Hospital-Wide Safety Performance Affects Complication Rates After Primary Total Hip and Knee Arthroplasty

Outcomes following total hip arthroplasty and total knee arthroplasty (THA/TKA) are influenced not only by surgical techniques but also by infrastructure in broader hospital systems. The association of hospital-wide patient safety performance with arthroplasty-specific complication rates remains incompletely understood.

We performed a retrospective hospital-level analysis of the Centers for Medicare & Medicaid Services Complications and Deaths-Hospital dataset spanning April 1, 2021, through June 30, 2024. Hospitals reporting both the risk-adjusted arthroplasty complication rate (COMP_HIP_KNEE) and the Patient Safety Indicator composite (PSI-90) were included. Hospitals reporting fewer than 25 arthroplasty cases were excluded. PSI-90 was analyzed as both a continuous variable and stratified into quartiles. Weighted linear regression evaluated the association between PSI-90 and arthroplasty complication rates, with weighting by procedural volume. Unweighted regression was performed as a sensitivity analysis.

A total of 1551 hospitals met inclusion criteria. Mean risk-adjusted THA/TKA complication rates increased across worsening PSI-90 quartiles, from 3.5% in the best safety quartile to 3.7% in the worst quartile (P < .001). In weighted linear regression analyses, worse hospital-wide safety performance was significantly associated with higher arthroplasty complication rates; each 1-unit increase in PSI-90 corresponded to a 0.47 percentage-point increase in complication rate (P < .001). Findings remained significant in unweighted sensitivity analyses (β = 0.26; P = .002).

Worse hospital-wide safety performance is associated with higher complication rates following primary THA and TKA. These findings suggest that arthroplasty outcomes are influenced not only by procedure-specific factors but also by broader institutional safety systems.