Health Care Quality Assessment

This section presents brief descriptions of each of the 12 PSIs covered in this report and why it is important to report them publicly. Most of these adverse events are considered potentially preventable (i.e., with good care, hospitals can prevent most of these adverse events).

• This indicator (formerly called foreign body left during procedure) measures how often a surgical instrument or tool (foreign body), such as a scalpel or a sponge, was accidentally left in a patient's body during an operation. It is also referred to as a "Never-event" because it is a clearly identifiable, serious medical error and usually preventable. The indicator which stands to show the number of hospitalized patients (i.e., among surgical and medical patients ages 18 years and older, or obstetric patients) with ICD-9 diagnosis codes for a retained surgical item or unretrieved device fragment, captures a rare event and therefore, it is reported as a count or volume.
  
  
• Reporting information on this indicator is important because foreign objects such as sponges, surgical or medical instruments or tools, bandages, etc. should never be left in a patient’s body after an operation or procedure. This error is preventable, and hospitals with such incidents need to put systems in place to prevent recurrence.

• This indicator measures how often incidents of iatrogenic pneumothorax occur in a given hospital. The rate shows the number of such incidents (i.e., discharges with ICD-9 codes for iatrogenic pneumothorax) per 1,000 eligible surgical or medical patients 18 years and older. Iatrogenic is a medical term for a condition in which air or gas is present in the pleural cavity or space around the lung. Air could be leaking from the lungs as a result of accidental puncture while performing procedures such as mechanical ventilation, tracheostomy tube placement, or other therapeutic intervention. Pneumothorax is a term used to describe a collapsed lung as a result of presence of air or gas in the pleural cavity which can impair oxygenation and/or ventilation.
  
  
• Information on this indicator is important because the complication, which is a relatively frequent event and potentially serious complication of procedures adjacent to the lung, is preventable, especially if appropriate precautions are taken and currently recommended techniques used. Treating this potentially preventable medical error sometimes requires putting a tube into a patient’s chest to remove the excess air.

• This indicator measures how often hospitalized patients broke a hip bone from a fall following any kind of operation. The event is considered preventable with proper medical and nursing care. The rate tells you the number of patients who broke a hip bone from a fall during a hospital stay (i.e., patients with ICD-9 codes for hip fracture in any secondary diagnosis field) per 1,000 eligible surgical discharges 18 years and older.
  
  
• Information on this indicator is important because breaking a hip bone as a result of a fall while in the care of a hospital is a type of medical error that is usually preventable. A fall can happen for different reasons, such as being given too much pain medication, having too little supervision when trying to walk after an operation or it may just happen. Postoperative hip fracture occurs very rarely.

• This indicator measures how often hospitalized patients bled too much either within their body or outside their body (hemorrhage) or develop a large clot (hematoma) following a surgical procedure. These complications were important enough to involve another operation to stop the bleeding or remove the blood clots. The rate tells you the number of patients with postoperative hemorrhage or hematoma (i.e., patients with ICD-9 codes for postoperative hemorrhage or hematoma in any secondary diagnosis field) per 1,000 eligible surgical patients 18 years and older.
  
  
• Information on this indicator is important because the event is considered preventable when proper guidelines and procedures are followed.

• This indicator measure how often patients experience a blood clot up in the lungs (pulmonary embolism) or in a large vein (deep vein thrombosis) following an operation. The rate tells you the number of patients with PE or DVT (i.e., discharges with ICD-9 codes for pulmonary embolism (PE) or deep vein thrombosis (DVT) in any secondary diagnosis field) per 1,000 surgical patients 18 years and older excluding obstetric patients.
  
  
• This information is important because both PE and DVT are common complications that can be prevented through continuous in-hospital risk assessment and appropriate infection treatments.

• This indicator measures how often hospitalized patients get a serious bloodstream infection (nosocomial postoperative sepsis) following a surgery. A serious infection of the bloodstream caused by toxin-producing bacteria, known as sepsis, can occur after surgery. The rate tells you the number of hospitalized patients that get a serious bloodstream infection (i.e., patients with ICD-9 codes for nosocomial postoperative sepsis) per 1,000 elective surgery patients age 18 years and older. The rate excludes patients with pre-existing infections as well as those with compromised immunity system such as cancer. Obstetric patients are also excluded.
  
  
• This information is important because it tells you the level of care provided by the hospital to prevent sepsis infections in patients. Analysis of these particular infections may provide a screen for potential medical errors and a method for monitoring trends in infections over time. Hospitals following the appropriate protocols, such as requiring staff frequently wash their hands, should see improvement of postoperative sepsis or other infections over time. Evidence has shown that, with proper monitoring and care, postoperative sepsis infections can be prevented.

• This indicator measures how often a surgical wound in the stomach or pelvic area splits open after an operation (i.e., postoperative wound dehiscence among abdominopelvic surgical patients). Wound reclosure is performed after the wound from surgical operation is accidently split open (wound dehiscence). Abdominopelvic surgical procedures include those performed on the stomach, liver, spleen, gallbladder, pancreas, kidneys, most of the small and large intestines, urinary bladder and internal reproductive organs. The rate tells you the number of patients who had experienced surgical wound in the stomach or pelvic area (i.e., discharges with ICD-9 codes for postoperative wounds dehiscence) per 1,000 eligible cases of abdominopelvic surgeries. Patients with pre-existing conditions (POA) and all obstetric admissions are excluded from this measure.
  
  
• Information on this indicator is important because it shows you how often a surgical wound in the stomach or pelvic area happens after an operation. Some or all of these complications may require treatment with another major operation to fix the wound. Wound dehiscence following surgery is a medical error that can be avoided. Studies show that proper surgical and nursing care can prevent wound dehiscence from occurring frequently.

• This indicator measures how often incidents of inadvertent cuts, punctures, perforations, and lacerations happen to patients during a surgical procedure. The rate tells you the number of patients who had an accidental cut or lacerations during a procedure (i.e., discharges with ICD-9 codes for accidental puncture or laceration) per 1,000 eligible surgical and medical discharges age 18 years and older. The number excludes patients with pre-existing conditions as well as obstetric admissions.
  
  
• This information is important because it tells you how often patients were accidentally cut, making an unnecessary or dangerous hole or tear in an organ of the body (called an accidental puncture and laceration), while receiving medical care in the hospital. With appropriate care, this medical error which occurs very frequently can be avoided, or at least minimized.

• This indicator measures how often patients get bad reaction to a blood transfusion. It captures patients who had experienced illness or injury resulting from administration of mismatched blood or blood products, based on ABO or Rh antigens (i.e., discharges with ICD-9 codes for transfusion reaction). Using the wrong type of blood or blood substitute are examples of why this type of medical error may occur. The indicator, which is reported as a count/volume since it is a very rare event, is considered a never-event because it should not happen at all.
  
  
• This information is important because transfusion reactions are considered preventable through adherence to proper blood typing, cross-matching, and patient monitoring.

• This indicator captures how often a newborn infant (neonate) experiences a problem during the birth process, such as a broken collarbone, an infection, or a head injury. Examples of what may cause a birth trauma to a neonate include: bleeding; delay ordering a medically necessary cesarean section (c-section); misuse of forceps or a vacuum extractor during delivery; or failure to respond to an umbilical cord that is dangerously wrapped around the newborn. The rate tells you the number of birth trauma (injury to neonate) cases per 1,000 live births caused by medical complications during labor and delivery. The rate excludes some preterm infants and infants with osteogenic imperfecta.
  
  
• This information is important because it shows how often birth traumas, which are potentially preventable errors occur. Many neonatal injuries that occur during delivery are considered preventable when clinical guidelines and procedures are followed properly.

• This indicator captures how often a woman experiences a tear (trauma) to her perineum (the area between her vagina and rectum) while giving birth when a health care provider is using forceps or other medical instruments to help her deliver the baby. The rate tells you the number of obstetric trauma cases (3rd or 4th degree lacerations, other obstetric lacerations) during instrument-assisted vaginal deliveries per 1,000 instrument assisted vaginal deliveries.
  
  
• This information is important because trauma cases during vaginal delivery that require the use of forceps or other instrument assistance is a medical error that is potentially preventable.

• This indicator captures how often a woman experiences a tear (trauma) to her perineum (the area between her vagina and rectum) while giving birth without the use of medical instruments. Such tears, which can happen even when medical instruments are not used, are often preventable. The rate tells you the number of obstetric trauma cases (4th degree lacerations, other obstetric lacerations) per 1,000 vaginal deliveries that occurred without a medical instrument.
  
  
• This information is important because it tells you the number of potentially preventable injuries or lacerations that occur during a vaginal delivery that did not require instrument assistance.