Clinical validity and relevance of accidental puncture or laceration as a patient safety indicator for children

Purpose Accidental puncture or laceration (APL) has been endorsed as a patient safety indicator and is being used to compare hospital performance and for reimbursement. We sought to determine the positive predictive value (PPV) of APL as a quality metric in a pediatric population. Methods We retrospectively reviewed all cases that met APL administrative criteria over 5 years in a quaternary pediatric hospital system. Events were categorized as false positive (FP) or true positive (TP). TP cases were further categorized as “potentially consequential” or “inconsequential”. The PPV of APL was calculated, and a z-test was used to provide 95% confidence intervals. Results Of the 238 cases identified, 204 were categorized as TP (86%; 95% CI: 80%–90%). Thirty-four of these events (17%) involved injuries that were considered “inconsequential”. True events that required repair were identified as “potentially consequential” (n = 170). Thus, the PPV of APL was 71% (95% CI: 65%–77%). Extenuating factors such as adhesive disease or abnormal anatomy were present in 39% of TP cases. Thirty-four cases (14%) were categorized as FP because no documented injury was found. Conclusions A large proportion of APL events are either false or clinically irrelevant, thus questioning its usability as a patient safety indicator for children undergoing surgery. Type of study Retrospective review. Level of evidence IV.