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Improving Perinatal and Neonatal Patient Safety: The AHRQ Patient Safety Indicators

Johnson, Christopher E. PhD; Handberg, Eileen PhD, ARNP; Dobalian, Aram PhD, JD; Gurol, Neslihan MS, MBA; Pearson, Vivian RNC, BSN, IBCLC

Journal of Perinatal & Neonatal Nursing:
Feature Articles

This study reviews the development and implementation of the Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs). The genesis of the use of administrative data as a tool to combat safety problems is presented, and how indicators were constructed using various administrative codes. Examples of how the PSIs are being used to identify potential safety problems within the general population are presented, with a special emphasis on how these are being used within the perinatal and neonatal arena to understand current issues within that subpopulation. Results from studies within the general population and targeted at perinatal and neonatal patients are presented. Finally, suggestions are discussed for clinicians to use the AHRQ PSIs as one of their early warning tools for potential safety-related problems.

Author Information

Rehabilitation Outcomes Research Center of Excellence, North Florida/South Georgia Veteran's Health System, Gainesville, Fla (Dr Johnson); Department of Health Services Research, Management and Policy, College of Public Health and Health Professions (Dr Johnson and Ms Gurol) and the Division of Cardiovascular Medicine (Dr Handberg), University of Florida, Gainesville; Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda Ambulatory Care Center and Nursing Home, VA Greater Los Angeles Healthcare System, Sepulveda, Calif (Dr Dobalian); and the Maternal/Child Services, Shands at AGH, Gainesville, Fla (Ms Pearson).

Corresponding author: Christopher E. Johnson, PhD, Rehabilitation Outcomes Research Center of Excellence, North Florida/South Georgia Veteran's Health System, 1601 SW Archer Rd, Gainesville, FL 32608 (e-mail:

Submitted for publication: August 17, 2004; Accepted for publication: November 10, 2004

© 2005 Lippincott Williams & Wilkins, Inc.