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Patients, payers, and policy organizations have demonstrated a significant interest in using intraoperative iatrogenic injury as a quality measure. These complications are high-profile and controversial measures of patient safety because they are often discreet occurrences that can be attributed to a specific encounter or physician, and they are events that the public largely perceives as preventable. However, efforts to use intraoperative iatrogenic injury as an outcome measure for either quality improvement or profiling physicians have been limited by problems with the Agency for Healthcare Research and Quality’s (AHRQ) patient safety indicator (PSI)–15 for accidental puncture and laceration, resulting in widespread objection from the surgical community.
Paruch JL, Ko CY, Bilimoria KY. A Case for Improving Measurement of Intraoperative Iatrogenic Injuries. JAMA Surg. 2014;149(9):887-888. doi:10.1001/jamasurg.2013.5237