Twenty Patient Safety Indicators

The Agency for Healthcare Research and Quality issued a list of 20 “Patient Safety Indicators (PSI’s).” 16 of these PSI’s were used as the basis for the HealthGrades study on medical errors. The following list consists of these indicators, all of which highlight the most common areas for hospital and medical errors to occur. The full guide to ‘Help Prevent Medical Errors: A Patient Fact Sheet’ can be viewed here.

Complications of Anesthesia: Complication or reaction to anesthetic generally used during surgery. Complications from insertion or removal of airways may cause respiratory problems such as coughing, gagging or muscle spasms in the voice box, or larynx, or in the bronchial tubes in the lungs. Insertion of airways also may cause an increase in blood pressure (hypertension) and heart rate (tachycardia). Other complications may include damage to teeth and lips, swelling in the larynx, sore throat and hoarseness caused by injury or irritation of the larynx. Other serious risks of general anesthesia include changes in blood pressure or heart rate or rhythm, heart attack or stroke.

Death in Low-Mortality Cases: This indicator is intended to identify in-hospital deaths in patients unlikely to die during hospitalization. The underlying assumption is that when patients admitted for an extremely low-mortality condition or procedure die, a health care error is more likely to be responsible. Patients experiencing trauma or who have an immune disease such as HIV or cancer are excluded, as these patients have higher non-preventable mortality.

Decubitus Ulcer (Bed Sores): Bed sores result from pressure on the skin, typically in patients during hospital recovery or whose mobility is limited in bed (e.g. paraplegics). They are also called “pressure sores” or the medical term “decubitus ulcer”. Symptoms include redness and swelling of the skin, sometimes with skin breakage if left untreated.

Failure to Rescue: When a patient dies following the development of a complication. The underlying assumption is that good hospitals identify these complications quickly and treat them aggressively.

Failure to rescue may be fundamentally different than other indicators reviewed in this report, as it may reflect different aspects of quality of care (effectiveness in rescuing a patient from a complication versus preventing a complication). This indicator includes pediatric patients. It is important to note that children beyond the neonatal period inherently recover better from physiological stress and thus may have a higher rescue rate.

Foreign Body Left During Procedure: These cases occur when a foreign body is accidentally left in a patient during a procedure. For example, if someone is having surgery and an instrument is left in their body after the surgery is complete. Sometimes the patient will feel pressure, or they do not get better, or different symptoms occur due to the foreign object in their body.

Latrogenic Pneumothorax (Breathing Problems): An adverse condition caused by treatment by any health professional where a leak in the lung causes air to accumulate in the space around the lung (pleural cavity). This prevents the lung from expanding fully and hence a partial lung collapse occurs. For example, a doctor may accidentally puncture the lung during a surgical operation. Symptoms: chest pain, difficulty breathing, shortness of breath, decreased or slowing of the heartbeat to less than 60 beats per minute; poor circulation such as the numbness in hands and fingers.

Selected Infections Due to Medical Care, Provider Level: Cases of infection due to medical care, primarily those related to intravenous (IV) lines and catheters. Patients with potential immunocompromised states (e.g., AIDS, cancer, transplant) are excluded, as they may be more susceptible to such infection.

This indicator includes children and neonates. It should be noted that high-risk neonates are at particularly high risk for catheter-related infections.

Postoperative Hip Fracture: These cases involve in-hospital fractures, specifically hip fractures. It excludes patients in MDC 8 (musculoskeletal disorders) and patients with indications for trauma or cancer, or principal diagnoses of seizure, syncope, stroke, coma, cardiac arrest or poisoning, as these patients may have a fracture present on admission.

Postoperative Hemorrhage (Bleeding) or Hematoma (Blood Clots): This indicator is intended to capture cases of hemorrhage (bleeding) or hematoma (blood clots) following a surgical procedure when it is unexpected.

Postoperative Physiologic and Metabolic Derangement: Cases of postoperative metabolic or physiologic complications after elective surgery.

Postoperative Respiratory Failure: Respiratory failure can occur after any surgical procedure. Respiratory failure is where the respiratory system becomes incapable of oxygenating the blood or removing the carbon dioxide. Respiratory failure is a serious and potentially fatal condition. Symptoms include coughing, tightness in the chest and wheezing.

Postoperative Pulmonary Embolism or Deep Vein Thrombosis: A blood clot that occurs in the lung after any surgical procedure. A pulmonary embolism is a blood clot that forms in another part of the body and then travels to the lung and causes a blockage. A pulmonary embolism can cause permanent lung damage due to lack of blood flow and insufficient oxygen supply. A deep vein thrombosis is a blood clot that occurs in deeper veins in the thigh or calf that can be very painful.

Postoperative Sepsis: Commonly called a “blood stream infection.” The presence of bacteria or other infectious organisms or their toxins in the blood or in other tissue of the body. Sepsis may be associated with clinical symptoms of illness, such as fever, chills, malaise, low blood pressure and mental status changes. Sepsis can be a serious situation, a life threatening disease calling for urgent and comprehensive care

Postoperative Wound Healing: Poor wound healing after abdominal surgery resulting in the wound splitting open. The wound breaks down and healing can be very lengthy and difficult and the risk of infection is high. Risk factors for the condition include diabetes, increased age, obesity, wound infection, poor wound closing and injury to the wound following the operation. Symptoms include abdominal pain, vomiting, diarrhea and wound discharge.

Accidental Puncture or Laceration: When an unexpected puncture or laceration occurs during surgery. If it is not corrected it could be life threatening due to loss of blood and decreased function from lacerated part.

Transfusion Reaction: When a person has an allergic reaction to the transfusion of blood products.Symptoms include anxiety, chest and/or back pain, jaundice, fever and chills.

Birth Trauma – Injury to Neonate: Birth trauma for infants born alive in a hospital. This excludes patients born pre-term, as birth trauma in these patients may be less preventable than for full-term infants. Some examples of trauma for infants are jaundice, asphyxia, brain damage and infection.

Obstetric Trauma – Vaginal Delivery with Instrument: Potentially preventable trauma during vaginal delivery with instrument. Some examples of trauma for infants are jaundice, asphyxia, brain damage and infection.

Obstetric Trauma – Vaginal Delivery without Instrument: Potentially preventable trauma during a vaginal delivery. Some examples of trauma for infants are jaundice, asphyxia, brain damage and infection.

Obstetric Trauma – Cesarean Delivery: Potentially preventable trauma during Cesarean delivery. Some examples of trauma for infants are jaundice, asphyxia, brain damage and infection.