In this study, we analysed the diagnosis codes and POA indicators of patients with confirmed AEs based on data from the PSII to evaluate the accuracy of PSI codes and POA indicators. Our methodology involved estimating the accuracy of PSI codes and POA indicators by verifying the presence of PSI codes corresponding to AE type, identified in patients’ diagnosis codes and whether the POA indicators assigned to these PSI codes were tagged as ‘N’. The evaluation results indicated low accuracy of PSI codes and POA indicators in South Korean hospitals. Analysis of each hospital’s data showed considerable variation in AE incidence rates and the accuracy of PSI codes and POA indicators. This study’s primary contribution is in highlighting the critical need to enhance the accuracy of diagnosis codes and POA indicators in administrative data as a means to more effectively gauge patient safety status.
Among the methods used to assess patient safety status, administrative data (including diagnosis codes) has commonly been used to detect the presence of various types of PSIs [1,2,3,4]. However, the comprehensive accuracy of this approach remains underexplored with most studies focusing solely on the accuracy of POA indicators for certain PSI categories [13,14,15]. The only known study that concurrently assessed a range of PSI codes and POA indicators has limited precision in evaluating accuracy due to its reliance on cross-validation of administrative data [12]. For a more robust evaluation of PSI codes and POA indicators’ accuracy, it is imperative to compare these findings with those obtained from methodologies deemed the gold standard in patient safety assessment, such as the medical records review [18]. This study is unique in that it validates the analysis method against the PSII, which verifies AE occurrences through a review of medical records, thereby serving as a comparative benchmark and enhancing the study’s validity [16].
Moreover, this study stands out for its comprehensive evaluation of the accuracy of PSI codes and POA indicators across six types of AEs, encompassing diagnosis-related AEs and facilitating a comparison of accuracy across different PSI types. With the overall average accuracy of PSI codes with POA indicators tagged as ‘N’ at 8.7%, we observed lower accuracy rates in AEs related to diagnosis, medication/fluids/blood, and patient care. We noted higher accuracy rates in AEs related to surgery/procedure and infection. The absence of PSI codes in diagnosis-related AEs might be understandable given the limited number of PSI codes—only two—available in the Korean Patient Safety Incidents Code Classification System [9]. Nonetheless, the lack of codes for patient care-related AEs (such as pressure ulcers)—despite the presence of specific codes like L890 (Stage I decubitus ulcer and pressure area) and L891 (Stage II decubitus ulcer and pressure area)—highlights significant oversight. These findings suggest that using pressure ulcer-related PSI codes to infer a decline in the incidence of pressure ulcers in South Korea may not be a valid approach [19].
Our findings indicate that the absence of diagnosis codes in administrative data is not limited to specific types of PSIs (such as pressure ulcers). Even in cases of infection-related AEs—which demonstrate comparatively high accuracy for PSI codes and POA indicators—AE-related accuracy remains alarmingly low, ranging from 20 to 30%. This underscores the urgent need for comprehensive interventions in South Korean hospitals to improve the accuracy of PSI codes and POA indicators within their administrative databases. Most importantly, there is a need to raise the awareness level of healthcare professionals, especially physicians, regarding PSI codes and POA indicators [20].
In South Korea, although health information managers play a supportive role in coding tasks, the primary responsibility and authority for code assignment rests with physicians. Thus, code assignment should be prioritised to monitor physicians’ level of awareness and improve their familiarity with PSI codes and POA indicators. At the same time, it is imperative to establish detailed training and guidelines for accurately entering PSI codes and POA indicators. While South Korea has somewhat established guidelines and training for POA indicators [21], such resources for PSI codes are notably absent. Given the diminished effectiveness of POA indicators without accurate PSI codes entered, developing targeted guidelines and training programmes for PSI codes should be a top priority.
Given the notable variability in the accuracy of PSI codes and POA indicators across South Korean hospitals, it may be beneficial for hospitals to adopt diverse evaluation metrics for assessing the precision of PSI codes and POA indicators [22]. At the most basic level, the presence of staff specifically tasked with managing PSI codes and POA indicators should be checked, including their completion of necessary training. Additionally, whether the hospitals conduct their own audits to improve the accuracy of PSI codes and POA indicators should be checked. Ultimately, hospitals need to implement outcome metrics that gauge the utilization of PSI codes or the precision of ‘Y’ or ‘N’ tagging for POA indicators [8, 10]. The Healthcare Quality Evaluation Grant Initiative, a pay-for-performance model, is already making strides towards improving the assessment of POA indicators [23]. However, there is a pressing need to bolster the evaluation framework for PSI codes. Moreover, offering incentives based on the outcomes of these accuracy evaluations could significantly elevate the importance placed on PSI codes and POA indicators in hospital settings.
This study has several limitations. First, the participation of only a select number of hospitals in the PSII, specifically regional public hospitals, may not allow our findings to accurately reflect the full spectrum of healthcare providers in South Korea. Subsequent studies are needed to assess the accuracy of PSI codes and POA indicators across a more diverse array of healthcare institutions, including university hospitals and nursing facilities.
Second, this study’s analysis was confined to verifying the presence of major AE-related diagnosis codes and their respective PSI codes. A more accurate assessment of PSI codes and POA indicators will require a concordance check between more specific AE types and corresponding PSI codes. Given these limitations, the likelihood of overestimating the accuracy of PSI codes reported in this study cannot be ruled out. Follow-up research should focus on examining the presence of PSI codes based on more specific characteristics of AEs.
Finally, variables related to accuracy of the PSI codes and POA indicators could not be identified. Although Pearson’s correlation coefficient was used, statistically significant results were not confirmed. While the accuracy of PSI codes and POA indicators is expected to be affected by individual medical institutions’ coding practices and audit procedures, such information was not available in this study. In future research, it is necessary to explore factors that affect the accuracy of PSI codes and POA indicators.
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