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## Complete Summary

#### TITLE

Accidental puncture or laceration: rate per 1,000 eligible discharges.

#### SOURCE(S)

AHRQ quality indicators. Pediatric quality indicators: technical
specifications \[version 3.2\]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2008 Feb 29. various p.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

### Measure Domain

#### PRIMARY MEASURE DOMAIN

Outcome

The validity of measures depends on how they are built. By examining the
key building blocks of a measure, you can assess its validity for your
purpose. For more information, visit the [Measure
Validity](http://www.qualitymeasures.ahrq.gov/resources/measure_domains.aspx)
page.

#### SECONDARY MEASURE DOMAIN

Does not apply to this measure

### Brief Abstract

#### DESCRIPTION

This measure is used to assess the number of cases of technical
difficulty (e.g., accidental cut or laceration during procedure) per
1,000 eligible discharges.

#### RATIONALE

This indicator is intended to track injuries occurring during a
procedure, specifically accidental cut, puncture, perforation, or
laceration. These procedures may be prevented through proper technique
during procedures.

#### PRIMARY CLINICAL COMPONENT

Accidental cut; puncture; perforation; laceration

#### DENOMINATOR DESCRIPTION

All surgical and medical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs)

Exclude cases:

-   with International Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) code denoting technical difficulty
    (e.g., accidental cut, puncture, perforation, or laceration) in the
    principal diagnosis field

-   Major Diagnostic Category (MDC) 14 (pregnancy, childbirth, and
    puerperium)

-   normal newborn (DRG 391)

-   neonates with a birth weight less than 500 grams

**Note**: Refer to the original measure documentation for specific DRG
and ICD-9-CM codes.

#### NUMERATOR DESCRIPTION

Discharges among cases meeting the inclusion and exclusion rules for the
denominator with International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) code denoting accidental cut,
puncture, perforation or laceration during a procedure in any secondary
diagnosis field

**Note**: Refer to the original measure documentation for specific
ICD-9-CM codes.

### Evidence Supporting the Measure

#### EVIDENCE SUPPORTING THE CRITERION OF QUALITY

-   A formal consensus procedure involving experts in relevant clinical,
    methodological, and organizational sciences

-   One or more research studies published in a National Library of
    Medicine (NLM) indexed, peer-reviewed journal

### Evidence Supporting Need for the Measure

#### NEED FOR THE MEASURE

Variation in quality for the performance measured

#### EVIDENCE SUPPORTING NEED FOR THE MEASURE

Agency for Healthcare Research and Quality (AHRQ). National healthcare
quality report. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2003.

Miller MR, Zhan C. Pediatric patient safety in hospitals: a national
picture in 2000. Pediatrics2004 Jun;113(6):1741-6. \[32 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173500)

Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon
M, Bahl V. Relevance of the Agency for Healthcare Research and Quality
Patient Safety Indicators for children\'s hospitals. Pediatrics2005
Jan;115(1):135-45. \[17 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15579669)

### State of Use of the Measure

#### STATE OF USE

Current routine use

#### CURRENT USE

Internal quality improvement\
Quality of care research

### Application of Measure in its Current Use

#### CARE SETTING

Hospitals

#### PROFESSIONALS RESPONSIBLE FOR HEALTH CARE

Physicians

#### LOWEST LEVEL OF HEALTH CARE DELIVERY ADDRESSED

Single Health Care Delivery Organizations

#### TARGET POPULATION AGE

Age less than 18 years

#### TARGET POPULATION GENDER

Either male or female

#### STRATIFICATION BY VULNERABLE POPULATIONS

Stratify rates by low birth weight neonate (under 2000 grams) and other
patients.

### Characteristics of the Primary Clinical Component

#### INCIDENCE/PREVALENCE

Surgeries in pediatric patients, because of their smaller anatomy, can
be technically more complex and can carry a high risk of accidental
puncture or laceration (e.g., 2.22 per 1,000 discharges at 0 to 17
years, 1.84 at 18 to 44 years, 2.82 at 45 to 64 years, and 3.47 at 65 or
more years). This indicator was investigated by two groups, although the
definition differed slightly from the definition proposed for this
measure. Miller and colleagues analyzed Healthcare Cost and Utilization
Project (HCUP) data in 2000, using a publicly released version of this
indicator applied to a pediatric population, and found a significant
incidence of accidental puncture or laceration in pediatric patients
(1.0 per 1,000 in 2000 among 0 to 18 year old children). Additionally,
Miller & Zhan found that this error resulted in increased mean length of
stay (by 7.7 days) and charges per stay (\$41,204 on average) in
affected patients, with 2.7 times higher odds of in-hospital mortality
(after adjusting for age, gender, expected payer, up to 30
comorbidities, and multiple hospital characteristics, including
ownership, teaching status, nursing expertise, urban location, bed size,
pediatric volume, coding intensity, intensive care unit (ICU) bed
percentage, and surgical discharge percentage). Sedman et al. found
observed rates varying from 1.7 per 1,000 in 1999 to 1.9 per 1,000 in
2002 in the National Association of Children\'s Hospitals and Related
Institutions (NACHRI) database (i.e., a slight upward trend over time),
when applying the publicly released Agency for Healthcare Research and
Quality (AHRQ) Quality Indicator (QI) definition to a pediatric
population.

#### EVIDENCE FOR INCIDENCE/PREVALENCE

Agency for Healthcare Research and Quality (AHRQ). National healthcare
quality report. Rockville (MD): Agency for Healthcare Research and
Quality (AHRQ); 2003.

Miller MR, Zhan C. Pediatric patient safety in hospitals: a national
picture in 2000. Pediatrics2004 Jun;113(6):1741-6. \[32 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15173500)

Sedman A, Harris JM 2nd, Schulz K, Schwalenstocker E, Remus D, Scanlon
M, Bahl V. Relevance of the Agency for Healthcare Research and Quality
Patient Safety Indicators for children\'s hospitals. Pediatrics2005
Jan;115(1):135-45. \[17 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15579669)

#### ASSOCIATION WITH VULNERABLE POPULATIONS

See the \"Incidence/Prevalence\" field.

#### BURDEN OF ILLNESS

Unspecified

#### UTILIZATION

See the \"Incidence/Prevalence\" field.

#### COSTS

See the \"Incidence/Prevalence\" field.

### Institute of Medicine National Healthcare Quality Report Categories

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Safety

### Data Collection for the Measure

#### CASE FINDING

Users of care only

#### DESCRIPTION OF CASE FINDING

All surgical and medical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs) (see the \"Denominator
Inclusions/Exclusions\" field)

#### DENOMINATOR SAMPLING FRAME

Patients associated with provider

#### DENOMINATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
All surgical and medical discharges under age 18 defined by specific
Diagnosis Related Groups (DRGs)

**Exclusions**\
Exclude cases:

-   with International Classification of Diseases, Ninth Revision,
    Clinical Modification (ICD-9-CM) code denoting technical difficulty
    (e.g., accidental cut, puncture, perforation, or laceration) in the
    principal diagnosis field

-   Major Diagnostic Category (MDC) 14 (pregnancy, childbirth and
    puerperium)

-   normal newborn (DRG 391)

-   neonates with a birth weight less than 500 grams

**Note**: Refer to the original measure documentation for specific DRG
and ICD-9-CM codes.

#### RELATIONSHIP OF DENOMINATOR TO NUMERATOR

All cases in the denominator are equally eligible to appear in the
numerator

#### DENOMINATOR (INDEX) EVENT 

Clinical Condition\
Institutionalization\
Therapeutic Intervention

#### DENOMINATOR TIME WINDOW

Time window is a single point in time

#### NUMERATOR INCLUSIONS/EXCLUSIONS

**Inclusions**\
Discharges among cases meeting the inclusion and exclusion rules from
the denominator with International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) code denoting accidental cut,
puncture, perforation or laceration during a procedure in any secondary
diagnosis field

**Note**: Refer to the original measure documentation for specific
ICD-9-CM codes.

**Exclusions**\
Unspecified

#### MEASURE RESULTS UNDER CONTROL OF HEALTH CARE PROFESSIONALS, ORGANIZATIONS AND/OR POLICYMAKERS

The measure results are somewhat or substantially under the control of
the health care professionals, organizations and/or policymakers to whom
the measure applies.

#### NUMERATOR TIME WINDOW

Institutionalization

#### DATA SOURCE

Administrative data

#### LEVEL OF DETERMINATION OF QUALITY

Not Individual Case

#### OUTCOME TYPE

Adverse Outcome

#### PRE-EXISTING INSTRUMENT USED

Unspecified

### Computation of the Measure

#### SCORING

Rate

#### INTERPRETATION OF SCORE

Better quality is associated with a lower score

#### ALLOWANCE FOR PATIENT FACTORS

Analysis by high-risk subgroup (stratification on vulnerable
populations)\
Analysis by subgroup (stratification on patient factors, geographic
factors, etc.)\
Case-mix adjustment\
Risk adjustment method widely or commercially available

#### DESCRIPTION OF ALLOWANCE FOR PATIENT FACTORS

Risk adjustment of the data is recommended using, at minimum, age, sex,
and 3M™ All-Patient Refined Diagnosis-Related Groups (APR-DRGs)\*.

Application of multivariate signal extraction (MSX) to smooth risk
adjusted rates is also recommended.

[Additionally, for this measure]{.underline}:

Stratify rates by low birth weight neonate (under 2000 g) and other
patients.

Risk adjust rates by procedure type recorded in patient record:

i.  no therapeutic

ii. minor therapeutic

iii. one major therapeutic without diagnostic

iv. one major therapeutic with minor diagnostic

v.  one major therapeutic with major diagnostic

vi. two major therapeutic

vii. three or more major therapeutic

Stratify rates by clinical category:

i.  Eye, ear, nose, mouth, throat, skin, breast, and other low-risk
    procedures

ii. Thoracic, cardiovascular, and specified neoplastic procedures

iii. Kidney, and male/female reproductive procedures

iv. Infectious, immunological, hematological, and ungroupable procedures

v.  Trauma, orthopedic, and neurologic procedures

vi. Gastrointestinal, hepatobiliary, and endocrine procedures

\***Note**: Information on the 3M™ APR-DRG system is available at
<http://www.3m.com/us/healthcare/his/products/coding/refined_drg.jhtml>.

#### STANDARD OF COMPARISON

Internal time comparison

### Evaluation of Measure Properties

#### EXTENT OF MEASURE TESTING

The development of the Agency for Healthcare Research and Quality (AHRQ)
Pediatric Quality Indicators utilizes a four pronged approach:
identification of candidate indicators, literature review, empirical
analyses, and panel review. Candidate indicators were identified through
both published literature and a brief survey of national organizations.
Literature review provided descriptions and evaluations of some
candidate indicators and the underlying relationship to quality of care.
Empirical analyses were conducted to explore alternative definitions; to
assess nationwide rates and hospital variation; and to develop
appropriate methods to account for variation in risk. Clinical panel
review helped to refine indicator definitions and risk groupings, and to
establish face validity in light of the limited evidence from the
literature for most pediatric indicators. Information from these sources
was used to specify indicator definitions and make recommendations to
AHRQ regarding the best indicators for inclusion in the pediatric
indicator set.

A structured review of each indicator was undertaken to evaluate face
validity (from a clinical perspective). This process mirrored that
undertaken during the initial development of the Patient Safety
Indicators. Specifically, the panel approach established *consensual
validity*, which \"extends face validity from one expert to a panel of
experts who examine and rate the appropriateness of each item\....\" The
methodology for the structured review was adapted from the RAND/UCLA
Appropriateness Method and consisted of an initial independent
assessment of each indicator by clinician panelists using an initial
questionnaire, a conference call among all panelists, followed by a
final independent assessment by clinician panelists using the same
questionnaire. The panel process served to refine definitions of some
indicators, add new measures, and dismiss indicators with major concerns
from further consideration.

Empirical analyses were conducted to provide the clinical panels and
peer review participants with additional information about the
indicators. These analyses were also used by the development team to
test the alternative specifications and the relative contribution of
indicator components in the numerator and denominator. These analyses
were not intended to inform issues of precision, bias and construct
validity, which will be addressed separately. The data source used in
the empirical analyses was the 2003 Kids\' Inpatient Sample (KID).

Refer to the original measure documentation for additional details.

#### EVIDENCE FOR RELIABILITY/VALIDITY TESTING

Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA appropriateness
method user\'s manual. Santa Monica (CA): RAND; 2001. 109 p.

Green L, Lewis F. Measurement and evaluation in health education and
health promotion. Mountain View (CA): Mayfield Publishing Company; 1998.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

### Identifying Information

#### ORIGINAL TITLE

Accidental puncture or laceration (PDI 1).

#### MEASURE COLLECTION

[Agency for Healthcare Research and Quality (AHRQ) Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=341)

#### MEASURE SET NAME

[Agency for Healthcare Research and Quality (AHRQ) Pediatric Quality
Indicators](http://www.qualitymeasures.ahrq.gov/Browse/DisplayOrganization.aspx?org_id=9&doc=8832)

#### DEVELOPER

Agency for Healthcare Research and Quality

#### ENDORSER

National Quality Forum

#### ADAPTATION

This measure was adapted from the AHRQ Patient Safety Quality
Indicators.

#### PARENT MEASURE

Accidental Puncture or Laceration, Provider Level (PSI 15) (Agency for
Healthcare Research and Quality \[AHRQ\])

#### RELEASE DATE

2006 Feb

#### REVISION DATE

2007 Mar

#### MEASURE STATUS

This is the current release of the measure.

#### SOURCE(S)

AHRQ quality indicators. Pediatric quality indicators: technical
specifications \[version 3.2\]. Rockville (MD): Agency for Healthcare
Research and Quality (AHRQ); 2008 Feb 29. various p.

McDonald K, Romano P, Davies S, Haberland C, Geppert J, Ku A, Choudhry
K. Measures of pediatric health care quality based on hospital
administrative data: the pediatric quality indicators. Rockville (MD):
Agency for Healthcare Research and Quality (AHRQ); 2006 Sep. 130 p. \[82
references\]

#### MEASURE AVAILABILITY

The individual measure, \"Accidental Puncture or Laceration (PDI 1),\"
is published in \"Measures of Pediatric Health Care Quality Based on
Hospital Administrative Data: The Pediatric Quality Indicators\" and
\"AHRQ Quality Indicators. Pediatric Quality Indicators: Technical
Specifications \[version 3.1\].\" These documents are available in
Portable Document Format (PDF) from the [Pediatric Quality Indicators
Download](http://www.qualityindicators.ahrq.gov/pdi_download.htm) page
at the Agency for Healthcare Research and Quality (AHRQ) Quality
Indicators Web site.

For more information, please contact the QI Support Team at
<support@qualityindicators.ahrq.gov>.

#### COMPANION DOCUMENTS

The following are available:

-   AHRQ quality indicators. Pediatric quality indicators: software
    documentation \[version 3.1\] - SAS. Rockville (MD): Agency for
    Healthcare Research and Quality (AHRQ); 2007 Mar 12. 42 p. This
    document is available in Portable Document Format (PDF) from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_sas_documentation_v31.pdf).

-   AHRQ quality indicators. Software documentation: Windows \[version
    3.1a\]. Rockville (MD): Agency for Healthcare Research and Quality
    (AHRQ); 2007 Apr 6. 99 p. This document is available in PDF from the
    [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/winqi/AHRQ_QI_Windows_Software_Documentation_V31a.pdf).

-   Pediatric quality indicators (PedQI): covariates \[version 3.1\].
    Rockville (MD): Agency for Healthcare Research and Quality (AHRQ);
    2007 Mar 12. 52 p. This document is available in PDF from the [AHRQ
    Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_covariates_v31.pdf).

-   Pediatric quality indicators (PedQI): covariates (with POA)
    \[version 3.1\]. Rockville (MD): Agency for Healthcare Research and
    Quality (AHRQ); 2007 Mar 12. 52 p. This document is available in PDF
    from the [AHRQ Quality Indicators Web
    site](http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_covariates_poa_age_v31.pdf).

-   HCUPnet. \[internet\]. Rockville (MD): Agency for Healthcare
    Research and Quality (AHRQ); 2004 \[accessed 2007 May 21\].
    \[Various pagings\]. HCUPnet is available from the [AHRQ Web
    site](http://hcup.ahrq.gov/HCUPnet.asp). See the related
    [QualityTools](http://www.innovations.ahrq.gov/content.aspx?id=543)
    summary.

#### NQMC STATUS

This NQMC summary was completed by ECRI Institute on December 28, 2007.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

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© 2009 National Quality Measures Clearinghouse

Date Modified: 2/9/2009