The Agency for Healthcare Research and Quality (AHRQ) is a federal agency for research on health care quality, costs, outcomes and patient safety. AHRQ has created software that screens billing records for potentially preventable complications (adverse events) that patients sometimes experience while receiving medical care. Mayo Clinic tracks and analyzes these events, called patient safety indicators (PSIs), in an effort to prevent future occurrences.
How PSIs are measured and evaluated
The indicators use administrative data and try to measure potentially preventable complications for patients who received their initial care and experienced complications during the same hospitalization period. The glossary below identifies the complications that are measured and defines them.
- Accidental puncture or laceration. Unintended injuries during a procedure.
- Birth trauma. Injury during delivery.
- Central venous catheter–related bloodstream infections. An infection that enters the blood via a catheter placed into a major venous blood vessel.
- Death in low-mortality DRGs. Death of a patient with a typically nonserious diagnosis. DRG stands for Diagnosis-Related Groups, a patient classification system.
- Death among surgical inpatients with treatable serious complications. Death of a patient who develops a treatable life-threatening complication after a surgical procedure.
- Foreign body left in during procedure. Unplanned sponge or equipment left in wound during a procedure.
- Iatrogenic pneumothorax. Lung collapse that occurs when air leaks into the area between the lungs and chest wall (pleural space). This is sometimes caused by accident during surgery or other procedures performed on the chest.
- Obstetric trauma — vaginal delivery with instrument. A severe vaginal laceration caused by a birth assist device.
- Obstetric trauma — vaginal delivery without instrument. A severe vaginal laceration that occurs during the birth process.
- Postoperative hip fracture. Broken hip after surgery.
- Postoperative hemorrhage or hematoma. Unexpected bleeding after surgery.
- Postoperative physiologic and metabolic derangements. Unexpected blood values after surgery.
- Postoperative respiratory failure. Breathing failure after an operation.
- Postoperative pulmonary embolism or deep vein thrombosis. Blood clots that travel to the lungs or blood clots that form in the deep veins.
- Postoperative sepsis. Unintended systemic infection occurring after surgery.
- Postoperative wound dehiscence. Reopening of a surgical incision.
- Pressure ulcer. The breakdown of skin tissue, not present on hospital admission, caused by sitting or lying in the same position for a long period of time.
- Transfusion reaction. A reaction to blood or blood byproducts after a blood transfusion.