The Texas Advocates for Patient Safety

Promoting disclosure in medical care for the state of Texas and beyond.

Examples of Errors

The Agency for Healthcare Research and Quality issued a list of 20 "Patient Safety Indicators." 16 of these PSI's were used as the basis for the HealthGrades study. 4 obstetrics-related indicators were not included in the study. The full 'Guide to Patient Safety Indicators' can be viewed here.

1. Complications of Anesthesia
2. Death in Low-Mortality DMG's
3. Decubitus Ulcer
4. Failure to Rescue
5. Foreign Body Left During Procedure
6. Iatrogenic Pneumothorax
7. Selected Infections Due to Medical Care
8. Postoperative Hip Fracture
9. Postoperative Hemorrhage or Hematoma
10. Postoperative Physiologic and Metabolic Derangements
11. Postoperative Respiratory Failure
12. Postoperative Pulmonary Embolism or Deep Vein Thrombosis
13. Postoperative Sepsis
14. Postoperative Wound Dehiscence
15. Accidental Puncture or Laceration
16. Transfusion Reaction
17. Birth Trauma – Injury to Neonate
18. Obstetric Trauma – Vaginal with Instrument
19. Obstetric Trauma – Vaginal without Instrument
20. Obstetric Trauma – Cesarean Delivery

#1 - Complications of Anesthesia
This indicator is intended to capture cases flagged by external cause-of-injury codes (ecodes) and complications codes for adverse effects from the administration of therapeutic drugs, as well as the overdose of anesthetic agents used primarily in therapeutic settings.

#2 - Death in Low-Mortality DMG's
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 having an immunocompromised state or cancer are excluded, as these patients have higher non-preventable mortality.

#3 - Decubitus Ulcer
This indicator is intended to flag cases of in-hospital decubitus ulcers. Its definition is limited to decubitus ulcer as a secondary diagnosis to better screen out cases that may be present on admission. In addition, this indicator excludes patients who have a length of stay of 4 days or less, as it is unlikely that a decubitus ulcer would develop within this period of time. Finally, this indicator excludes patients who are particularly susceptible to decubitus ulcer, namely patients with major skin disorders (MDC 9) and paralysis.

#4 - Failure to Rescue
This indicator is intended to identify patients who die 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.

#5 - Foreign Body Left During Procedure
This indicator is intended to flag cases of a foreign body accidentally left in a patient during a procedure. This indicator is defined on both a provider level (by restricting cases to those flagged by a secondary diagnosis or procedure code) and an area level (by including all cases).

#6 - Iatrogenic Pneumothorax
This indicator is intended to flag cases of pneumothorax caused by medical care. indicator is defined on both a provider level including cases of iatrogenic pneumothorax occurring as a secondary diagnosis during hospitalization) and on an area level (by all cases of iatrogenic pneumothorax).

Iatrogenic pneumothorax excludes all trauma patients because these patients may be more susceptible to non-preventable iatrogenic pneumothorax or may be miscoded for traumatic pneumothorax. The smaller anatomy of children, especially neonates, may increase the technical complexity of these procedures in this population (however, these procedures are less likely to be performed in unmonitored settings).

#7 - Selected Infections Due to Medical Care, Provider Level
This indicator is intended to flag cases of infection due to medical care, primarily those related to intravenous (IV) lines and catheters. This indicator is defined both on a provider level (by including cases based on secondary diagnosis associated with the same hospitalization) and on an area level (by including all cases of such infection). 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.

#8 - Postoperative Hip Fracture
This indicator is intended to capture cases of in-hospital fracture - specifically, hip fractures. This indicator limits diagnosis codes to secondary diagnosis codes to eliminate fractures that were present on admission. It further 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. This indicator is limited to surgical cases since previous research suggested that these codes in medical patients often represent conditions present on admission.

#9 - Postoperative Hemorrhage or Hematoma
This indicator is intended to capture cases of hemorrhage or hematoma following a surgical procedure. This indicator limits hemorrhage and hematoma codes to secondary procedure and diagnosis codes, respectively, to isolate those hemorrhages that can truly be linked to a surgical procedure.

#10 - Postoperative Physiologic and Metabolic Derangement
This indicator is intended to flag cases of postoperative metabolic or physiologic complications. The population at risk is limited to elective surgical patients, because patients undergoing non-elective surgery may develop less preventable derangements. In addition, each diagnosis has specific exclusions, designed to reduce the number of flagged cases in which the diagnosis was present on admission or was more likely to be non-preventable.

#11 - Postoperative Respiratory Failure
This indicator is intended to flag cases of postoperative respiratory failure. This indicator limits the code for respiratory failure to secondary diagnosis codes to eliminate respiratory failure that was present on admission. It further excludes patients who have major respiratory or circulatory disorders and limits the population at risk to elective surgery patients.

#12 - Postoperative Pulmonary Embolism or Deep Vein Thrombosis
This indicator is intended to capture cases of postoperative venous thromboses and embolism¯specifically, pulmonary embolism and deep venous thrombosis. This indicator limits vascular complications codes to secondary diagnosis codes to eliminate complications that were present on admission. It further excludes patients who have principal diagnosis of DVT, as these patients are likely to have had PE/DVT present on admission.

#13 - Postoperative Sepsis
This indicator is intended to flag cases of nosocomial postoperative sepsis. This indicator limits the code for sepsis to secondary diagnosis codes to eliminate sepsis that was present on admission. This indicator also excludes patients who have a principal diagnosis of infection, patients with a length of stay of less than 4 days, and patients with potential immunocompromised states (e.g., AIDS, cancer, transplant).

#14 - Postoperative Wound Dehiscence
This indicator is intended to flag cases of wound dehiscence in patients who have undergone abdominal and pelvic surgery. This indicator is defined both on a provider level (by including cases based on secondary diagnosis associated with the same hospitalization) and on an area level (by including all cases of wound dehiscence).

#15 - Accidental Puncture or Laceration
This indicator is intended to flag cases of complications that arise due to technical difficulties in medical care¯specifically, those involving an accidental puncture or laceration.

#16 - Transfusion Reaction
This indicator is intended to flag cases of major reactions due to transfusions (ABO and Rh). This indicator is defined both on a provider level (by including cases based on secondary diagnosis associated with the same hospitalization.

#17 - Birth Trauma - Injury to Neonate
This indicator is intended to flag cases of birth trauma for infants born alive in a hospital. The indicator excludes patients born pre-term, as birth trauma in these patients may be less preventable than for full-term infants.

#18 - Obstetric Trauma - Vaginal Delivery with Instrument
This indicator is intended to flag cases of potentially preventable trauma during vaginal delivery with instrument.

#19 - Obstetric Trauma - Vaginal Delivery without Instrument
This indicator is intended to flag cases of potentially preventable trauma during a vaginal delivery without instrument.

#20 - Obstetric Trauma - Cesarean Delivery
This indicator is intended to flag cases of potentially preventable trauma during Cesarean delivery.

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