Patient Safety Indicators Agency for Healthcare Research and Quality

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 adverse events (potentially preventable complications) that patients sometimes experience while receiving medical care. Mayo Clinic tracks and analyzes these events (called patient safety indicators, or 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 indentifies the complications that are measured and defines them.

• Accidental puncture or laceration. Unintended injuries during a procedure.
• Birth trauma. Injury during delivery.
• Complications of anesthesia.
• Death in low-mortality DRGs. When a patient with a typically nonserious diagnosis dies. DRG stands for Diagnosis-Related Groups, a patient classification system.
• Decubitus ulcer. A sore caused by sitting or lying in the same position for a long period of time. Also called pressure sore or bedsore.
• Failure to rescue. When a patient's condition seriously deteriorates and medical staff fail to notice it.
• Retained foreign object. 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). Sometimes caused by accident during surgery or other procedures performed on the chest.
• Obstetric trauma. Injury to mother during delivery.
• 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 wound dehiscence. When a surgical incision reopens.
• Selected infections due to medical care. Specific infections the patient gets as a result of care.
• Transfusion reaction. A reaction to blood or blood byproducts after a blood transfusion.