification of postoperative DVT/PE events were compared using ICD-9-CM codes and medical record abstraction in random samples of hospital discharges of Medicare beneficiaries in 2002-2004. Among 20,868 eligible surgical hospitalizations, 232 DVT cases and 95 PE cases were identified by ICD-9-CM codes; 108 DVT cases and 31 PE cases by medical record abstraction; 72 DVT cases and 23 PE cases by both methods. The resulting estimates of PPV of ICD9-CM coding were 31% (72/232 cases) for DVT, 24% (23/95) for PE, and 29% (90/308) for DVT/PE combined. The resulting sensitivity estimates were 67% (72/108 cases) for DVT, 74% (23/31) for PE, and 68% (90/133) for DVT/PE combined. ICD-9-CM codes in Medicare claims are sensitive but have limited predictive validity in identifying postoperative DVT/PE. Improvements in the validity are needed before the indicator can be used for safety performance assessment.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 07/2007; 33(6):326-31.
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    ABSTRACT: The inability to distinguish complications acquired in hospital from comorbid conditions that are present on admission (POA) has long hampered the use of claims data in quality and safety research. Now pay-for-performance initiatives and legislation requiring Medicare to reduce payment for acquired infections add imperative for POA coding. This study used data from 2 states currently coding POA to assess the financial impact if Medicare pays based on POA conditions only and to examine the challenges in implementing POA coding. Medicare payments were calculated based first on all diagnoses and then on POA diagnoses in the Medicare discharge abstracts from California and New York in 2003, using the Diagnosis Related Group (DRG)-based Prospective Payment System (PPS) formula. The potential savings that result from excluding non-POA diagnoses were calculated. Patterns of POA coding were explored. Medicare could have saved $56 million in California, $51 million in New York, and $800 million nationwide in 2003 had it paid hospital claims based only on POA diagnoses. Approximately 15% of the claims had non-POA codes, but only 1.4% of the claims were reassigned to lower-cost DRGs after excluding non-POA diagnoses. Excluding non-POA diagnoses resulted in reduced payment for operating costs, but increased outlier payments because some of the claims were designated as "unusually high cost" in the lower-cost DRGs. POA coding patterns suggest some problems in current POA coding. To be consistent with pay-for-performance principles and make claims data more useful for quality assurance, incorporating POA coding into DRG-PPS could produce sizable savings for Medicare.
    Medical Care 05/2007; 45(4):288-91. · 3.23 Impact Factor
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    ABSTRACT: The purpose of this study was to use 2003 nationwide United States data to determine the incidences of primary total hip replacement, partial hip replacement, and revision hip replacement and to assess the short-term patient outcomes and factors associated with the outcomes. We screened more than eight million hospital discharge abstracts from the 2003 Healthcare Cost and Utilization Project Nationwide Inpatient Sample and approximately nine million discharge abstracts from five state inpatient databases. Patients who had undergone total, partial, or revision hip replacement were identified with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. In-hospital mortality, perioperative complications, readmissions, and the association between these outcomes and certain patient and hospital variables were analyzed. Approximately 200,000 total hip replacements, 100,000 partial hip replacements, and 36,000 revision hip replacements were performed in the United States in 2003. Approximately 60% of the patients were sixty-five years of age or older and at least 75% had one or more comorbid diseases. The in-hospital mortality rates associated with these three procedures were 0.33%, 3.04%, and 0.84%, respectively. The perioperative complication rates associated with the three procedures were 0.68%, 1.36%, and 1.08%, respectively, for deep vein thrombosis or pulmonary embolism; 0.28%, 1.88%, and 1.27% for decubitus ulcer; and 0.05%, 0.06%, and 0.25% for postoperative infection. The rates of readmission, for any cause, within thirty days were 4.91%, 12.15%, and 8.48%, respectively, and the rates of readmissions, within thirty days, that resulted in a surgical procedure on the affected hip were 0.79%, 0.91%, and 1.53%. The rates of readmission, for any cause, within ninety days were 8.94%, 21.14%, and 15.72%, and the rates of readmissions, within ninety days, that resulted in a surgical procedure on the affected hip were 2.15%, 1.61%, and 3.99%. Advanced age and comorbid diseases were associated with worse outcomes, while private insurance coverage and planned admissions were associated with better outcomes. No consistent association between outcomes and hospital characteristics, such as hip procedure volume, was identified. Total hip replacement, partial hip replacement, and revision hip replacement are associated with different rates of postoperative complications and readmissions. Advanced age, comorbidities, and nonelective admissions are associated with inferior outcomes.
    The Journal of Bone and Joint Surgery 04/2007; 89(3):526-33. · 3.23 Impact Factor
  • Chunliu Zhan, Maureen Smith, Daniel Stryer
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    ABSTRACT: Iatrogenic pneumothorax (IP) is an inherent risk to patients who undergo procedures that involve the intentional puncturing of the lung. IP also could occur accidentally to patients who do not undergo such procedures; such accidental IP (AIP) is suggestive of lapses in safe care. This study assessed the risk for AIP in patients hospitalized with specific diagnoses who underwent specific procedures. We analyzed 7.5 million discharge abstracts from 994 short-term acute care hospitals across 28 states in 2000 in the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AHRQ Patient Safety Indicators (PSIs) were used to identify AIP. AIP incidences and associated diagnoses and procedures were explored. Patients who were admitted for pleurisy, cancer of the kidney and renal pelvis, or conduction disorders and complications of cardiac devices had the highest rates of developing AIP during hospitalization, with AIP rates at 2.24%, 1.14%, and 0.83% respectively. The procedure-specific rates for AIP varied from 2.68% for patients who underwent thoracentesis to 1.30% for those who underwent nephrectomy, to 0.06% for those who underwent gastrostomy. Thoracentesis appeared to be a high-risk procedure for patients who were admitted for secondary malignancies, pleurisy, or pneumonia, with AIP rates at 3.76%, 3.13%, and 2.28%, respectively. Although AIP is most common after thoracentesis, it is a substantial threat to patients undergoing a wide range of procedures.
    Medical Care 03/2006; 44(2):182-6. · 3.23 Impact Factor
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    ABSTRACT: The potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied. A national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed. Facilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, mis-communication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors. A national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.
    American Journal of Health-System Pharmacy 03/2006; 63(4):353-8. · 1.98 Impact Factor
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    ABSTRACT: 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. The article then suggests strategies for refining future research on racial/ethnic disparities based on patient assessment of health care.
    American Journal of Medical Quality 01/2006; 21(2):109-14. · 1.47 Impact Factor
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    ABSTRACT: This study estimates that Medicare extra payments under the hospital prospective payment system (PPS) range from about $700 per case of decubitus ulcer to $9,000 per case of postoperative sepsis in the five types of adverse events identifiable in Medicare claims. Medicare extra payment for the five types of events totals more than $300 million per year, accounting for 0.27 percent of annual Medicare hospital spending. But these extra payments cover less than a third of the extra costs incurred by hospitals in treating these adverse events. We conclude that both Medicare and hospitals gain financially by improving patient safety.
    Health Affairs 01/2006; 25(5):1386-93. · 4.64 Impact Factor
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    ABSTRACT: Adverse d[rug events (ADEs) are a well-recognized patient safety 4concern, but their magnitude is unknown. Ambulatory viisits for treating adverse drug effects (VADEs) as recordeed in national surveys offer an alternative way to estimatte the national prevalence of ADEs because each VA]DE indicates that an ADE occurred and was seriousenough to require care. A nationallyrepresentative sample of visits to physician offices, hospital outpatient departments, and emergency departments was analyzed. VADEs were identified as tthe first-listed cause of injury. In 2001, there Awere 4.3 million VADEs in the United States, averaging 15 visits per 1,000 population. VADE rates at physicianoffices, hospital outpatient departments, and hospittal emergency departments were at 3.7, 3.4, and 7.3 lper 1,000 visits, respectively. There was an upward tr'end in the total number of VADEs from 1995 to 2001 ((p < .05), but the increases in VADEs per 1000 visits an.d per 1,000 population were not statistically significant. VADEs were lower in children younger than 15 and higher in the elderly aged 65-74 than in adults aged 225-44 (p < .01) and were more frequent in females than irn males (p < .05). Although methodologically conservative, the study suggests that ADEs are a significant threat to patient safety in the United States.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 07/2005; 31(7):372-8.
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    ABSTRACT: 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. 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. This study is a selective review of definitions, frameworks, data sources, measures, and emerging developments for assessing patient safety in the United States. Available data and measures for patient safety assessment in the nation are inadequate, especially for comparing regions and subpopulations and for trend analysis. However, many opportunities are emerging from the recently increased investments in patient safety research and many ongoing safety improvement efforts in the private sector and at the federal, state, and local government levels. There are many challenges in assessing national performance on patient safety today. Ongoing developments on multiple fronts will provide data and measures for more accurate and more comprehensive assessments of patient safety for future NHQRs.
    Medical Care 04/2005; 43(3 Suppl):I42-7. · 3.23 Impact Factor
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    ABSTRACT: To assess the prevalence and correlates of potentially harmful drug-drug combinations and drug-disease combinations prescribed for elderly patients at outpatient settings. Retrospective analysis of the 1995-2000 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS). Physician offices and hospital outpatient departments. Outpatient visits by patients aged 65 and older in the NAMCS and NHAMCS (n=70,203). Incidences of six drug-drug combinations and 50 drug-disease combinations that can place elderly patients at risk for adverse events according to expert consensus panels. Overall, 0.74% (95% confidence interval (CI)=0.65-0.83) of visits with two or more prescriptions had at least one inappropriate drug-drug combination, and 2.58% (95% CI=2.44-2.72) of visits with at least one prescription had one or more inappropriate drug-disease combinations. Of visits with a prescription of warfarin, 6.60% (95% CI=5.46-7.74) were prescribed a drug with potentially harmful interaction. Of patients with benign prostatic hypertrophy, 4.06% (95% CI=3.06-5.06) had at least one of six drugs that should be avoided. The number of drugs prescribed is most predictive of inappropriate drug-drug and drug-disease combinations. Potentially harmful drug-drug and drug-disease combinations occur in various degrees in outpatient care in the elderly population. Targeting combinations such as those involving warfarin that are high in prevalence and potential harm offers a practical approach to improving prescribing and patient safety.
    Journal of the American Geriatrics Society 03/2005; 53(2):262-7. · 4.22 Impact Factor
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    ABSTRACT: Measures of health care quality for children are not as well developed as those for adults. It is also unclear the extent to which the current pool of measures address common causes of illness and health care utilization for children. The goal of this study was to create lists of high-priority conditions for children based on different vantage points for defining burden relative to both inpatient and outpatient care for children. These high-priority conditions were then cross-tabulated with all known existing quality measures for pediatric health care. High-prevalence conditions for children were identified by using the 2000 National Ambulatory Medical Care Survey, 2000 National Hospital Ambulatory Medical Care Survey, 1999 Medical Expenditure Panel Survey, 2000 Healthcare Cost and Utilization Project's State Inpatient Databases, and 2000 Healthcare Cost and Utilization Project's State Ambulatory Surgery Databases. Burden assessments were done using frequencies of visits, charges, in-hospital deaths. Existing quality measures for children were identified from a recent compendium of such measures and a search of the National Quality Measures Clearinghouse. There are numerous and large gaps in existing quality-of-care measures for children relative to high-burden conditions in both the inpatient and outpatient setting. With the ever increasing efforts to measure and even publicly report on health care, efforts for children need to include focus on building a representative repertoire of quality measures for the high-burden conditions children experience.
    Ambulatory Pediatrics 01/2005; 5(5):268-78. · 1.60 Impact Factor
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    Preventing chronic disease 08/2004; 1(3):A03. · 1.82 Impact Factor
  • Marlene R Miller, Chunliu Zhan
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    ABSTRACT: To describe potential patient safety events for hospitalized children, examine associated factors, and explore impacts of safety events. The newly released Patient Safety Indicators (PSIs), 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 hospital discharge data. All 5.7 million discharge records for children younger than 19 years from 27 states in the 2000 Healthcare Cost and Utilization Project were analyzed for PSI events. Prevalence of PSI events and associations with patient-level and hospital-level characteristics were examined. Multivariate regression adjusting for patient severity of illness was used to estimate impacts of safety events in terms of excess length of stay, charges, and in-hospital mortality. The prevalence of pediatric patient safety events is significant. PSI events occurred more frequently in the very young and those on Medicaid insurance, some of the most vulnerable hospitalized children. Regression analysis found that almost all PSIs are associated with significant and substantial increases in length of stay, charges, and in-hospital death. Using the estimates derived here and the actual number of cases identified in the 2000 data, we estimate that patient safety events incurred >1 billion dollars in excess charges for children alone in 2000. Patient safety problems for hospitalized children occur frequently and with substantial impacts to our health care industry. Unmeasurable by this study are the additional "costs" and "burdens" of safety events that our patients are forced to handle. Additional work to describe and quantify better these outcomes in addition to ones measured here can help solidify the "business case" for patient safety efforts.
    PEDIATRICS 06/2004; 113(6):1741-6. · 4.47 Impact Factor
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    ABSTRACT: To examine the effects of health maintenance organization (HMO) penetration on preventable hospitalizations. 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. Preventable hospitalizations due to 14 ambulatory care sensitive conditions were identified using the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators. Multiple regressions were used to determine the association between preventable hospitalizations and HMO penetration while controlling for demographic and socioeconomic characteristics and health care capacity of the counties. A 10 percent increase in HMO penetration was associated with a 3.8 percent decrease in preventable hospitalizations (95 percent confidence interval, 2.0 percent-5.6 percent). Advanced age, female gender, poor health, poverty, more hospital beds, and fewer primary care physicians per capita were significantly associated with more preventable hospitalizations. Our study suggests that HMO penetration has significant effects in reducing preventable hospitalizations due to some ambulatory care sensitive conditions.
    Health Services Research 05/2004; 39(2):345-61. · 2.29 Impact Factor
  • Herbert Wong, Chunliu Zhan, Ryan Mutter
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    ABSTRACT: Considerable controversy exists about the appropriate way hospital competition should be measured and whether findings are accurate if certain methods are employed. Data from the Healthcare Cost and Utilization Project (HCUP), the American Hospital Association (AHA), and other supplemental data sources are used to create and evaluate hospital competition measures. Correlation coefficients of these measures are assessed. Moreover, each measure is independently included as an explanatory variable in otherwise identical hospital cost function regressions. Their corresponding parameter estimates are then compared. Most measures are highly correlated. Inferences about the effect of competition on hospital cost remain the same when alternative hospital competition measures are employed. We caution researchers against using this finding to arbitrarily select a competition measure when the magnitude of the estimates is important. Copyright Springer 2004
    Review of Industrial Organization 01/2004; 26(1):27-60. · 0.48 Impact Factor
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    C Zhan, M R Miller
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    ABSTRACT: 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.
    Quality and Safety in Health Care 01/2004; 12 Suppl 2:ii58-63. · 2.16 Impact Factor
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    Chunliu Zhan, Marlene R Miller
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    ABSTRACT: Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact. To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. Length of stay, charges, and mortality that were recorded in hospital discharge abstracts and were attributable to medical injuries according to 18 PSIs. Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranged from 0 dollar for obstetric trauma (without vaginal instrumentation) to 57 727 dollars for postoperative sepsis, and excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, 40 323 dollars in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, 38 656 dollars in excess charges, and 4.31% attributable mortality. Some injuries incurred during hospitalization pose a significant threat to patients and costs to society, but the impact of such injury is highly variable.
    JAMA The Journal of the American Medical Association 10/2003; 290(14):1868-74. · 29.98 Impact Factor

Publication Stats

2k Citations
124.75 Total Impact Points


  • 2005–2009
    • U.S. Department of Health and Human Services
      • Agency for Healthcare Research and Quality (AHRQ)
      Washington, D. C., DC, United States
  • 2003–2008
    • Agency for Healthcare Research and Quality
      Maryland, United States
  • 2004–2005
    • Johns Hopkins University
      • Department of Pediatrics
      Baltimore, MD, United States
  • 2000
    • Social & Scientific Systems
      Silver Spring, Maryland, United States